In this post I want to return to the issue of non-clinical community-based experience as a context for identity-work among medical students. While I recognise that it is not particularly radical to think about medical education as an arena in which activity of this kind takes place I want to pursue my thoughts in a particular direction that I think represents a path less well trodden. In the first place, I am not interested in here in the identity work per se but considering how we might orient and position students such that they can better understand and use whatever identity work they engage in. Judicious and thoughtful positioning can no only provide students with ways of theorising their own experiences but also, and here’s the real added-value, offer them theoretically robust ways of thinking about how experience and identity ca be bound up with the production of useful knowledge about the world.
Nice as it would be to present my thinking as a narrative account of a sequence of ruminations mapping in a neat and orderly way onto the chronology of my trip, it hasn’t been like that at all. My thinking didn’t really take any kind of coherent shape, in fact I am not even sure if I was conscious of what I was thinking, until I tried to understand some comments made by students at UWS during a workshop that I ran with them at the end of their period on community placement. It was at that moment that the connections between a number of previously fragmented ideas accumulated from out of my own academic practice, and over the course of encounters with many different people became apparent. A debt of gratitude is owed to the various people who contributed to this process but the debt is particularly great with respect to the students whom I think were clever enough to know what I was thinking before I did.
Getting me started
The important role that the students play in my thinking comes about because they brought me short. I have, in general, been writing positively about community placements, but when I asked these UWS medical students to describe their community-based experiences and to identify learning associated with it, I was bowled over by the response of a vociferous and angry minority unafraid to tell me what they thought. In essence, they were saying it was waste of time; that things were poorly organised, that they were given pointless, repetitive or no clear tasks while on placement. It had added nothing to their knowledge of the world and had nothing to do with medicine.
It took me a little while to realise that what I was hearing was a projection of difficulties with identifying the role that they were supposed to playing while on placement. Frustration, confusion and anxiety underpinned the anger. These feeling flowed from uncertainty about what there supposed to be doing; lack of confidence about what contribution they were making to the organisation providing the placement, uncertainty about what they had learnt and whether what they had learnt was what they were supposed to have learnt, and, above all, frustration caused by an inability to discern any relevance in their experience to medicine and to being a doctor.
‘If you don’t know who you’re supposed be and what you’re supposed to be doing’, they seemed to saying, ‘how can you learn anything?’
I appreciated their frustration. Whether it is true or not, medical students and many of us who work with them have come to believe that they probably have too much to learn and too little time to learn it. They are also in the main, committed, energetic and motivated young people. The experience of uncertainty about relevance of learning to them and to their aspiration to be good doctors can be almost physically painful. The problem of wanting to do well, and wanting to do things properly may be compounded by a sense of competitiveness. I have little doubt that things are wound yet tighter by the added pressure to demonstrate wholehearted engagement with each and every aspect of medical education for fear of being perceived as unprofessional. In this context how do you engage with that which you may not really understand or see the point of? The community placement must seem to some to rub vigorously on these vulnerable and sore points.
I think that this what I was hearing from the few UWS students who dominated proceedings in the seminar. They didn’t really lack for support or guidance, or, in when we thrashed it out have any problems with the activities that were on offer to them while on placement. Their concerns were reflections of more elemental anxieties produced by dissonance between some implicit ideas about medical education, medicine and doctoring and experience in the non-clinical community setting. Some of these students just could not see where medicine and the doctor was in all this and it worried them.
Of course, in my view this is to wrongly structure the problem. Rather than ask, ‘How does the community placement fit into my idea of medical education and medicine?’, a more interesting and facilitative version runs as follows, ‘How does medicine and my idea of doctoring fit in with what the community is howing me is important?’
If this is a plausible interpretation, then it becomes reasonable to ask, if there is a role that we can make available to students that enables them to arrive at this formulation, to answer it and, how can we insert them into it?
Experiential learner in the community as ethnographer
I am sure that there is more than one answer. It might be by orienting them as a community-development worker perhaps, or health advocate, for example. Here I want to focus on how it is done in my own practice at Durham.
At Durham we do this by inviting medical students to become ethnographers in the community.
I think that there are a number of reasons why this role has the potential to enable students to grapple with the identity-related questions implied above and to reposition themselves in consideration of them:
First, ethnography as an approach to understanding the social world draws on a rich theoretical and empirical base which is sufficient and appropriate to the aim of enabling students to understand the inter-play of structure, culture and agency in the production of identities. That is, identities and identity-work are not troublesome, intruding issues getting in the way of some process in the context of ethnography, but an important and valued part of the repertoire of ethnographic practice and epistemology.
