Received: 28 January 2021 | Revised: 24 March 2021 | Accepted: 21 April 2021

DOI: 10.1111/medu.14544

RESEARCH APPROACHES

The curious case of case study research

Jennifer Cleland1 | Anna MacLeod2 | Rachel Helen Ellaway3

1
Lee Kong Chian School of Medicine,
Nanyang Technological University Ringgold Abstract
Standard Institution, Singapore City, The conceptualisation of ‘good’ medical education research as hypothesis testing to
Singapore
2 identify universal truths that are generalisable across contexts has been challenged.
Division of Medical Education, Clinical
Research Centre, Dalhousie University, Joining this conversation, the field of health professions education research is com-
Halifax, NS, Canada
plex and contextual and there are ways of examining and reporting locally based ac-
3
Community Health Sciences, Foothills
Medical Centre, University of Calgary,
tivities and innovations, which can be of general value. This position leads to a focus
Calgary, AB, Canada on case study research (CSR), inquiry bound in time and place that generates thick

Correspondence
Jennifer Cleland, Lee Kong Chian School of
Medicine, Nanyang Technological University
Ringgold Standard Institution, Singapore
City 639798, Singapore
Email: jennifer.cleland@ntu.edu.sg
descriptions and close interpretations to reach explanations. CSR has grown in so-
phistication in recent years and can inform practice and advance the science of medi-
cal and health professions education. The authors evaluated the current state of the
science of CSR in the medical education literature by identifying and reviewing 160
papers. Most articles presented as ‘case studies’ were not in fact CSR. Moreover, most
articles failed to go beyond a ‘we did this’ account. The authors explore definitions of
CSR, and they examine dominant CSR methodologists, Yin, Stake and Merriam, and
their respective approaches to CSR. They then set out some of the basic tenets of
CSR (case definition, methods of data collection and analysis) and consider the log-
ics of CSR (its structures, purposes, assumptions and symbols). CSR challenges are
considered next (such as emic and etic perspectives; ethical complexities; generalis-
ability; quality; and reporting and reflexivity). The authors conclude that context is a
mechanism, which needs to be understood, and rigorous CSR provides the structures
and criticality to do so, opening up new areas of understanding and inquiry.

1 | I NTRO D U C TI O N
You know my method. It is founded upon the obser-
1
vation of trifles. (Arthur Conan Doyle )
The conceptualisation of ‘good’ medical education research as hy-
pothesis testing so as to identify universal truths that are generalisable
across all contexts has long been contested.2-­6 Similarly, in medicine,
Montgomery7 has argued that the work of the clinical encounter is
more closely aligned with the detective work of Sherlock Holmes than
the scientific approach of Galileo or Newton. Like Sherlock Holmes,
physicians are tasked with solving a case: the case of the individual
before them. This is not a pure or objective process; it is an act of
interpretation. Signs and symptoms, disease and illness come together
to make sense of the biological and social complexities of a patient, to
identify and pursue the best path for the individual, in their context.
Hypothetico-­deductive reasoning can play a role in this interpretive
process, but it is only a part of it.
Despite these conversations, the tendency to value global the-
ories and practices that transcend context over those that embrace
and explore contextual effects remains. By this, we refer to posi-
tivism and post-­
positivism, their ontological and epistemological
assumptions of objectivity, use of quantitative methods to test hy-
pothesis and focus on replicability and generalisability. Even qualita-
tive studies within health professions education have been ‘subject
to the pull of this domain's [science] dominant epistemological

© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education

Medical Education. 2021;55:1131–1141. wileyonlinelibrary.com/journal/medu | 1131


1132 | CLELAND Et AL.
forces’5 (p. 132). Fortunately, the field has moved on epistemologi-
cally and methodologically in the decade or so since these conversa-
tions began. Qualitative methodologies grounded in constructivist,
interpretivist and critical paradigms are now increasingly visible
within the field's journals, conferences and programmes. However,
we would argue that the deep-­seated and widespread desire for
predictability and order remains, evidenced by the chronic tendency
to simply explore ‘what works’.8 And yet, we know that HPE is not
simple and predictable. If it were, what holds in one medical school,
one clinical placement or one rotation would hold in every other;
translation and implementation would be seamless and consistent.
Clearly, this is not the case: context matters.9-­11
Just as every patient is unique, so is every learner, situated in a
series of overlapping and nested cultures and contexts that define
and legitimise what is learned and assessed, how it is learned and
assessed, and what constitutes appropriate trajectories from learn-
ing in to practice. The impossibility of true generalisability in social
12
science is reflected in Merton's concepts of middle-­range theory
and Bhaskar's concepts of critical naturalism13 that clearly challenge
the solipsism of radical constructivism. There is a continuum rather
than a binary between nomothetic inquiry (absolute generalisability)
and idiographic inquiry (exploring non-­generalisable specifics).
It is in this spirit that we encourage health professions educa-
tion researchers to embrace different ways of examining and re-
porting locally based activities and innovations that can still be of
14
general value. Embracing this worldview can allow us to engage in
interpretive practice: research that is contextual, and specific, and
that draws on multiple perspectives, sources and ideas in order to
achieve deeper understanding and interpretations of the case at
hand. This position leads naturally to valuing case study research—­
inquiry bound in time and place and generating thick description,
which needs narrative, analogic and casuistic interpretation to reach
explanation.
2 | C A S E S T U DY R E S E A RC H : TH E S TATE
O F TH E S C I E N C E
Although case study research (CSR) ‘has been around as long as re-
corded history’,15 it has grown in sophistication in recent years and
is now ‘viewed as a valid form of inquiry to explore a broad scope of
complex issues, particularly when human behaviour and social inter-
actions are central to understanding topics of interest’.16 Moreover,
we would argue that it is time to conceptually expand on an earlier
review of case study research by Cheek et al,17 to inform practice
and advance the science of health professions education, as well as
consider the challenges of CSR.
With these aims in mind, our first step was to evaluate the cur-
rent state of the science of CSR in the medical education literature.
Using a rapid mapping review approach18 [REF], we conducted a
PubMed search on ‘case study’ AND ‘medical education’ on 31
October 2020. We set no date limits. This returned 860 papers. We
allocated them equally between the three researchers and we each
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reviewed the metadata from the searching for educational focus and
excluding papers that were non-­educational. This left 218 papers for
further investigation (an additional 24 were excluded as not available
in English, and there was one duplicate). A second filter of using the
phrase ‘case study’ in the title or abstract left 184 papers.
We developed a simple extraction pro-­
forma iteratively and
discursively, with fields for description, methodologist followed,
multiple sources of evidence used, type of case study, justifica-
tion for type of case study and conformance to CSR principles (as
per Table 2). Full texts for the 184 papers were reviewed through
November 2020. Of these 24 proved inaccessible, leaving 160 pa-
pers to be reviewed. Among the remaining papers, 16 (10%) had high
conformance to the principles of CSR, 12 (7.5%) had medium confor-
mance, and 132 (82.5%) had low or no conformance to broad CSR
principles (see Box 1). There was a high degree of agreement among
authors as to the categorisation of papers.
In short, although we found quite a large number of case study
papers published in medical education, most articles presented as
‘case studies’ were not in fact CSR as we defined it (citing CSR meth-
ods and following an explicit CSR methodology). Most papers used
‘case study’ as a lay term rather than to indicate the use of a specific
methodology. This included case reports, ‘n = 1’ case studies and
single-­site studies using a gamut of methods from randomised con-
trolled trials, survey research and qualitative interviews. Moreover,
we struggled to find more than a handful of articulations of case
study inquiry that were more than a ‘we did this’ account that re-
flected Glassick, Huber and Maeroff's19 criteria for scholarship and
reflective critique as recommended by case study methodologists
(see Table 2). Rather, the case study, as currently conceptualised in
health professions education research and even when conforming
to broad CSR principles, typically provides a prescriptive and formu-
laic ‘order’, giving guidance that fits well with a scientific worldview:
if you have three methods (observations, interviews and artefacts)
and one place, you have got yourself a case. The dominance of this
reductionist execution or conceptualisation of CSR in the health pro-
fessions education literature has been limiting in not only in terms of
how we conceptualise and approach the case, but also in terms of
the richness of the insights garnered through CSR.
3 | W H AT D O W E M E A N BY C A S E S T U DY
R E S E A RC H?
Case studies can be considered in-­depth, descriptive accounts of
‘unique, temporally circumscribed reality[ies]’ (p. 12), which draw on
‘middle-­range theory’, theory that applies to certain contexts (and
is common to those contexts) but makes no claims beyond them.12
Case study research has a long and rich multidisciplinary his-
tory,16 and, to that end, should be understood as a group of meth-
odologies that set out how inquiry should be designed, conducted
and reported. The dominant CSR methodologists, Yin, Stake and
Merriam, 20-­22 have all presented subtly different definitions of and
different approaches to CSR 23 (see Table 1). Common to all these
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CLELAND Et AL. | 1133

constructivist in her perspective. Other case study methodologists

BOX 1 Results of a PubMed search on ‘case study’ have taken their own, subtly different views. For example, those op-

