Making sense of how physician preceptors interact with medical students: discourses of dialogue, good medical practice, and relationship trajectories

Abstract

Work based learning and teaching in health care settings are complex and dynamic. Sociocultural theory addresses this complexity by focusing on interaction between learners, teachers, and their environment as learners develop their professional identity. Although social interaction between doctors and students plays a crucial role in this developmental process, socio-cultural research from the perspective of doctors is scarce. We performed discourse analysis on seven general practitioners’ audio diaries during a 10-week general practice clerkship to study how they gave shape to their interaction with their students. Examination of 61 diary-entries revealed trajectories of developing relationships. These trajectories were initiated by the way respondents established a point of departure, based on their first impression of the students. It continued through the development of dialogue with their student and through conceptualizations of good medical practice. Such conceptualizations about what was normal in medical and educational practice enabled respondents to recognize qualities in the student and to indirectly determine students’ desired learning trajectory. Towards the end, discursive turns in respondents’ narratives signaled development within the relationship. This became evident in division of roles and positions in the context of daily practice. Although respondents held power in the relationships, we found that their actions depended strongly on what the students afforded them socially. Our findings address a gap in literature and could further inform theory and practice, for example by finding out how to foster constructive dialogue between doctors and students, or by exploring different discourses among learners and teachers in other contexts.

Appendix: Gee’s building tasks and tools of inquiry

Building tasks

• Significance Using language to make things significant or important in various ways or to lower their significance or importance.

• Practices (activities) Using language to enact specific practices (activities) alone or with others. A practice means a socially recognized and institutionally or culturally supported endeavor that usually involves sequencing or combining actions in certain specified ways.

• Identities Using language to enact specific socially situated identities or to project such identities onto others, or to privilege or disprivilege such identities. The identity building task refers to identity as how we recognize and act out social role or different social positions in society; different ways of being in the world at different times and places for different purposes.

• Relationships Using language to create or sustain social relationships or to end or harm them.

• Politics Using language to give or take away social goods or projecting how social goods (anything a person or group in society wants and values) are or ought to be distributed. This involves speaking/writing/acting in ways that say or imply what is “appropriate”, “normal”, “natural”, “good”, or “acceptable” (or their opposites) in regard to certain people, things, or activities.

• Connections Using language to make things connected or relevant to each other or to make them disconnected or irrelevant to each other.

• Sign systems and knowledge Using language to create, sustain, revise, change, privilege or disprivilege any language or sign system or characteristic way of knowing the world or making knowledge claims about the world.

Tools of inquiry

• Situated meaning The specific meanings words and phrases take on in actual contexts of use. Speakers and writers construct their utterances or sentences to guide listeners and readers in constructing these specific meanings based on what was said and the context in which it was said.

• Social language—specialist language Any variety or style of speaking or writing associated with a socially situated identity of any sort (this identity may be associated with a social group, profession, culture, practice, social role, or interest-driven activity like video gaming).

• Figured worlds (espoused, evaluative, world(s)-in-interaction) A theory, story, model, or image of a simplified world that captures what is taken to be typical or normal about people, practices, things, or interactions. What is taken to be typical or normal, of course, varies by context and by people’s social and cultural group.

• Intertextuality Spoken or written text alludes to, quotes, or otherwise relates to another one; a sort of cross-reference.

• Discourses Ways of combining and integrating language, actions, interactions, ways of thinking, believing, valuing, and using various symbols, tools and objects to enact a particular sort of socially recognizable identity.

• Conversations Debates in society or within specific social groups that large numbers of people recognize, both in terms of what “sides” there are to take in such debates and what sorts of people tend to be on each side.