Tony Egan

‘Do as I say, not as I do’: Medical Education and Foucault's Normalizing Technologies of Self

Medical training as a process of professional socialization has been well explored within the fields of medical education, medical sociology and medical anthropology. Our contribution is to outline a bio-power, more specifically an anatomo-politics, of medical education. The current research aimed to explore perspectives on what is commonly termed the ‘hidden curriculum’. We conducted interviews with pre-clinical medical students, clinical teachers and medical educators within a New Zealand medical school. In this paper, we outline ways that respondents described the juxtaposition of the undeclared or hidden aspects of medical education with the formal declared curriculum. Our respondents were aware of incongruencies across these components that resulted in mixed messages to students. Curricula initiatives aim to encourage new forms of subjectivity so that students are often expected to be the kinds of doctors that their teachers are not. However, the success of such initiatives is dependent on the degree of alignment between informal and formal components of the curriculum.

Communities of clinical practice and normalising technologies of self: learning to fit in on the surgical ward

This paper reports observational research of Fourth Year medical students in their first year of clinical training doing their surgical attachment. Previously, the authors have argued that medical curricula constitute normalising technologies of self that aim to create a certain kind of doctor. Here, they argue that a key mechanism through which these normalising technologies are exercised in the workplace is Etienne Wengers communities of practice. In the clinical environment the authors identify communities of clinical practice (CoCP) as groups of health professionals that come together with the specific and common purpose of patient care. Fourth Year medical students join these transient communities as participants who are both peripheral and legitimate. Communities of clinical practice are potent vehicles for student learning. They learn and internalise the normative professional values and behaviours that they witness and experience within the disciplinary block of the medical school and teaching hospital; specifically, the authors suggest, it is through their participation in communities of clinical practice that medical students learn how to ‘be one of us’.

Predicting Child Abuse and Neglect in New Zealand

We describe the three stages of our attempt to predict parenting problems and child abuse antenatally. In the first stage, we made an intuitive check list of ten items from 173 risk factors drawn from the literature. The check list was useful in predicting who would relinquish care or have majorparenting difficulty in two different samples drawn four years apart and before and after some major sociocultural changes in New Zealand. In the second stage we used statistical techniques rather than intuition to maximise the predictive ability of the checklist and produced a new one of 9 items. In the third stage we validated the new list in a random sample of pregnant mothers. It was effective in predicting parenting difficulty In the 2 years after childbirth. We recommend it for routine use in a New Zealand setting. We do not know how useful the checklist will be in other cultural settings.

Was a breach of examination security unfair in an objective structured clinical examination? A critical incident

One-third of a class of students was inadvertently given the names of stations immediately prior to an OSCE and two-thirds of the class were not.This provided an opportunity to explore student perceptions of fairness and to explore any effect of this cueing. The subjects were medical students undertaking an end of fifth year multidisciplinary OSCE. OSCE score data from the 20 students who had received the information were compared with those of the 40 students who did not.We also compared their performance on other assessments to determine whether the two groups were comparable. The overall OSCE mark was not significantly different between the two groups.There were significant differences between groups on four stations but this was not in a consistent direction that advantaged one group.There were no significant differences between the two groups in their performance on the other examinations.This inadvertent security breach had no systematic effect on student OSCE station scores.This incident provided a valuable opportunity to admit error, approach it rationally and restore any resulting breach of trust.

Communities of clinical practice in action: Doing whatever it takes:

Burgeoning numbers of patients with long-term conditions requiring complex care have placed pressures on healthcare systems around the world. In New Zealand, complex patients are increasingly being managed within the community. The Community of Clinical Practice concept identifies the network of carers around an individual patient whose central participants share a common purpose of increasing that patient’s well-being. We conducted a focused ethnography of nine communities of clinical practice in one general practice setting using participant observation and interviews, and examined the patients’ medical records. Data were analysed using a template organising style. Communities of clinical practice were interprofessional and included informal supports, services and non-professionals. These communities of clinical practice mediate practice, utilising informal networks to cut across boundaries, bureaucracy, mandated clinical pathways and professional jurisdictions to achieve optimum patient-centred care. Communities of clinical practice’s repertoires are characterised by care and are driven by the moral imperative to care. They do ‘whatever it takes’, although there is a cost to this form of care. Well-functioning communities of clinical practice use patient’s well-being as a guiding light and, by sharing a vision of care through trusting and respectful relationships, avoid fragmentation of care. The Community of Clinical Practice (CoCP) model is particularly useful in accounting for the ‘messiness’ of community-based care.

An exercise to map patient-centred care networks

An interview study of participants in primary health carebased CoCPs highlighted their potential complexity. We found that the visual representation of CoCPs as maps facilitated the assimilation of this complexity. Each patient was shown their map to confirm whether they agreed that it represented their care world. The optimal care and wellbeing of the patient at the centre of the CoCP is the common purpose of its participants. CoCPs are dynamic: the composition changes as the patient’s needs change. Participants have varying roles and levels of engagement (Figure 1).5 CoCP maps include family, social clubs, community and health care services. They articulate the formal and informal care networks that sustain individuals in the community.

The Safe and Effective Clinical Outcomes (SECO) clinic: learning responsibility for patient care through simulation.

Background: This article describes a simulated General Practice clinic for medical students, which incorporates specific features to aid learning of clinical problem solving. Description: We outline the overall objectives of the simulation, explain the concept, and describe how the clinic works. The clinic is novel in that it utilises clinical outcomes as measures for student success in the consultation. There are no time restrictions on a consultation. Students are unobserved and have open access to clinical information and telephone advice from a senior colleague. Evaluation: The achievement of the case-specific outcomes is assessed by reference to students’ clinical notes and the responses of the simulated patients to specific scenario-related questions. Following the clinic there is a debrief session, and students are provided with the evidence base and outcomes for each scenario. Conclusions: The clinic has been part of our undergraduate curriculum since 2004. Collectively, students rate it as their most effective learning experience.