AND ‘medical education’ erating from socio-­material perspectives have conceptualised the
case as an assemblage of social and material elements. 25
High conformance to case study research (CSR)
The advantage of this variety of stances is that case study re-
All of the high-­
conformance papers (n = 10) explicitly
search is ‘not assigned to a fixed ontological, epistemological or
grounded their work in CSR methodologies. The two most
methodological position’26 (p. 447). This accommodation means CSR
common methodologists cited were Stake (50% of the pa-
is versatile and can be tailored according to the research problem (eg
pers) and Yin (44%). Although both are used as key authori-
Ref.16; see later for further discussion). Moreover, researchers can
ties on CSR, there are key differences between them as
select and configure a case study methodology to reflect their own
discussed in Tables 3 and 4. However, the way that CSR
ontological and epistemological positions. The only caveat is that
was articulated in the papers nominally aligning to one or
they must clearly describe the alignment of chosen methods with
other school of thought did not reflect the differing philos-
their philosophical assumptions and their chosen approach. What is
ophies of CSR thought or consider their implications in any
critical is consistency and alignment in terms of perspective, plan-
depth. There were also 14 other CSR sources cited35,37 and
ning, data collection and analysis, 27 and evaluation. There are differ-
eight other relatively methodological sources.30,32,65 As for
ent ways of ensuring rigour and quality in case studies, depending
the other indicators: 14 (87.5%) of the high-­conforming pa-
on the researcher's stance. For example, interpretative case studies
pers used multiple sources of data (the other two only used
should not be justified by criteria derived from positivism as they are
interviews, but these were from multiple sources and per-
based on a different ontology and epistemology. 28
spectives), the type of case study was explicitly stated in
We suggest that quality in reporting CSR should include explicit
10 out of 16 papers (see Table 4), and a justification for the
attention to one's stance, and make clear the proposed alignment of
type of case study was provided in seven of the 16 papers.
epistemology, design, data collection, analysis and validation. For ex-
Medium conformance to case study research
ample, the nature of the case study research carried out by Cleland
Papers in this category (n = 12) either self-­identified as
et al29 was reported as their ‘epistemological stance’ with a broad
CSR but had major omissions or flaws, or they had many
alignment with Yin's perspective exemplified by their focus on ‘an
characteristics of CSR but did not self-­identify as such.
extreme case with a clear research plan and protocols, addressed
Of these, six (50%) explicitly cited a CSR methodological
construct validity by checking data credibility and used a theoretical
position (most commonly Yin), seven of 12 used multiple
framework to summarise the findings and to aid analytical (concep-
sources of evidence, two were explicitly self-­identified as
tual) generalisability’ (p.11).
CSR and described the type of case study approach used,
whereas 10 implied it, and five of seven provided some
form of justification for a case study approach.
4 | TH E BA S I C TE N E T S O F C A S E S T U DY
Low to no conformance to case study research
R E S E A RC H
Of the 132 papers in this category, 113 (85%) were purely
descriptive (for instance of a programme, context or inno-
vation). Of the rest, 11 (8%) identified as case study but
You know my methods. Apply them.
actually employed a very different methodology (such as
Arthur Conan Doyle30
RCT, evaluation, statistical, opinion, various qualitative).
Interestingly, eight (6%) described the use of case study as
Although this is not a ‘how to’ guide to case study research, it is
educational processes or artefacts (PBL, etc).
useful to set out some of the basic tenets of CSR before going on
to consider the logics and challenges of CSR. According to Yin, 22 a
case study design should be considered when the focus of the study
definitions is that a case is an in-­depth investigation of an organi- is to answer ‘how’ and ‘why’ questions; when you cannot manipu-
sation, an individual, a context or a phenomenon, single or multiple, late the behaviour of those involved in the study; when you want to
set in a real-­life context, bound by time and space, which aims to cover contextual conditions because you believe they are relevant
develop a deep comprehension of how the object of the research to the phenomenon under study; or when the boundaries are not
relates to its context. 24 clear between the phenomenon and context. These and other basic
Yin, Stake and Merriam20-­22 have each expressed their own elements of CSR are presented in Table 2.
epistemic positions (worldviews), which have impacted their per- The first step in CSR is defining the case, which is ‘in effect, your
spectives on case study methodology and the approaches they have unit of analysis’22 (p. 25). For example, in the context of developing
recommended. Yin demonstrated post-­positivist leanings towards clinical decision-­making skills, a case might focus on the experiences
discovery and structure, and Stake's position has been more one of of a specific group of learners. Another might explore how a specific
constructivism or interpretivism, whereas Merriam has been soundly programme approaches teaching and mentoring its learners. A third
 13652923, 2021, 10, Downloaded from https://asmepublications.onlinelibrary.wiley.com/doi/10.1111/medu.14544 by Loughborough Universitaet, Wiley Online Library on [17/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1134 | CLELAND Et AL.

TA B L E 1 Main case study

Methodologist Definition Epistemology
methodologists, their definitions of a case
Yin (2003) Case is ‘a contemporary phenomenon within Post-­positivism realism and epistemic stance
its real-­life context, especially when the
boundaries between a phenomenon and
context are not clear and the researcher
has little control over the phenomenon and
context’ (p. 13).
Stake (1995) Case is ‘a specific, a complex, functioning Constructivism and
thing’, more specifically ‘an integrated system’ interpretivism
which ‘has a boundary and working parts’
and purposive (in social sciences and human
services) (p. 2). (p.xi)
Merriam (2009) Case is ‘a thing, a single entity, a unit around Constructivism
which there are boundaries’ (p. 27) and it can
be a person, a program, a group, a specific
policy and so on.
‘… an in-­depth description and analysis of a
bounded system’ (p.40).

