This chapter summarises common realist methodologies and methods in health professions education research (HPER), including key principles of sampling, data collection, and data analysis. Scientific realism suggests that real entities can be articulated in theory, with mature, well-confirmed theories being approximately true. Critical realism, on the other hand, is seen as combining a realist ontology with a relativist/constructivist epistemology. Realism is often considered as an epistemological middle ground to the extremes of radical positivism and radical constructivism. The chapter explains the main indicators of quality employed in realist approaches. Realist economic evaluations essentially integrate economic analyses and realist evaluations within a realist framework. Realist methodologies seek to understand how things work in complex systems, offering a conceptualisation of causation different to the causality-as-constant-conjunction understanding inherent in scientific experimentation. Configurational analysis is a key quality marker for realist approaches. The chapter discusses the strengths and challenges of realist approaches for HPER.