Students' reflections on the relationships between safe learning environments, learning challenge and positive experiences of learning in a simulated GP clinic.

Learning environments are a significant determinant of student behaviour, achievement and satisfaction. In this article we use students’ reflective essays to identify key features of the learning environment that contributed to positive and transformative learning experiences. We explore the relationships between these features, the students’ sense of safety in the learning environment (LE), the resulting learning challenge with which they could cope and their positive reports of the experience itself. Our students worked in a unique simulation of General Practice, the Safe and Effective Clinical Outcomes clinic, where they consistently reported positive experiences of learning. We analysed 77 essays from 2011 and 2012 using an immersion/crystallisation framework. Half of the students referred to the safety of the learning environment spontaneously. Students described deep learning experiences in their simulated consultations. Students valued features of the LE which contributed to a psychologically safe environment. Together with the provision of constructive support and immediate, individualised feedback this feeling of safety assisted students to find their own way through clinical dilemmas. These factors combine to make students feel relaxed and able to take on challenges that otherwise would have been overwhelming. Errors became learning opportunities and students could practice purposefully. We draw on literature from medical education, educational psychology and sociology to interpret our findings. Our results demonstrate relationships between safe learning environments, learning challenge and powerful learning experiences, justifying close attention to the construction of learning environments to promote student learning, confidence and motivation.

Moral Economy and Moral Capital in the Community of Clinical Practice

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient’s journey. The concept of moral capital offers another route into the “black box” of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

Communities of clinical practice: understanding how to optimize medical student experience on a surgical rotation

The interface between the preclinical years and the clinical years is a particularly stressful time for the medical student. After the relatively familiar territory of the laboratories and lecture theatres of the preclinical years, the clinical environment is viewed as difficult for students. The importance of a positive experience on a surgical rotation goes beyond overcoming the difficulties of transition, however. In a study from Australia, it was shown that 98% of students who expressed an interest in training as a surgeon could identify a positive influence by a Senior Doctor, or Trainee, at some stage during their undergraduate surgical experience. The teaching hospital is the primary site of clinical learning for medical students. However, the primary function of the teaching hospital is health care provision, and only secondarily is it a learning environment. As a result, much clinical learning is opportunistic and dependent upon patient census. Similarly, the nature of service provision means that clinical teachers are often put in situations where they are obliged to prioritize patient care over the teaching of medical students. Within this working environment, medical students are required to apply and expand their medical knowledge, learn clinical skills and to think of themselves as emergent medical professionals. This process requires developing and internalizing professional values, attitudes and behaviours. While professional attributes may be formally taught through courses at the medical school, they are also informally learned through participation in clinical activities in the teaching hospital. Egan and Jaye have applied Wenger’s model of communities of practice to the process of learning that occurs as students negotiate their training in the teaching hospital. They use the term ‘communities of clinical practice’ (CoCP) to describe the specific clinical groups that form around the patient’s bedside with the uniting purpose of patient care. Because the bedside is also the site of student learning on the ward, this is where students encounter a CoCP during their clinical attachments. Two important features characterize student participation in a CoCP. In the first instance, they are transient members who will be on the ward for only a few weeks. Second, their participation is both legitimate and peripheral. One mechanism by which legitimate peripheral participation leads to full participation is alignment – the sense of fitting in or sense of belonging that members of a CoCP experience. Importantly for medical students in the teaching hospital, legitimacy allows exposure to actual practice, while students who remain only peripherally involved require close supervision and special assistance, thus limiting intensity, risk, and the potential for error and consequent learning. Furthermore, it is through their participation in a CoCP that medical students learn how to ‘be one of us’. Medical students begin by practicing on the periphery of a CoCP and only move towards full participation if the right conditions occur. This process may not be fully complete until after graduation. How far the student moves towards full participation is both a function of the CoCP and the individual, but the surgical team can make this easier by making sure that the student is well prepared and has knowledge and skills required for the surgical rotation, perhaps gained in tutorials or a formal orientation. Some students put themselves forward, but many are inhibited by a wide range of concerns such as getting in the way, hurting the patient or making a mistake. The more supported and legitimate they feel, the greater will be their appropriate and effective participation. Helpful suggestions and signs of approval from other members of the team will help, while feeling that they are in the way, that the patient has not consented to their participation, belittling or delegation of inappropriate responsibility will tend to drive them away to the library. Wenger describes boundaries to participation in communities of practice. In many cases, these boundaries are very clear, such as professional roles and tasks, but some are obscure such as where people stand around a bed on ward rounds. A number of objects can also be boundaries such as the patient chart and, indeed, patients themselves. Allowing medical students to participate in record keeping and basic clinical tasks help to break down these barriers and make them feel useful members of the team. Surgical Trainees are in a unique position to help in this process, having been in this position themselves only recently. With their own recent experience and their understanding of the clinical environment, the Trainee, as a near-peer role model (people ‘near’ to the learner professionally and also in proximity and in frequency of social contact), is able to help guide the medical student through the complex ecosystem that is the clinical learning environment, and to enable them to fit into the surgical team. If surgeons are serious about the training of the next generation, it is incumbent upon the surgical community to welcome medical students into their CoCP. Orientating students to the hospital and to the team, and providing opportunities for medical students to function within the team, are vital to their enjoyment of their surgical rotations. Encouraging and educating Surgical Trainees to help medical students to fit into surgical teams will make this much easier. PERSPECTIVES