Invited Commentary: Philosophy of Science
Postmodernism and Medical Education
Rachel H. Ellaway, PhD
Abstract
Postmodernism emerged in the mid-20th
century in the context of postwar Europe
where philosophers and artists were
taking increasingly skeptical and critical
positions on modernist thinking and
practice. Postmodernism is not a single
organized and coherent perspective; it
is a collection of related philosophies,
techniques, models, and perspectives that
take a skeptical and critical perspective
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on thinking and practice. Ontologically,
postmodernism is predicated on the
belief that power and its underlying
meanings, manipulations, and ideologies
shape our ability to act in and think
Editor’s Note: This article is part of a collection of
Invited Commentaries exploring the Philosophy of
Science.
Postmodernism is perhaps one of
the more misunderstood concepts in
contemporary philosophy of science,
not least because of its many other
applications, including postmodern
architecture (e.g., Frank Gehry),
postmodern music (e.g., Steve Reich),
and postmodern literature (e.g., Kurt
Vonnegut). This Invited Commentary
describes postmodernism in the context of
the philosophy of science, how it developed
(and stumbled) as an intellectual tradition,
what its core tenets and practices are,
what its strengths and weaknesses are, and
its application to and intersections with
medical education and scholarship.
Historical Basis of Postmodernism
Before we can talk about postmodernism,
we need to understand what is meant
Please see the end of this article for information
about the author.
Correspondence should be addressed to Rachel H.
Ellaway, Community Health Sciences, Cumming
School of Medicine, University of Calgary, 3E19, TRW
Bldg., 3280 Hospital Drive NW, Calgary, Alberta,
T2N 4Z6 Canada; telephone: (403) 220-6076; email:
rachel.ellaway@ucalgary.ca.
Acad Med. 2020;95:856–859.
First published online December 17, 2019
doi: 10.1097/ACM.0000000000003136
Copyright © 2019 by the Association of American
Medical Colleges
856
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
about the world. Epistemologically,
postmodernism seeks to explore and
understand underlying meanings,
structures, and intents in the world and
to consider alternative explanations and
interpretations for them. Axiologically,
postmodernism can be used to analyze
value in the context of inequity,
oppression, and hegemony within social
systems and structures. Due to the lack of
coherence within postmodernist thought,
there is no one definitive methodological
stance. However, there are many
postmodernism-informed methodological
stances, which vary both in terms of what
by modernism. Modernism was a
broad intellectual, creative, and social
trend that developed in the mid-
19th century. Modernists embraced
rationalism and science, while rejecting
romanticist and sentimental worldviews.
The concept of progress, the idea
that science, technology, and social
innovations can and should lead to
intrinsic improvements in the human
condition, was a core organizing concept
in modernist thought. These tenets
are reflected in the work of modernist
thinkers such as Charles Darwin, Karl
Marx, Sigmund Freud, and Karl Jung.
Modernism dominated Western thinking
throughout the first half of the 20th
century and had significant interactions
with the esthetics of the time, such as art
deco and jazz, and emerging technologies,
such as mass-produced automobiles, air
travel, and cinema. However, modernism
was also implicated in the horrors
of 2 World Wars, the fall of Western
empires, and the threat of nuclear and
environmental obliteration.
Postmodernism emerged in the mid-
20th century in the context of post-
war Europe as many philosophers and
artists took increasingly skeptical and
critical positions relative to modernist
thinking and practice. Like modernism,
postmodernism was not a single
organized and coherent undertaking—it
emerged out of many loosely connected
areas of activity with a common shared
is examined and how it is examined. As
an approach within medical education,
postmodernist perspectives can help
to expose and analyze the political
and ideological positioning of much
of what is done, particularly in the
interests of addressing systemic problems
of justice and equity. It is somewhat
paradoxical that postmodernism allows
researchers to challenge the nature and
expression of truth, and it allows them
to problematize and deconstruct the
ideologies and agendas of those who
are themselves challenging the nature
and expression of truth.
principle of skepticism toward the broad,
unchallenged modernist assumptions
that shaped the modern world (e.g.,
the intrinsic desirability, systematicity,
and optimism of progress, and the
central role of technology in bringing it
about). Lyotard called these aggregate
assumptions the grand narratives of
modernism.1 Targets for postmodern
critique included the intrinsic rightness
of the ideologically opposed systems of
capitalism and communism, the manifest
destinies of Western empires and
religions, and the intrinsic beneficence of
science and technology. Other targets for
postmodern critique have included social
systems of health, education, justice,
gender, and race,2–5 all of which affect
medical education.6,7
Philosophical Foundations of
Postmodernism
Ontology: The nature of reality
Rather than being a coherent school of
thought or practice, postmodernism
is a collection of related philosophies,
techniques, models, and perspectives
that share a broadly skeptical and critical
perspective on thinking and practice.