Note: Adapted from Ref.22

TA B L E 2 The basic elements of case study research (CSR)

Element Description Example

The case The case is based on an entity of interest or unit of analysis,
which might be a programme, individual, group, social situation,
organisation, event, phenomena or process
A bounded system The case is specifically bounded by time, space and activity. This
helps to manage contextual variables although the boundaries
between the case and its context may be blurred
Studied in context The case is studied in its real-­life setting or natural environment.
Contextual variables may include political, economic, social,
cultural, historical and/or organisational factors
In-­depth study The case affords intensive analysis of an issue that yields
to fieldwork and that may vary in depth and engagement
depending on the philosophical orientation of the research,
purpose and methods. Given the subjective nature of
interpretation, reflexivity is an essential part of the research
process
Selecting the case The case should reflect the purpose and conditions of the study.
This may include people, settings, events, phenomena, social
processes.
This may involve single, within case and between or multiple
case sampling in order to capture ordinary, unique, varied, etc,
examplesa
Multiple sources of The case draws on multiple sources of evidence to be
evidencea comprehensive in depth and breadth of inquiry. This can
include multiple methods, data and/or analyses. Triangulation
a highly valued and often used logic of combining sources of
evidence.
A group of core surgical trainees (residents in their
first two years of specialty training)
General surgery department in a large tertiary hospital
in one country and medical education system over a
specified 6-­month period
Studied in the context of the particular programme,
department and hospital, as well as the wider health
care and medical education cultures in which they
work
Fieldwork over a period of six months capturing
different events and interactions over that extended
period of time. The relationships between the
researcher and the trainees should also be described.
Purpose—­to uncover the communications, activities,
contradictions and complexities of trainee practices
during handover from the perspective of the trainees
and those they interact with.
Fieldwork included observations, interviews (formal
and ‘in situ’), reflexive diary entries, and document
analysis of trainee reports and evaluations.

Note: Adapted from Ref.16

a
See Table 3 for more detail on sources of evidence, data collection, analysis and validation, and Table 4 for further discussion of different types of
case.

alternative might be to focus on comparing several (nested) cases common factor is that it would be impossible to gain a true picture of
of developing decision making in different specialties in the same the phenomenon under study, decision making, without studying it
school. What is examined is subtly different in each approach, but the within the real-­life setting or context (fieldwork).

CLELAND Et AL.
Ensuring that the case is manageable as the subject of inquiry re-
quires boundaries. Different authors propose different ways to bind
a case, including time and place31; (b) time and activity32; and (c) by
definition and context.33 For example, using Cleland et al’s study of
service training tensions in general surgery as a running example, 29
the site was one surgical department in one hospital. The context
was described clearly, not just in respect of the health care and train-
ing systems, but also why that department was of particular interest
at that point in time.
Being clear about the case boundaries (time, place, subject, con-
text) will determine the breadth and depth of the study. Inherently,
however, CSR is in-­depth research, considering an issue intensively
and critically using multiple sources of evidence (eg interviews, ob-
servations, document analysis). Although the precise methods of
data collection and analysis adopted will depend on the method-
ological position, triangulation is highly valued and commonly em-
ployed in respect to data validation (see Table 3).
5 | TH E LO G I C S O F C A S E S T U DY
R E S E A RC H
The logics of a methodology are reflected in its ‘continuity with [and]
34
difference from’ other methodologies. Collectively, these logics
reflect a structural theory of a methodology.35 We used Silverman's
approach to methodological logics in considering CSR’s structures,
its purposes, and its assumptions and symbols.34
5.1 | Structures
Different authors use different terms to describe their approaches
to case study research (see Table 4; adapted from Baxter and Jack,
36
2008 ). The differences in essence are whether the case itself is the
focus of interest, or whether the case develops our understanding
of a wider phenomenon. This is sometimes described as outcomes,
which are ‘internalised’ to the particular case, or the outcomes are
intended to tell the researcher something beyond the case. The
latter is achieved, either by facilitating theory development or by
enlightening the researcher's understanding of a broader phenom-
enon. This differentiation is important to generalisability (see later
for further discussion).
Single-­case and multiple-­case studies can further be classified
as holistic or embedded.37 In an embedded case study, the case is
split in multiple units of analysis, whereas a holistic case study has
one unit of analysis for each case. For example, a single holistic case
could be about a medical school and its response to a government
edit to widen participation to medicine by attracting and selecting
applicants from particular socio-­economic groups or more diverse
backgrounds. However, if, within the medical school, several dif-
ferent approaches to doing this were studied (eg an outreach initia-
tive, a pre-­medical year, near-­peer mentoring), then these sub-­cases
would be embedded within the overall case.
13652923, 2021, 10, Downloaded from https://asmepublications.onlinelibrary.wiley.com/doi/10.1111/medu.14544 by Loughborough Universitaet, Wiley Online Library on [17/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 1135
5.2 | Purposes
The extent to which generalisability is sought in CSR will shape
the case sampling. Case selection may reflect extreme or deviant
cases, ‘maximum variation cases’, cases to support logical deduction,
or ‘paradigmatic cases’ that establish the domain of inquiry38 (see
Table 4). For example, Cleland et al (2018) ‘selected an extreme case
in order to maximise the richness of information on the tension be-
tween service and training and the consequences of this tension’29
(p. 4).
5.3 | Assumptions and symbols
Eisenhardt39 describes the process of theory building from case
studies in a systematic way comparable to hypothesis testing.
Merriam and Yin20,22,40,41 are less positivist in their respective
stances, proposing instead that starting with some theoretical
propositions is helpful in CSR planning. More recently, Rule 42
suggested that theory is related to case study research in several
ways: the theory of, for and from the case, and the interaction
between theory and case.
Rule 42 suggests that the theory of the case originates from the-
ory and literature and helps the researcher to conceptualise the
bounded nature of the case, what it constitutes and what is included
and excluded. In respect to theory for the case, they propose that
explanatory and instrumental CSR often begins with ‘a particular
theory and seek to apply it to one or more cases and sometimes in
different contexts’ (p. 5). In contrast, theory from the case is reflec-
tive of an inductive approach in which it is generated from the case.
For example, exploratory, intrinsic and grounded theory qualitative
case studies are not intended to test or apply existing theory, but
to generate theory (Ref.42; see also Table 4). Finally, their dialogical
model between theory and case acknowledges that ‘theory influ-
ences research in all its aspects… [from the research purpose, use of
literature, selection of the case, etc] On the other hand, research in
all these phases can have implications for developing and modifying
or revising theory’42 (p. 7).
Although the focus of this paper is not on comparing qualita-
tive methods, the relationship between case study research and
other qualitative methodologies is discussed briefly later in this
paper.
6 | TA K I N G PA I N S : C H A LLE N G E S A N D
K E Y CO N S I D E R ATI O N S I N C A S E S T U DY
R E S E A RC H
They say that genius is an infinite capacity for taking
pains’, he remarked with a smile. ‘It's a very bad defi-
nition, but it does apply to detective work.
Arthur Conan Doyle 43
 | 1136

