Foreword: Foundations?

This book is about foundations; the foundations of a field that many scholars have built up over the years to the point that a volume reassessing and outlining those foundations has become necessary. But what does it mean for something to have foundations? I ask you to pause and reflect before diving deeper into this book as thinking about the significances and meanings of foundations will help make your exploration of this volume all the more rewarding.

The term 'foundation' can refer to whatever a structure, whether physical, social, or cultural, has been built upon. Foundations may be deliberately constructed as a basis for what follows, or they may simply be what was there before. There is a temporality to this sense of foundation. Foundations precede, they imply something historical, something archaeological, something focused on the contexts that gave rise to something else and within which those later things need to be understood. The foundations of health professions education research (HPER) from this perspective imply therefore that there was a 'before' on which HPER was built. And yet, although the history of health professions education (HPE) can be linked to the founding of schools and programmes, and to system-wide reforms, HPER did not start at one point in time; it coalesced out of many threads and actions over an extended period of time. In terms of education, we might think back to the influence of Hippocrates or Galen, William Harvey or Thomas Sydenham, or to the traditions of medical training developed at Padua or Edinburgh, all of which have contributed to the foundations of HPE.

Foundations in this sense are akin to the tributaries of a great river. Some are long and deep like sociology, psychology, economics, and organisational science, while others are more obscure such as the epidemiological philosophies of science, or the emergent practices of action research and design research implied in the work of innovators and inventors. These foundations are often philosophies of science, scientific disciplines, or paradigms, each with their own histories and narratives, which beyond historical curiosity, may have limited relevance to HPER today. Who today worries much about the contested threads of 'continental' philosophy and how Kant and later Nietzsche shaped the thinking of Husserl, whose work in turn shaped phenomenology and much of the hermeneutic aspects of the qualitative sciences that HPE researchers employ? The foundations of HPER are primarily the foundations of the social sciences in general, albeit infused with beliefs and values from medicine and from the basic sciences.

Foundations can also refer to the deliberate creation of something new, such as the founding of a school or university, or the functions of a foundry where things of substance are forged and cast. In this case, although historicity is implied, the focus is more on the intent and the acts of the founders. Indeed, this is the sense invoked whenever the emphasis is on the foundational person or people, or on their intentions, vision, hopes, or values. This is often a normative perspective that considers how things should have been according to some definitive source, and how reality has diverged from this founding vision ever since.

Foundations can also refer to that which underlies something in the present moment. From this perspective, foundations focus instead on the here and now and surveying and appraising the reasons for the current form and function of things; warts and all. This usually means unravelling the peculiar entanglements of different elements, traditions, structures, and practices that may never have been designed to interact. Foundations from this point of view can therefore be understood as a palimpsest of earlier things inscribing those that follow them. Examining foundations in this light can tell us much about the morphogenesis of contemporary HPE and HPER. For instance, in HPER we can think of the idiosyncrasies of professional identity formation with its jumble of service, vocation, agency, hierarchy, status, and other principles. Some of this foundational thinking comes from ancient tradition, some from current social realities. Some comes from guild-like collectivism, some from entrepreneurial competitiveness. As another example, we might consider Norman's generational model [1], starting with a coalescence of scholars from very different backgrounds moving in and out of the, as yet undefined, spaces of HPER. These pioneers were followed by those who trained in other disciplines but pursued careers in HPER and established it as a distinct field, and they were followed in turn by scholars who trained in HPER, who knew little else, and who thought of it as a discipline as much as a field [1]. Each generation reinvented (and will reinvent) the foundations they encountered such that foundations become a standing wave defined both by tradition and the changing perspectives of the scholars in the field over time. For instance, that the historical figures I mentioned earlier were all men reflects a male-dominated past that is not reflected in the present or (I hope) in the future of our field.

Finally, foundations can mean covering over things or erasing them altogether. Indeed, although concealment and elision are not what one may first consider in thinking about foundations, they are important concerns. Foundations may simply just cover over what preceded, forming another stratum of change and development, such as the widespread adoption of Internet technologies over the past three decades. Foundations may also deliberately erase what went before, creating a terra nullius on which something new and better might be built. This sense of foundations is reflected in the episodic paradigm changes in scientific fields and disciplines that are often as much about what is rejected as they are about what replaces such ejecta. For example, some examples of historical people and places I gave earlier were drawn from Western and Anglophone perspectives, but what about others? The elision of non-Western traditions' influence on the foundations of Western medicine and healthcare is a long-standing concern, reflected, for instance, in the extent to which Hippocrates and Galen are celebrated while the influence of Ibn Sina, Ibn Rushd, and Confucius (among many others) is rarely acknowledged.

Whether we focus on the unintended or deliberately shaped bases on which other things were built, or on the simple facts and consequences of precedence, or on acts of founding, or even on the underlying assumptions and idiosyncrasies of origins and their consequences, a consideration of foundations may tell us many things. Exploring foundations can help us to remember that science is not itself an objective or natural phenomenon; it was created by many people, working both together and in parallel, as well as cumulatively over time. Not one of them laid the foundations for science alone; they all contributed to them. We do not stand only on the shoulders of giants; we stand on the shoulders of everyone who has preceded us - giants and lesser mortals alike.

Although we talk about foundations as single entities, the foundations of HPER are made of many parts, as this book outlines. Chapter 1 argues the foundational purposes of HPER are both 'to generate new knowledge and to improve education'. Chapter 2 explores theoretical and philosophical foundations of HPER with a particular focus on the purposes and bases of scientific disciplines in the context of HPER. Chapter 3 outlines the ethical and moral foundations of HPER. Chapter 4 considers different methodological foundations and their meaning in designing and appraising quality in HPER. These foundations are then expanded on in exploring different approaches to HPER with their differing foundational ideas. Chapter 5 illustrates scientific foundations, Chapter 6 outlines realist foundations, Chapter 7 outlines interpretivist foundations, Chapter 8 explores critical foundations, and finally, Chapter 9 outlines pragmatic approaches and their associated foundations. The book closes by describing the foundations of participation in HPER communities and discourses, with Chapter 10 outlining the foundations of expressing and communicating HPER in putting studies together, Chapter 11 describing the foundations of disseminating HPER once a study has been completed, and Chapter 12 outlining the foundations of translating HPER into practice and the potential impacts thereof.

There are clearly many dimensions to the foundations of a field like HPER. However, when we speak of foundations, we imply coherence and contiguity among their constituent parts. As much as this book outlines where this contiguity can or might be found, like any area of human activity, there are also gaps and conflicts. Indeed, if HPER had been deliberately designed, it would not resemble the HPER we have today, which has evolved organically and haphazardly over time. A study of foundations can tell us how we got to where we are. To that end, we might employ concepts of morphogenesis or poststructuralist discourse analyses. A study of foundations can also tell us why it is we do what we do when we know it is not ideal. From this perspective, we might draw on bounded rationality theory to consider the symbolic orders within which we practice [2]. A study of foundations can get us to reappraise and deepen our understanding and commitment to what we do in terms of moral agency and paradigm (ideology). A study of foundations can help us to be more selective and critical of why we do what we do;...