Nevertheless, we can generalize (and in so
doing, we proclaim paradoxically a grand
narrative) to say that postmodernists
see the world as fragmented and
unresolvable to a single universal
reality, an idea that had its roots in the
work of Friedrich Nietzsche despite his
Academic Medicine, Vol. 95, No. 6 / June 2020

associations with modernist thought.
An ontology of postmodernism is
therefore predicated on the belief that
power and its underlying meanings,
manipulations, and ideologies shape
our ability to act in and think about the
world. Postmodernists challenge these
grand narratives, particularly where they
erase and manipulate the heterogeneity
of individuals, cultures, organizations,
and societies and impose categories and
identities on them as if they were part of
the natural order of the universe.
Epistemology: The nature of knowledge
Epistemologically, postmodernism seeks
to explore and understand underlying
shared meanings (that are often multiple,
contrasting, and even conflicting), social
structures, and intents in the world and
to consider alternative explanations
and interpretations for them. Given
then that postmodernism is predicated
on rejecting any sense of universal
truth, it explores the social and cultural
construction of truth—in the shape
of human systems and relations, the
ways in which language reflects power
and ideology, or the ways in which
social realities are or can be shaped and
manipulated. Indeed, language itself can
be considered problematic, particularly
when it is positioned as representing
objective or intrinsically superior truths.
Postmodernism is an epistemology
of interpretation, of discovering and
exposing underlying meanings and
intents, of deconstructing and critiquing
erstwhile absolute and unassailable
constructs and beliefs, and of considering
alternative ways of understanding
and explaining these phenomena. As
an example, Lingard explored issues
associated with “god terms” in medical
education (idealized superordinate
concepts that cannot be gainsaid), noting
that scholars should make these terms
“unfamiliar, excavating the motivations
that underpin them, and opening space
for an adaptive and flexible discourse.”8
Axiology: The study of values and how
they influence the research process
Axiologically, postmodernism has
been used in identifying and analyzing
expressions of inequity, oppression, and
hegemony (actual and suspected) within
social systems and structures. However,
it is important to note that there is
no intrinsically normative trope in
postmodernism despite its use in support
Academic Medicine, Vol. 95, No. 6 / June 2020
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of protest and socially progressive
agendas. Although postmodernists
observe that social fragmentation and
grand narratives exist and that they are
contradictory and problematic, they do
not necessarily assume a position on what
should be done about them. As Foucault
noted, “power is always already there …
one is never outside it.”9(p141)
Methodology: How to conduct scientific
research
Due to the lack of coherence within
postmodernist thought, there is no one
definitive postmodern methodological
stance. However, we can consider
different methodological stances and
identify what postmodernists look for
and how they look for it.
As an approach to inquiry,
postmodernism focuses on searching
out and analyzing grand narratives in
terms of their assumptions and structures
that are used to organize, rationalize,
legitimize, and control social systems.1
An example from medical education
could be a critique of professionalism as
an intrinsically desirable and uniform
construct. A postmodern reading of
professionalism might look for ways in
which it has been defined or advanced
to advantage or give authority to
certain individuals or groups at the
cost of others. A second postmodern
focus is on the creation, manipulation,
and destruction of subjects and
subjectivities.2,3 For example, medical
education requires its participants to take
on roles (and their associated legitimized
ways of being and acting) such as
teacher, learner, and mentor, while
downplaying their roles in other contexts,
such as their participation in ethnic or
faith communities. A third focus is on
expressions of power: exploring who is
expressing or experiencing expressions
of power, how are these expressions
articulated, and with what effects or
consequences? A fourth focus is on
intersectionalities: the intersections
and interactions between the different
dimensions of identity that define us and
the problems of assigning any absolute or
a priori meaning to them.10,11
Postmodernists may use different
approaches to inquiry. The first is to
consider phenomena in terms of their
relationships with the things around
them rather than in terms of any absolute
categories and structures. This involves
Invited Commentary: Philosophy of Science
closely considering the settings for
phenomena, and it focuses on the ways
in which phenomena have been shaped
by their settings, and in particular how
expressions of power have influenced these
relationships. Not only do postmodernists
examine contextual dependencies and
critically appraise any inherited, intrinsic,
or assumed qualities or characteristics
from them, but they also critique the
categories, symbols, and identities that
are imposed upon them.2,12 For instance,
we might consider the competence of
a medical trainee not as a quality of an
individual but as something that emerges
and changes from one moment to the next
according to the contexts within which it is
being expressed.13 We might also consider
how the construct of competence shapes
the social realities and practices of medical
education and how it benefits some at the
cost of others.