TA B L E 3 Case study design, data collection, analysis and validation approaches, presented by methodologist

Methodologist Case study designs Data collection Data analysis Data validation

Yin (1994, 2003, 2014) Five core components: Multiple sources of evidence, including Data analysis ‘consists of examining, Emphasis on validity and reliability
questions, propositions, documents, interviews, direct observations, categorizing, tabulating, testing, or (eg construct validity [through the
unit(s) of analysis, participant observations and physical artefacts. otherwise recombining both quantitative triangulation of multiple sources of
linking the data to Quantitative and/or qualitative evidentiary and qualitative evidence to address the evidence, chains of evidence and member
the propositions and sources (and thus the potential for mixed-­ initial propositions of a study’ (p. 109). checking] and reliability [eg through use of
criteria for interpreting methods case studies) study protocols]).
the findings.
Four types of design;
single holistic design,
single embedded
design, multiple holistic
design and multiple
embedded design.
Stake (1995) Flexible, iterative design Qualitative data sources only—­observation, Simultaneous, iterative data collection and Emphasis on triangulation—­data source
where the research interview and document review. analysis. triangulation, investigator triangulation,
questions structure The researcher's interpretive role is essential in Data analysis is ‘a matter of giving meaning theory triangulation and methodological
data collection. the process. to first impressions as well as to final triangulation.
Assumes that the compilations’ (p. 71).
course of the study
cannot be charted in
advance.
Merriam (2009) Literature review is an Both quantitative and qualitative methods Simultaneous, iterative data collection and Emphasis on validity and reliability.
essential first phase acceptable, but more the latter aimed analysis. Internal validity via triangulation, member
contributing to theory at generating inductive reasoning and Data analysis ‘involves consolidating, checks, etc External validity via thick
development, research interpretation rather than testing. Observation, reducing, and interpreting what people description, typicality or modal categories,
questions, research interview and document review as data have said and what the researcher has and multi-­site designs.
design and selecting gathering tools. seen and read –­it is the process of making Reliability via explanation of investigator's
the sample. meaning’ (p.178) position with regard to the study,
triangulation and an audit trail.

Note: Adapted from Ref.22

CLELAND Et AL.

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CLELAND Et AL. | 1137

TA B L E 4 Definitions of different types of case studies

Methodologist Type Description

Yin (1994, 2003, 2014)
Stake (1995)
Merriam (1989, 2009)
Illustrative or descriptive To describe an intervention or phenomenon and the real-­life context in
which it occurred (Yin, 2003), that is to explain a particular situation,
phenomenon or event, describe the problem. Put simply, what
happened, involving whom and where?
Exploratory To explore those situations in which the intervention being evaluated
has no clear, single set of outcomes. Put simply, how or why did
something happen?
Explanatory To answer a question that seek to explain the presumed causal links
in real-­life situations or interventions that are too complex for the
survey or experimental strategies. Again, how or why did something
happen?
Single-­vs multiple-­c ase studies A single-­c ase study design can be used for studying an extreme or
unique case; a critical case—­that is one that can test a particular
theory; a representative case—­a case that is representative, or
typical, of a particular situation; a revelatory case or a longitudinal
case (Yin, 2009). A multiple case study enables the researcher to
explore differences within and between cases. The goal is to replicate
findings across cases, or predict contrasting results based on a theory.
Intrinsic Where the case itself is of interest, not because the case represents
other cases or because it illustrates a particular trait or problem.
Instrumental To provide insight into an issue or helps to refine a theory. The case
is of secondary interest; it plays a supportive role, facilitating our
understanding of something else.
Collective Similar to multiple-­c ase studies
Descriptive The end product is a rich, thick description of the phenomenon under
study.
Particularistic Focus on a particular situation, event, phenomena or programme.
The case itself is important for what it reveals and what it might
represent.
Heuristic Illuminates understanding of the phenomenon under study. Can
bring about the discovery of new meaning or confirm what is known
already.

