Uncovering the ecology of clinical education: a dramaturgical study of informal learning in clinical teams

Abstract

Off-the-job faculty development for clinical teachers has been blighted by poor attendance, unsatisfactory sustainability, and weak impact. The faculty development literature has attributed these problems to the marginalisation of the clinical teacher role in host institutions. By focusing on macro-organisational factors, faculty development is ignoring the how clinical teachers are shaped by their everyday participation in micro-organisations such as clinical teams. We set out to explore how the roles of clinical teacher and graduate learner are co-constructed in the context of everyday work in clinical teams. Using an ethnographic study design we carried out marginal participant observation of four different hospital clinical teams. We assembled a dataset comprising field notes, participant interviews, images, and video, which captured day-to-day working and learning encounters between team members. We applied the dramaturgical sensitising concepts of impression management and face work to a thematic analysis of the dataset. We found that learning in clinical teams was largely informal. Clinical teachers modelled, but rarely articulated, an implicit curriculum of norms, standards and expectations. Trainees sought to establish legitimacy and credibility for themselves by creating impressions of being able to recognise and reproduce lead clinicians’ standards. Teachers and trainees colluded in using face work strategies to sustain favourable impressions but, in so doing, diminished learning opportunities and undermined educational dialogue. These finding suggest that there is a complex interrelationship between membership of clinical teams and clinical learning. The implication for faculty development is that it needs to move beyond its current emphasis on the structuring effects of institutional context to a deeper consideration of how teacher and learner roles are co-constructed in clinical teams.

Thinking about social power and hierarchy in medical education

“…Hierarchies can also obstruct interprofessional teamwork and collaboration 47–50 . The presence of the clinical hierarchy may encourage trainees to ‘fake it’ rather than disclose ignorance, error or ask for help 4,51,52 . Being a low‐status member of a hierarchy can result in trainees performing acts they know are morally wrong when instructed by a supervisor 53–55 .…”

“…[47][48][49][50] The presence of the clinical hierarchy may encourage trainees to 'fake it' rather than disclose ignorance, error or ask for help. 4,51,52 Being a low-status member of a hierarchy can result in trainees performing acts they know are morally wrong when instructed by a supervisor. [53][54][55] An understanding of the entrenched nature of hierarchy also helps explain why few trainees report mistreatment and abuse they experience from superiors in the clinical environment.…”

“…This perspective allows us to see that one of the ways power operates is through the establishment and operationalization of hierarchies, an organisational form that stratifies people or groups based on their possession of social resources 3 . The clinical environment is intensely hierarchical, and clinical work and learning are contingent on interaction, which makes consideration of power and hierarchy directly relevant to medical education 4 …”

“…hierarchical, and clinical work and learning are contingent on interaction, which makes consideration of power and hierarchy directly relevant to medical education. 4 In the current paper, we offer reflections on the usefulness of several conceptualizations of power and hierarchy to medical education, addressing some of the ways these concepts have appeared, often implicitly, in medical education literature. We offer suggestions for where the incorporation of these concepts may be fruitful and counter common assumptions that may constrain understanding of the multiple ways power operates within hierarchies in medical education.…”

The social construction of teacher and learner identities in medicine and surgery

“…[14][15][16][17][18] There has been little research into how identity formation, clinical supervision and the influence of cultural context relate to one another. 19 Self-report studies have shown how postgraduate trainees master shared practices, rules of thumb and embodied understandings, [20][21][22][23][24] but such methodologies have been largely insensitive to the implicit effects of cultural context. 25,26 Observational studies have shown how graduate learners seek legitimacy in clinical teams by reproducing socially sanctioned token behaviours, but not how social and cultural contexts shape the roles of teachers and learners.…”