A second approach is deconstruction,
unpacking the components or aspects
of a phenomenon to look for variant
interpretations and meanings, with a
particular focus on contradictions.12
For instance, the hidden curriculum
in medical education (as defined by
Hafferty) embodies a deconstructionist
approach in that it reflects the
contradictions between the intended and
unintended messages learners receive.14
A third approach involves discourse
analysis, exploring the ontological
and epistemological assumptions in
communicative acts (typically in the
form of text, speech, and images).9
This may include seeking out instances
of significance, practice, identity,
relationships, politics, connections, and
sign systems within a body of text or some
other communicative act.15 For instance,
we might study medical school policy
documents for underlying assumptions
and the messages they send.16 It should
be noted that while these 3 approaches
can be considered as relatively distinct at
a theoretical level, in practice they tend to
be less distinct and more intertwined.
Practical Example
We can illustrate a postmodernist
approach in medical education using
the example case of Lee (see Box 1). A
postmodern reading of this case could
focus on a number of points. In terms
of grand narratives, the case reflects
medicine and medical education as
857
 Invited Commentary: Philosophy of Science

It is also worth noting that

Box 1 postmodernism and its practices are
Sample Casea themselves imbued with grand narratives.
Lee was a resident assigned to monitor a postop patient. The patient had a periodically low
While there is nothing in postmodernism
respiratory rate and lower-than-normal pulse and blood pressure. Narcan was ordered on an “as to say that its tenets cannot be applied to
needed” basis, to be given in doses of 0.2 mg intravenously. In checking the patient’s vitals, Lee itself—in other words, to problematize
decided it was time to administer an intravenous (IV) dose of Narcan. and critique the grand narratives of
postmodernism—it is notable that
Once Lee injected the vial of Narcan into the IV port, Lee noticed it was labeled “2 milligrams this has not been a substantial part of
per 1 milliliter (ml)”—the entire vial should not have been injected. Feeling panicky, Lee reported
the mistake to an attending and rushed back to the patient’s side to monitor the vital signs. postmodernist contributions within the
Lee was surprised to find that the patient’s vitals had come up to normal rates, and the patient field to date. This is not solely a problem
was actually much more alert. When Lee reported this change to the attending surgeon and for postmodernism, however, since
anesthesiologist, they told Lee to continue to monitor the patient closely, remarking that it may recursive reflective practice is arguably
have been just what the patient needed.
lacking in many areas of contemporary
Lee felt hugely relieved, but was still overwhelmed and very upset. In most cases, giving 10
medical education science. Being mindful
times a normal dose of any medication could have led to extremely serious consequences, and and reflexive about the hidden agendas,
even death. Still, Lee managed to remain outwardly composed and took the time to complete biases, and other potentially confounding
an incident report. At the end of the day, when Lee finally sat down to rest, the incident played factors that can influence our work is a
over and over again. Lee did not sleep. necessary part of being a scientist in the
a
T his sample case is used throughout the Philosophy of Science Invited Commentaries to illustrate each research field of medical education. Indeed, this
paradigm.