As a case study researcher, it is important to articulate not just
the problem and research question, but also the role of literature
and theory, before considering the type of case study design. In
short, it is important to enter into inquiry from an informed posi-
43
tion. Despite its affordances, or, perhaps because of them, case
study research (CSR) is not without challenges. We have identified
eight important elements that require consideration in advance of
any given CSR project.
1. Challenges of emic and etic perspectives in case study research:
CSR, with its focus on thickness and context, requires in-­depth
documentation, interpretation and analysis. Although some argue
that being an insider allows for a nuanced understanding, others
note that being too firmly embedded within the case results
in blind spots. Whether approached from an emic (insider) or
etic (outsider) perspective, there are important considerations
associated with each.
a. Emic (from within)—­The benefits of studying your own context
or case include a built-­in familiarity with the scenario under
study, allowing for a good sense of ‘how things work’. This,
in turn, may increase the feasibility of the case, leading to
increased access to potential data sources, and perhaps im-
proved ‘buy-­in’ or participation. Along with this comes the
benefit of precision in cultural interpretation, by virtue of
being a member of the culture under study. Despite these
affordances, the challenges of an emic perspective are note-
worthy. These challenges relate to being so deeply embedded
in the case at hand, that it is difficult to notice, and call into
question, taken for granted ideas or approaches or practices.
The issue of multiple biases also comes into play, as it is diffi-
cult, perhaps impossible, to view the case under study with
truly ‘fresh eyes’. Finally, conflicts of interests are sure to be
increased for an insider, and these must be considered and ad-
dressed via reflexivity (see later).
b. Etic (from without)—­T he positive elements associated with
being external to the case under study relate to objectiv-
ity. Because of a lack of expectation, history and relation-
ships, it is more likely that an investigator can approach the
case at hand from a somewhat neutral perspective, free
from conflicts of interest. However, not participating in

1138 | CLELAND Et AL.
the cultural context may lead to an increased likelihood of
misinterpretation and even stereotyping. Attempting to ac-
cess data sources as an outsider—­w hether these sources are
people, documents, events or other—­may be more challeng-
ing. Finally, and by contrast with the nuanced perspective
available from emic perspectives, approaching a case from
an etic point to view means that it is entirely possible that
there will be oversights, as you cannot know what you do
not know.
c. There are ways of balancing the emic and the etic. For exam-
ple, in Cleland et al’s case study of the socio-­cultural com-
plexity of a surgical training ‘boot camp’, data were collected
by the first author (an outsider) and two surgical residents.44
Cleland's ‘etic’ perspective allowed her to see things differ-
ently, whereas the resident's ‘emic’ status (as more senior
trainees and junior faculty members) enabled them to ask dif-
ferent questions. The combined data gave a fuller picture than
would have been possible with only one perspective.
2. Challenges of ethical complexities of case study research: Relating to
the search for thick description and richness of interpretation, the
goal of CSR is to deeply understand the scenario at hand. This
may lead to the identification and/or disclosure of information
that is uncomfortable, problematic, even unsafe. In some cases,
the researcher may find themselves having to make difficult de-
cisions about what can and/or should be disclosed through the
written account, deciding whether to take a ‘whistleblowing’
stance. These scenarios are particularly pronounced in the con-
text of health professions education, where those engaged in CSR
may find themselves privy to issues of patient safety, learner mis-
treatment, problematic research practices and other such things.
Depending on the institutional culture of the case under study, a
CSR investigator will find themselves having to decide how much
can and should be disclosed. Although CSR in the realm of health
professions education is governed by the Declaration of Helsinki
(2013), the real-­world challenges of managing risk and weighing
ethical responsibilities in CSR are pronounced, particularly when
the case under investigation is, in fact, your workplace. For ex-
ample, MacLeod and colleagues learned about the ways in which
videoconferencing technologies in a distributed medical educa-
tion programme sometimes unknowingly allowed access to con-
versations, situations and information that were intended to be
45
private.
3. Challenges of disentangling method and methodology in case study
research: Our literature review demonstrated that CSR has been
frequently conceptualised as a series of distinct steps or meth-
ods: (a) observations; (b) interviews; and (c) documents. This sub-
sumption of method over methodology has led, in recent years, to
CSR being used only to a fraction of its potential. We appreci-
ate efforts from authors who have made every effort to clarify
CSR, making it make accessible to many. We also recognise that
there is appeal in a step-­by-­step approach that separates a po-
tentially overwhelming project into manageable steps. We do,
however, question whether this ‘checklist’ approach to CSR has
13652923, 2021, 10, Downloaded from https://asmepublications.onlinelibrary.wiley.com/doi/10.1111/medu.14544 by Loughborough Universitaet, Wiley Online Library on [17/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
subverted its purpose and methodological commitment to depth
and context. We encourage those engaging in CSR to use multiple
methods; however, those methods should be carefully selected
and engaged in in the interest of building a thorough description
and nuanced interpretation. For example, in a study of resident
mobile technology use, MacLeod and colleagues used traditional
CSR method of interviews; however, in order to gain a depth of
understanding, they also drew on individual residents’ logging of
technology use, and reflexive writing by participants.46
4. Challenge of description versus interpretation in case study research:
Much of the literature we reviewed used CSR from a purely de-
scriptive stance. Missing from these accounts were analyses and
interpretations of the data collected. Certainly, good quality CSR
is committed to providing enough descriptive detail so that a
reader can understand the context in which these data were col-
29
lected (see, for example, ). However, it should not stop there.
We believe that CSR is most effectual when it is elevated beyond
the descriptive, into the realm of analysis and interpretation. The
authors must make an effort to explain, and critically interpret,
the insights garnered through the study, ideally using appropriate
theoretical lens to support conceptual generalisability.44
5. Challenges of delineating case study research from other qualitative
approaches: Research in the field of HPE has been steadily im-
proving in quality. The standard is such that those who engage in
research are expected to present work that is theoretically based,
rigorous in execution and meaningful. Along with this expecta-
tion comes a proliferation of studies that are methodologically
sophisticated. For example, in recent years, there has been an
increase in HPE studies that identify as ‘ethnography’. Given the
fact that ethnographic studies tend to use the same methods as
CSR, and both approaches share a commitment to rigorous, in-­
depth investigation, it can be challenging to know exactly when a
piece of research should be identified as CSR, and when it should
be identified as ethnography. Although there is certainly overlap,
we encourage researchers to be clear on the boundaries and dif-
ferences between ethnography and case study, which we believe
ultimately translate into purpose. CSR is bound in time, place and
culture and should be theory generating. Ethnographic studies
can be considered a specialised type of case study, which is ulti-
mately focused on cultural practices47,48 or long duration studies
with large amounts of participant-­observer data.49
There are also broad intersections between CSR and grounded
theory, and CSR and realist enquiry. Developing an in-­depth descrip-
tion and analysis of a case, or multiple cases, may lead to building a
‘grounded theory’39,50 and certain types of case study are partic-
ularly suitable for generating theory (Ref.42; see earlier). Moreover,
although CSR is a ‘what’ methodology, grounded theory concen-
trates more on the ‘how’ processes of inquiry. It is not unusual there-
fore for case study researchers to borrow analytical techniques from
GT such as coding, memoing and the use of constant comparative
method.

