Medical Education 2010: 44: 449–458 Context Medical education in the UK has recently undergone radical reform. Tomorrow’s Doctors has prescribed undergraduate curriculum change and the Foundation Programme has overhauled postgraduate education. Objectives This study explored the experiences of junior doctors during their first year of clinical practice. In particular, the study sought to gain an understanding of how junior doctors experienced the transition from the role of student to that of practising doctor and how well their medical school education had prepared them for this. Methods The study used qualitative methods comprising of semi‐structured interviews and audio diary recordings with newly qualified doctors based at the Peninsula Foundation School in the UK. Purposive sampling was used and 31 of 186 newly qualified doctors self‐selected from five hospital sites. All 31 participants were interviewed once and 17 were interviewed twice during the year. Ten of the participants also kept audio diaries. Interview and audio diary data were transcribed verbatim and thematically analysed with the aid of a qualitative data analysis software package. Results The findings show that, despite recent curriculum reforms, most participants still found the transition stressful. Dealing with their newly gained responsibility, managing uncertainty, working in multi‐professional teams, experiencing the sudden death of patients and feeling unsupported were important themes. However, the stress of transition was reduced by the level of clinical experience gained in the undergraduate years. Conclusions Medical schools need to ensure that students are provided with early exposure to clinical environments which allow for continuing ‘meaningful’ contact with patients and increasing opportunities to ‘act up’ to the role of junior doctor, even as students. Patient safety guidelines present a major challenge to achieving this, although with adequate supervision the two aims are not mutually exclusive. Further support and supervision should be made available to junior doctors in situations where they are dealing with the death of a patient and on surgical placements.
Where an increasing amount of medical education occurs in workplace contexts, sociocultural learning theories offer a best-fit exploration and explanation of such learning. We need to continue to develop testable models of learning that inform safe work practice. One type of learning theory will not inform all practice contexts and we need to think about a range of fit-for-purpose theories that are testable in practice. Exciting current developments include dynamicist models of learning drawing on complexity theory.
Analytical methods tend to lose the concrete story and its emotional impact to abstract categorizations, which may claim explanatory value but often remain descriptive. Stemming from discomfort with more integrative methods derived from the humanities, a science-orientated medical education may privilege analytical methods over approaches of synthesis. Medical education can redress this imbalance through attention to 'thinking with stories' to gain empathy for a patient's experience of illness. Such an approach can complement understanding of story as discourse - how narratives may be used rhetorically to manage both social interactions and identity.
Medical students must be prepared for working in inter-professional and multi-disciplinary clinical teams centred on a patient's care pathway. While there has been a good deal of rhetoric surrounding patient-centred medical education, there has been little attempt to conceptualise such a practice beyond the level of describing education of communication skills and empathy within a broad 'professionalism' framework. Paradoxically, while aiming to strengthen patient-student interactions, this approach tends to refocus on the role modelling of the physician, and opportunities for potentially deep collaborative working relationships between students and patients are missed. A radical overhaul of conventional doctor-led medical education may be necessary, that also challenges the orthodoxies of individualistic student-centred approaches, leading to an authentic patient-centred model that shifts the locus of learning from the relationship between doctor as educator and student to the relationship between patient and student, with expert doctor as resource. Drawing on contemporary poststructuralist theory of text and identity construction, and on innovative models of work-based learning, the potential quality of relationship between student and patient is articulated in terms of collaborative knowledge production, involving close reading with the patient as text, through dialogue. Here, a medical 'education' displaces traditional forms of medical 'training' that typically involve individual information reproduction. Students may, paradoxically, improve clinical acumen through consideration of silences, gaps, and contradictions in patients as texts, rather than treating communication as transparent. Such paradoxical effects have been systematically occluded or denied in traditional medical education.
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