critical reflexivity has been proposed
as an essential component of any social
primarily a technical undertaking: the with other philosophies of science, in science that seeks to claim some level of
unidentified patient is passive and treated particular with critical theory. Although objectivity.22
as a biological entity to which drugs are it predated postmodernism, critical
administered and through which the theory was substantially advanced In the context of medical education,
results are observed. There is no indication through postmodernism. There are Michel Foucault and Ivan Illich both
that the error was disclosed to the patient other overlaps, for instance, with social wrote about the problems of medicine
nor that there were any compassionate constructionism, and there is also some and education: Foucault in terms
or remedial steps taken to comfort the debate as to whether postmodernism of subjectivities and power,2 Illich
patient. Another postmodernist reading and poststructuralism are in fact distinct in terms of individual and system
might focus on the power relations philosophies.17 fallibility and the negative aspects of
between the trainee and his attendings and institutionalization.4,5 We can expand
the ways in which Lee’s obligations and However, one of postmodernism’s on this to consider both medicine and
identity as a trainee shape his actions and most notable features is the extent to medical education as sociocultural
reactions. For instance, Lee complied with which it has been criticized. Perhaps systems that are shaped and controlled
disclosure and incident reporting policies the most well-known example of this (rather than naturally emergent). A
and remained “outwardly composed,” was the “Sokal hoax,” where a paper postmodernist perspective on medical
despite being upset at his mistake. suggesting that quantum gravity was education could therefore ask questions
Deconstruction and discourse analyses a social and linguistic construct was such as: “How do Western models and
could focus on the nature of the language accepted by a postmodernist literary theories of medical education (such as
used in this narrative. For instance, while studies journal.18 Its publication and the problem-based learning or competency-
some aspects are reported dispassionately, subsequent declaration that it had been based medical education) translate
others use more hyperbolic language. For a hoax called into question the rigor to other cultures and contexts and
instance, Lee “rushed back to the patient’s and intellectual merits of postmodernist how is power and control enacted in
side” and he “felt hugely relieved.” We academic practices. Other thinkers have translation?” or “How do the tensions
might also consider what was not said in also been critical. For instance, Noam between residents as physicians and
this narrative. Not only is the patient an Chomsky has been particularly critical of residents as learners arise from the
apparent cipher, but it is also unclear who postmodernism’s failure to add materially language and culture of postgraduate
is actually responsible here or what the to methods or knowledge,19 while Daniel medical education?” The pursuit of
consequences of this episode are for those Dennett has criticized postmodernism social missions or professionalism or
involved. It is also notable that there are for its nihilist rejection of absolute truth competence could similarly be examined
no gender markers used—Lee, the patient, (something that has found new voice in through a postmodern lens. At a more
and the attendings are all abstract with the “post-truth” public debates of recent fundamental level, a postmodernist
respect to identity and context beyond the years).20 This pits realists (who believe perspective could allow us to question
specifics of these named roles. that there are intrinsic shared truths the assumed benevolence of medical
and realities) against postmodernists in education or our assumptions about
a somewhat acrimonious debate about what constitutes a good doctor or a good
Discussion the very nature of science.21 Whether or medical education program. Applied
Not only is postmodernism a broad and not postmodernist perspectives should to medical education scholarship, we
somewhat heterogeneous philosophical be limited to the study of sociocultural might critique the assumptions and
collective but it also has many overlaps phenomena is a key part of this debate. ideological positioning of the theories we

858 Academic Medicine, Vol. 95, No. 6 / June 2020

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.

use, the way we conduct studies, or the
ways in which the findings from medical
education research are (or are not) used
to shape practice.
Conclusion
As an approach within medical
education, postmodernist perspectives
can help to expose and analyze the
political and ideological positioning
of much of what we do, particularly
in the interests of addressing systemic
problems of justice and equity. However,
given that the intent of this series of
Invited Commentaries is to serve as
an introduction to the philosophy
of science in medical education,
this article has perforce glossed over
the deep historical and conceptual
complexities of postmodernism and
its legacy. For instance, there are other
key postmodernist thinkers that I have
not covered, such as Gilles Deleuze and
Jean Baudrillard, as well as other issues
and other debates. The concern that
postmodernism, when taken to extremes,
can be nihilistic and even socially
destructive does not negate its utility as
a philosophical lens through which we
can explore phenomena within medical
education. However, postmodernism’s
limitations, its lack of coherence, and
the kinds of phenomena to which it can
and cannot be meaningfully and usefully
applied need to be well understood by
those seeking to work with it. After all,
skepticism and critical positioning are
healthy practices for a scientist, and
power relations within the science and
practice of medical education should
be problematized in the interests of
advancing the field and responding to our
social contract. However, given that what
Academic Medicine, Vol. 95, No. 6 / June 2020
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constitutes truth and our obligations with
respect to truth have become increasingly
central to public debate, it is paradoxical
that postmodernism both supports
relativist ideas about the nature of
truth and provides tools and techniques
to problematize and deconstruct the
ideologies and agendas that have brought
about this crisis of public trust and
accountability.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
R.H. Ellaway is professor, Department of
Community Health Sciences, and director, Office of
Health and Medical Education Scholarship, University
of Calgary, Calgary, Alberta, Canada.
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