CLELAND Et AL.
Realist evaluation, on the other hand, seeks to explain how and
under what circumstances programmes, interventions or innova-
tions ‘work’ in real-­world contexts, such as particular health care
51
or education settings. Realism and CSR therefore share a focus
on context and on explanatory accounts that link context to top-
ics of interest. Combinations of the two approaches have been
explored in other domains and may well prove useful in our own
field. 52
6. Challenges of generalisability in case study research: The issue of
generalisability in CSR is an important consideration. Stake53
called the level of generalisation that can be expected from a
single-­
case study ‘naturalistic generalisation’, meaning a thick,
situated description that resonates with the readers’ tacit
knowledge, allowing them to make connections and associa-
tions for themselves. On the other hand, Bassey claimed that
it is possible for a researcher to generalise, even from single
54
cases—­
albeit only in fuzzy terms. He argued for employing
a ‘best estimate of trustworthiness’ approach, which he de-
fines as ‘[…] a professional judgement, based on experience, in
the absence of [definitive] research data’.55 Yin reaffirmed this
principle, noting that insights from CSR are ‘generalizable to
theoretical propositions and not to populations or universes’.41
7. Challenges of quality in case study research: The focus on depth and
rich description in CSR means that there is considerable variabil-
ity in how CSR is conducted and reported. Understanding what
makes a project of high quality can be challenging to discern. In
general, the principles for determining rigour in qualitative re-
search apply.56,57 In particular, CSR calls for focused attention to
the issue of triangulation, and of trustworthiness. Although there
are multiple strategies available for assessing the quality of CSR,
we direct readers to Stake's checklist as an approach that mirrors
the philosophical principles underpinning CSR.21
8. Challenges of reporting and case study research: The penultimate
challenge of CSR is a practical one. Health professions educa-
tion journals tend to mirror science journals in terms of report-
ing expectations. This means authors are working with restrictive
word counts, expectations of paper presentation (eg introduc-
tion, methods, results and discussion [IMRAD]) and limitations on
number of tables, figures and illustrations. Given the focus on rich
description, context and depth, reporting CSR in sufficient detail
15,58
can be challenging given these confines. The joy and sense
marking of the case study report are in its narrative, but this is
a tough sell in a culture of structure, hypotheses and evidence.
However, our experience is that a number of journals in the field
have become more open to longer papers and more diverse for-
mats, indicating a positive direction of travel.
Although not a challenge as such, reflexivity also plays a critical
role in ensuring the rigour of case study research (see Table 3).
Given the potential for observer partiality and bias, fieldwork de-
mands a high degree of reflexivity. 59 This in part reflected in some
of the issues we described in our consideration or etic and emic
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| 1139
perspectives. However, reflexivity is has a broader scope. Being
reflexive means actively acknowledging that the researchers are to
some extent part of the social world they study, 60 that their ‘social
background, location and assumptions affect their research prac-
tice’61 and that this will inevitably influence the co-­construction
of experience and meaning. 62 Thus, qualitative researchers must
acknowledge their positionality, any changes engendered by the
research process, and how these changes may have affected the
process or research. Reflexivity can therefore help in mitigating
bias, interrogating researcher positionality and disclosing these
aspects of the study in its write-­up as part of the case study's
‘thick description’.
To this end and taking a ‘medium as message’ perspective, we
here consider our own stance(s) in relation to CSR.63 Our experience
as researchers and ‘social positions’ within HPE research, as well as
other factors such as our gender, life stage and social backgrounds,
no doubt influence our views of CSR and its utility in health profes-
sions education.64 However, there is more to reflexivity than expla-
nation: reflexivity must also be interpretative to make CSR claims
more transparent.65 ‘Interpretive reflexivity claims to reveal cultural
miscues and convergences’ 63
—­in other words, shows others how
you put the clues together and identified the patterns in CSR.
7 | WHEN AND WHY DO WE NEED CASE
S T U DY R E S E A RC H I N M E D I C A L E D U C ATI O N
You see, but you do not observe
(Arthur Conan Doyle,66)
Given that the limits to generalisability are a perpetual challenge
in our world, why add to this (potentially) with case study research?66
As we have stated before, CSR is not just a matter of ‘we did this’ or
‘me too’ studies—­C SR has an essential role to play in our field. The
strength of CSR is capturing context rather than controlling for it.
Researchers can engage in case study research when context
modifies or confounds an ideal. 67 For instance, why did two im-
plementations of competency-­b ased medical education (CBME)
lead to such different outcomes, or how were CBME principles
adapted to fit a particular programme context? CSR can also be
used to explore how context modifies or shapes practice over
time. For instance, how and why did a particular programme
change over time, and what might explain unexpected or unan-
ticipated changes? Why does problem-­b ased learning (PBL) in one
setting look different from PBL in another place? Sometimes CSR
can be used to present a new thing as an exemplar. These might
be pilots of innovations, new programmes or training contexts (eg
the early studies of programmatic assessment implementations).
Sometimes CSR can be used to report on extreme events or sen-
tinel events, such as responses to disruption (such as the 2020-­1
COVID-­19 pandemic) or institutional crises (such as major profes-
sionalism breaches or mass casualty incidents). In summary, CSR

