Welcome to this the first instalment of my diary recording some of my experiences as I visit three Australian medical schools to look at how they employ non-clinical community-based education as part of their undergraduate programmes.
In this instalment I focus on my initial experiences at my first port of call, Monash University, Melbourne. These involved me visiting students on placement and hearing about the impact of the programme on them, representatives of their host organisations and sometimes people in the community that they serve.
Anyone who spends time with young medical students at Monash University talking to them about their experiences of community-based practice (CBP) will be left in no doubt about the contribution that experiential learning in this context makes to their education and their development as future doctors. This is learning so visceral that one can feel it taking place. This is partly because the kinds of experiences that students have on placement can take them close to the edge of the comfort zone that delineates their prior understanding of people and communities and indeed ideas about themselves from those in which they are now immersed.
Despite the fact that this experiential learning is visceral and palpable it’s not al heart and no head. These students can also step back from their learning and reflect on the experience. Indeed, many of them described the challenges and excitement that comes with trying to integrate new experience with their existing schema and feeling their way through dissonance between the ‘here and now’ of the placement and ‘there and then’ of prior knowledge and values. One of the things I was reminded of is that medical students are smart and willing and able to exploit opportunities for learning.
Seeing things differently
I am conscious it is a simplification to suggest that the richness of the various experiences that these young people shared with me can be distilled into a few sentences, but there were some striking commonalities between students’ accounts within and across different placements which I think are worth trying to pick out. One essential feature seems to be reflected in the words of the student who summed up her CBP as being about ‘seeing things differently’.
The beauty of this is its discursive malleability. Seeing it differently might mean a shifting of perspective in terms of understanding, alteration of an attitude or opinion and/or be about increased observational acuity. I think very often when they said they ‘saw it differently’ these students were very often referring to all three.
For example, some of the students whom I met were based in a school working with children and young people with moderate to severe physical, learning and multiple disabilities. Students described themselves as fulfilling roles as teaching assistants. They seemed to enjoy this responsibility although it had evidently been daunting at first. They had been prepared – oriented, given an induction, relevant and necessary training and policy and practice awareness – and were well-supported by a field educator (more on this in a future post) – but they noted that you can’t be prepared for everything when it comes to being a classroom and you can’t learn about the classroom from outside it. They had to pitch in, get involved and figure it out as they went along. This presented lots of challenges not least how to interact with children and young people who might seem in many important not at all like themselves and in particular defined by their disabilities.
One student noted that a striking learning opportunity that arose in this context concerned their understanding and skills around communication. Like most medics these students learnt about communication as primarily a verbal exchange between two people, generally conducted in a shared language, to a tacitly agreed set of cultural conventions which help to structure and construct meaning, purpose and understanding and so on.
What this student had experienced was working with children and young people who did not use words at all, with whom, it could seem at first and to the uninformed glance, that communication was nigh on impossible. Through the classroom experience, this student now knew this was not the case and that touch, motion, light and sensation were all modes of interaction open between them and these children and young people. This was an important change in this student’s understanding – a way of seeing communication differently.
But it went further. This new way of seeing had grown out of the formation of a relationship with a particular human being. In this case a child with a severe disability. It wasn’t a book-based exercise or some other form of vicarious exposure to experience. This student knew and was thinking about a person known to them when they thought and talked about communication. As a consequence not only was their learning reified but also contextualised. In this case, it meant that they had a sense of the role that a family might play in caring and supporting a child with a disability and how they might all be affected by stigmatising failures in understanding of their needs. This student had been particularly struck by the level of parental frustration when a child was offered sub-optimal care by health professionals who equated the absence of verbal communication with the absence of feeling and sensation. Putting it very succinctly, the student said that they realised that not being able to talk about pain was not the same as not feeling it. That’s a potent lesson. It’s about, at the very least, what communication means, what patient-centred care might involve, the role of family in healthcare and the way that small failures in service response have big implications for individuals and for expectations among others around them.
Other students on placements in the school said it was also an example of the effects of stigmatisation of people living with disabilities through the construction of disability as deficit. Some were now very acutely aware of how socially enstructured these were – from the small ways in which services can be inaccessible or at best difficult to access to the discursive positioning of people living with disabilities as needing things done for them when in fact what is required is the removal of barriers to their action.
