What Do Our Respondents Think We're Asking? Using Cognitive Interviewing to Improve Medical Education Surveys.

Consider the last time you answered a questionnaire. Did it contain questions that were vague or hard to understand? If yes, did you answer these questions anyway, unsure if your interpretation aligned with what the survey developer was thinking? By the time you finished the survey, you were probably annoyed by the unclear nature of the task you had just completed. If any of this sounds familiar, you are not alone, as these types of communication failures are commonplace in questionnaires.1–,3 And if you consider how often questionnaires are used in medical education for evaluation and educational research, it is clear that the problems described above have important implications for the field. Fortunately, confusing survey questions can be avoided when survey developers use established survey design procedures. In 2 recent Journal of Graduate Medical Education editorials,4,5 the authors encouraged graduate medical education (GME) educators and researchers to use more systematic and rigorous survey design processes. Specifically, the authors proposed a 6-step decision process for questionnaire designers to use. In this article, we expand on that effort by considering the fifth of the 6 decision steps, specifically, the following question: “Will my respondents interpret my items in the manner that I intended? ” To address this question, we describe in detail a critical, yet largely unfamiliar, step in the survey design process: cognitive interviewing. Questionnaires are regularly used to investigate topics in medical education research, and it may seem a straightforward process to script standardized survey questions. However, a large body of evidence demonstrates that items the researchers thought to be perfectly clear are often subject to significant misinterpretation, or otherwise fail to measure what was intended.1,2 For instance, abstract terms like “health professional” tend to conjure up a wide range of interpretations that may depart markedly from those the questionnaire designer had in mind. In this example, survey respondents may choose to include or exclude marriage counselors, yoga instructors, dental hygienists, medical office receptionists, and so on, in their own conceptions of “health professional. ” At the same time, terms that are precise but technical in nature can produce unintended interpretations; for example, a survey question about “receiving a dental sealant” could be misinterpreted by a survey respondent as “getting a filling. ”2 The method we describe here, termed “cognitive interviewing” or “cognitive testing,” is an evidence-based, qualitative method specifically designed to investigate whether a survey question—whether attitudinal, behavioral, or factual in nature—fulfills its intended purpose (B O X). The method relies on interviews with individuals who are specifically recruited. These individuals are presented with survey questions in much the same way as survey respondents will be administered the final draft of the questionnaire. Cognitive interviews are conducted before data collection (pretesting), during data collection, or even after the survey has been administered, as a quality assurance procedure. During the 1980s, cognitive interviewing grew out of the field of experimental psychology; common definitions of cognitive interviewing reflect those origins and emphasis. For example, Willis6 states, “Cognitive interviewing is a psychologically oriented method for empirically studying the way in which individuals mentally process and respond to survey questionnaires. ” For its theoretical underpinning, cognitive interviewing has traditionally relied upon the 4-stage cognitive model introduced by Tourangeau.7 This model describes the survey response process as involving (1) comprehension, (2) retrieval of information, (3) judgment or estimation, and (4) selection of a response to the question. For example, mental processing of the question “In the past year, how many times have you participated in a formal educational program? ” presumably requires a respondent to comprehend and interpret critical terms and phrases (eg, “in the past year” and “formal educational program”); to recall the correct answer; to decide to report an accurate number (rather than, for example, providing a higher value); and then to produce an answer that matches the survey requirements (eg, reporting “5 times” rather than “frequently”). Most often, comprehension problems dominate. For example, it may be found that the term “formal educational program” is variably interpreted. In other words, respondents may be unsure which activities to count and, furthermore, may not know what type of participation is being asked about (eg, participation as a student, teacher, or administrator). More recently, cognitive interviewing has to some extent been reconceptualized as a sociological/anthropological endeavor, in that it emphasizes not only the individualistic mental processing of survey items but also the background social context that may influence how well questions meaningfully capture the life of the respondent.8 Especially as surveys increasingly reflect a range of environments and cultures that may differ widely, this viewpoint has become increasingly popular. From this perspective, it is worth considering that the nature of medical education may vary across countries and medical systems, such that the definition of a term as seemingly simple as “graduate medical education” might itself lack uniformity.