1140 | CLELAND Et AL.
has particular utility when reporting on adversity, complexity, pol-
itics, compromises, misalignments, inconsistencies, failure, rapid
and unexpected change, and decision making.
In terms of those who consume research, there are two essen-
tial different potential uses of CSR. The first is providing ‘how to’
and ‘how not to’ guides. These could include cases describing how
to implement something new, how something had to be adapted in
order to implement or fix it, or how something was managed and
sustained over time. The case may be an exemplar for other to follow
(the fictional ‘best practice’), an illustration of how things might play
out (effectiveness), or a forensic worst-­case scenario as a warning
to others to avoid. The second is in documenting something unusual
and yet significant, in order to inform others of what might happen
or what might be done in extremis. These can include innovations,
sentinel events and unexpected outcomes. These are what Flyvbjerg
has called ‘Black Swan’ cases38; there may only be one incident and
it may be idiosyncratic, but it is still of key interest to the field as a
whole.
8 | CO N C LU S I O N
Our use of Holmesian aphorisms and quotes reflects a long relation-
ship between the fictional great detective and medical education.68,69
Like Sherlock Holmes’ detective work, in case study research, we must
attune to, and account for, detail and do so using particular methods
of enquiry. The time has come to accept that context is not a pas-
sive entity to be ignored or glossed over in health professions edu-
cation research. Instead, context is a mechanism, which needs to be
understood to allow those in the area to consider similarities and dif-
ferences, understand complex issues in real-­world settings and decide
what knowledge is pertinent to their own space and place. Regehr6
stated that ‘there may be no generalisable solutions to our collective
education problems’ (p. 31). We agree, but rigorous case study re-
search provides structures and forensic criticality applicable to a wide
range of why, what and how questions, helping those in other contexts
consider if findings are applicable to them, and opening up new areas
of understanding and inquiry. Embracing case study research has the
potential to help us mature as a discipline and develop the confidence
to embrace interpretive processes and resources.
E TH I C A L S TA N DA R DS
The work reported in this paper did not involve primary data collec-
tion and so ethical approval was not required.
AC K N OW L E D G E M E N T S
We acknowledge those discussions and papers which sparked the
idea for writing this paper.
C O N FL I C T O F I N T E R E S T
The authors declare that they have no competing interests.
13652923, 2021, 10, Downloaded from https://asmepublications.onlinelibrary.wiley.com/doi/10.1111/medu.14544 by Loughborough Universitaet, Wiley Online Library on [17/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
AU T H O R S ’ C O N T R I B U T I O N S
The idea for this paper came from JC and evolved through discus-
sions involving all three authors. JC led on drafting the paper, with
substantial inputs from AM and RHE. All authors reviewed the final
draft and approved the paper.
ORCID
Jennifer Cleland https://orcid.org/0000-0003-1433-9323
Anna MacLeod https://orcid.org/0000-0002-0939-7767
Rachel Helen Ellaway https://orcid.org/0000-0002-3759-6624
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How to cite this article: Cleland J, MacLeod A, Ellaway RH.
The curious case of case study research. Med Educ.
2021;55(10):1131–1141. https://doi.org/10.1111/medu.14544