Stephen Loftus

Rethinking clinical reasoning: time for a dialogical turn

Medical Education 2012: 46: 1174–1178

Pain and its Metaphors: A Dialogical Approach

Most health professionals are unaware of the extent to which aspects of language, such as metaphor, influence their practice. Sensitivity to metaphor can deepen our understanding of healthcare and, arguably, improve its quality. This is because metaphors, and the linguisticality of which they are a part, shape medical practice in important ways. Examples are the metaphors used in pain management. By exploring the dialogical tension between such metaphors, we can better understand the ways in which they influence medical practice.

Researching the Individual in Workplace Research.

Researching how people are educated for practice has often been seen as problematic. We recommend qualitative approaches that draw on hermeneutic phenomenology and narrative inquiry. It is our intention to outline approaches that we believe can be used in an emerging research agenda. We begin by examining assumptions underlying much workplace research and recent trends, such as social constructionism. There has been a gradual recognition of the importance of the social aspects of practice with the rise in popularity of such ideas as communities of practice, and the recognition of the significance of the work of scholars such as Vygotsky. However, the individuals interaction with the practice environment and their interpretation of their own experience has been somewhat neglected. We argue that there is an important dialogical relationship between the individual and the practice environment, affected by personal histories, workplace cultures and education. We need more research that deeply engages with the individuals perspective on practice. We argue that combining hermeneutic phenomenology and narrative inquiry can allow research to engage with the individuals subjective experience and explore the relationships between individuals and their communities of practice. We also draw on the ideas of the Russian scholar, Mikhail Bakhtin, to further develop the importance of studying the dynamic dialogical relationships that individuals establish with themselves and their practice environments.

Teaching Clinical Reasoning

Clinical reasoning skills are essential to the everyday practice of health professionals. Clinical reasoning distinguishes independent, thinking and decisionmaking professionals from individuals who implement technical activities under instruction from others. Teaching health professional students to engage in clinical reasoning requires explicit attention and strategy by teachers and strategies designed to model this skill. In this chapter we explore our collective research and practical experience to present an understanding of clinical reasoning that beginning teachers can draw upon in their practice.

Educating Health Professionals

Health professionals who teach may be salaried health sector employees who are directly engaged by a higher education institution in adjunct or conjoint academic appointments. Many teaching health professionals also provide learning activities through good will and altruism. Another group consists of academics with health professional degrees for whom academia is the primary employment; these professionals may engage in professional clinical practice in only a limited capacity.University teachers are a heterogeneous group, reflective of the society from which they are drawn, but can be considered in three loose groupings. One group is made up of people who are primarily educators and who hold educational qualifications in support of their academic roles. Another group hold qualifications in a health profession such as nursing and forego their professional practice in order to become full-time university teachers.

Embodiment in the Practice and Education of Health Professionals

In this chapter, embodiment is explored as a means of coming to a deeper understanding of what occurs in the clinical encounter between patient and health professional, together with what health professionals must learn in order to manage such encounters. Using a real encounter between an oral surgeon and a ‘difficult’ patient as a framework, embodiment is used to open up our thinking about the relationship between bodily experience and our attempts to articulate the meaning of that experience. Participants in a clinical encounter must work together, by using their embodied experience, along with their attempts to narrativise that experience in both the past and the present, if there is to be mutual understanding. Using embodiment as a focus enables us to see that participants use multiple ontologies and epistemologies to dialogically construct a local reality that is contingent and emergent from the clinical encounter itself. Aspects of this localised reality include the rituals that the clinician must bodily enact and the different timespaces occupied by the participants. Embodiment also gives us insights into the complex ways that medical technology can shape the clinical encounter. The clinical encounter is no longer to be seen as a simplistic exchange of information. Through embodiment, we can start to open up the subtleties and nuances that characterise the complexities of the relationship between patient and clinician.

Health professional education in the future

We live in interesting times in higher education; times that are especially interesting for those of us involved in preparing new generations of health professionals. This is because there are great changes in motion. The last few decades have seen major upheavals in the ways in which we understand and practise higher education. Changes are likely to continue for the foreseeable future for a number of reasons. There are also clear trends emerging that indicate something of what we might expect in the years to come.

Thinking about curriculum

Curriculum has been attracting a lot of attention in recent years. Not too long ago there were complaints that the idea of curriculum was neglected in higher education (e.g. Barnett & Coate, 2005) with more attention being paid to pedagogy and to the activities that foster teaching and learning. This has changed. There is now a substantial and growing literature on various aspects of curriculum. In this chapter we focus on some of the key aspects of curriculum that we believe are important for a new academic teacher, without attempting to be exhaustive.

Being a Health Professional Educator

The core purpose of health professional education is to prepare practitioners who can cope with the many demands of working in a range of health settings, not only as these settings exist today but also as they might exist tomorrow. This can include traditional clinical roles in metropolitan and regional hospitals, suburban and rural clinics, specialist centres and the many varieties of community care.

Researching Living Practices

Qualitative research has come a long way since its origins in anthropology well over a century ago (Loftus & Rothwell, 2010). Numerous influences have shaped the development of qualitative research, which has flourished and branched off in many different directions such as grounded theory, narrative inquiry, the many approaches shaped by phenomenology, critical inquiry, and action research. There was a long period in which qualitative research had to justify its existence as a valid form of inquiry in many disciplines, the so-called “paradigm wars”. Qualitative researchers were challenged because what they were doing did not seem to be rigorous or methodical in the same way that quantitative researchers claimed for their projects.