I saw lots of other examples of powerful learning that day. Take the students on placement with a community-based service providing leisure and social activities to elderly people. These students also drew attention to early challenges around working out what their role should be in this setting. They had had to learn to use their initiative, to engage and thereby partly to develop a role, find jobs and points of engagement with the group. They had spent a lot time chatting to the older people. They eventually came to see that this was the valuable work. That these people were at risk of becoming socially isolated and that the craft activity in which they were engaged got them out, got them together and facilitated socialising. One student said that they thought it might help to prevent people feeling depressed. They said that he had previously not considered that this might be a major issue faced by the elderly. They could see that aging was not solely a biological process but had psycho-social dimensions which might be as important per se and also represented context without which their understanding of growing old as a biological process was diminished.
Again these students’ learning went further. They looked back on their initial experiences of engaging with the group, especially the nervousness and insecurity that they had felt about their role and interaction with the older people and reflected on its basis and implications. They picked out two things for me. First, recognition that what was being exposed for them were expectations, beliefs and norms around inter-generational interaction of which they been previously unaware. These students had been forced to consider culturally embedded conventions about respect, independence, deference and their relationship to aging and the elderly and to rework them in a context where there proto-professionals.
Second, they had seen just how important the project was to the people involved and engaged with it and just how important it would be for healthcare professionals, and especially GPs to be aware of it and others like it. Here was an emergent recognition of the extent of healthcare taking place beyond the surgery and the value of connecting up surgery and community in pursuit of the promotion of good health and well-being.
These are just two examples illustrating some of the learning opportunities outlined to me by Monash students during my first day in the field. There was much more. I noted al the following that day: CBP gives Monash students opportunities to:
- Gain experience of working in a multi-disciplinary context and alongside other professionals. To see what they do, how they work, and where medicine and doctors might fit in;
- Develop their communication skills;
- Understand the ways that culture, including their own, influences perceptions of roles, forms of interactions and other social practice;
- Develop a better understanding of the social determinants of health – how environmental, cultural and social factors, especially disadvantage and marginalisation affect health and well-being;
- See the breadth and depth but sometime fragility of community action and endeavour;
- Engage in identity work – I saw ideas about being a student, young person, medical student, doctor all being worked out and also gender, age, ethnicity and class being made available for consideration infixing the delf and others;
- Explore advocacy in heath, support community development and thriving and consider how links between formal healthcare and wider social networks might be enhanced.
Some final thoughts
A number of things strike me as I write.
First, I haven’t addressed the programme from the perspective of the organisations that provide placements for students: what value do they see in it; and, what outcomes does it have for them?
Second, I have not drawn attention to some of the challenges CBP can throw up. These might concern students, the organisations that they are placed with or the academics and administrators running the programmes.
Third, I haven’t written about the structure of the CBPP at Monash: how students’ time in the field in managed and organised; how their learning is supported and assessed. This is important because it is the means by which these learning opportunities are created and contained and indeed directed back into the broader programme of medical education.
Fourth, the importance of bringing my account of this academic practice and these students’ learning experiences into dialogue with theory in order to interrogate and explore it, make sense of it and ultimately make it accessible to others who might want to develop similar provision.
I will turn to each of these issues in future blogs. But, my aim here has been to try and convey some of the substance of my impressions of the outcomes of CBP at Monash and to reflect the energy and excitement that it can generate for students.
Doing it differently
At the time that I wrote this post I found an article in an Australian magazine called the ‘The Monthly’ – a collection of journalism about political, cultural and social issues – which reflected on the changing role of the doctor. Writing from her perspective as a practitioner of General Medicine in a Hospital, the author, Karen Hitchcock, describes the consequences of a drift towards to specialism in medicine and benefits of a turn back towards recognising the skills and contribution of the General Physician. Her article is littered with examples of ways that thinking and practicing medicine holistically benefits patients. Hitchcock writes about an elderly patient Maria who she is treating for a chest infection. It’s not that the medicine isn’t important but what Hitchcock says is, ‘even if Maria did have a chest infection, it was obvious that it was not her main problem…all her medical problems needing sorting out but above and beyond any medical management we could throw at her, what Maria needed was a course of physical rehabilitation if she was to return home with her daughter – which is what she very much wanted. ‘I told mum’, her daughter said…’if you can’t get out of bed, I can’t care for you any more.’
You can probably see what I was thinking about when I read this…
You can find Karen Hitchcock’s article at: http://www.themonthly.com.au/how-rebirth-general-medicine-will-save-lives-last-resort-karen-hitchcock-5619