Second, the role of the ethnographer provides some clarity to students about what constitutes appropriate and relevant activity in the context of the community placement: the task is to immerse themselves in a setting and through this engagement as observer and participant in the everyday life of an organisation and the people whom it is made up of, learn about conventions, practices and meanings – the culture – of that setting and the people within it;
Third, and as a consequence, it legitimises observation and engagement in forms of everyday action as modes of knowing about the world;
Fourth, and above all, it means that we can give students access to the concept and practice of reflexivity and hence to a way of understanding positioning and person as a legitimate subject and object in the experience of knowing about the world and phenomena in it. Indeed, according to reflexivity, identity awareness and associated identity work becomes an essential part of the process of understanding the relation between self and other. We can use self-awareness and openness to how our identity is made an remade through interaction with others as a way of seeing how we inscribe ourselves on the our view of the world and, through careful, thoughtful reading of this, see how aspects of the world are inscribed back on us. Thus, reflexivity provides a mechanism for linking understanding of the self and other to understanding of culture and structure in a theoretically robust way. And here’s the critical point, this linkage is a critical asset in grasping the threshold concepts so important in understanding the social basis and context and health.
Of course, there are lots of important questions to ask about the challenges around trying to insert students into this role. They include the following:
- Is it possible to create an environmental and intellectual context in which ethnographic research can be undertaken by a medical student?
- What are the ethical and other risks to the communities in which they participate? And, can these be mitigated and/or managed?
- Can students be given enough time in the field, give enough attention to the work, be adequately supervised and supported to do ethnography?
- Is it possible to equip them with sufficient understanding of the knowledge paradigm and adequate research skills and acumen to conduct themselves as ethnographers?
- What are the risks that the experience and work will be so modest that it will negatively affect students’ grasp of the paradigm and regard for research practice and potentially undermine the work of experienced ethnographers?
These are, I think, important but not insurmountable considerations and concerns. I suggest that the answers lay in appropriate scoping of student enterprise, provision of adequate expert support and guidance and the construction of safe guards.
This effort feels worth it given that the opportunities seem to me to be very great indeed.
For example, the ethnography provides a highly appropriate vehicle for rich description of communities and community engagement, for capturing an immersive experience in a wide variety of organisational activity, for interpretation and valuation of meanings attached and ascribed to actions, things and practices by people. It is, in many ways, a person-centred research paradigm that can speak of lived experience in exactly the ways that students tell us they feel about their placements. It is a robust coherent epistemological framework through which to think about encounters between the self and others and learning about medicine and health (Russell, 2011).
Furthermore, as an approach or paradigm it gives access to a number of bodies of disciplinary thought which are potentially valuable to medics – especially anthropology and sociology where ethnography is a common mode of engaging with and producing knowledge about the world. For example, it seems to me that thinking of a community placement as an ethnographic experience enables the student to insert themselves into theoretical terrain where they can see how ‘private troubles link to public worries’ (Mills, 1959).
Knowledge producer and knowledge consumer
I also suggest that it worth considering positioning the medical student as ethnographer because it speaks so well to current concerns about the extent to which doctors should be knowledge producers and/or knowledge consumers.
This debate is often approached on the basis of an assumption that the quantity of research now available to the doctor is so great that they need to spend time on honing skills in finding, evaluating and digesting and not producing knowledge. I wonder if this mutual exclusivity is quite right and quite helpful. For example, in what ways is understanding of research informed and enriched by experience of engagement in it? What might be the outcomes in terms of understanding of different epistemologies?
Getting medical students to be ethnographers is not a solution but considering this as a way of positioning them in the community may give them and us further scope and resource as we weigh the problem.
First, in what ways might positioning medical students as producer of knowledge inflect and inform their understanding of evidence-based medicine?
Second, what are the implications of positioning doctors as consumers of knowledge in terms of the hierarchies in the knowledge economy? Is the consumer a different, lower status than the producer? What is the relationship implied through the marketised discourse of demand and supply? Is this resistable, worth resisting, and does linking community placements to research opportunities play a role in that process?
Third, where might the splitting off of knowledge production and consumption position medicine within the Academy? If Higher Education is about induction into the world of knowledge production where might a consumer-based training sit? Could a qualification in medicine without a research component be perceived as less academic?
Fourth, how does the knowledge production/consumption positioning relate to what non-clinical community-based placement practice seems to be about?
I think this last question is critical since the case studies I have reported on this blog suggest that knowledge production via engagement in research is a key component in many non-clinical community placement programmes. Although the forms that this takes are diverse – via ethnography, the development of case studies, reports or specific agency-determined needs assessments or evaluations – it seems to be a something that can be built into community experience both to enhance and structure student experiential learning, link personal experiences to broader course content, theory and ideas, and, in some cases, add value to the knowledge and/or practice of the agency offering the placement.
What I have been exploring here is the extent to which positioning medical students as knowledge producer through ethnography has something particular to offer as a means of enabling engagement in and understanding of identity-work.
I think it does – it makes the self an instrument of research and an entity on which knowledge about the world is written via interaction with it. It legitimises being present in experience of the world and provides a rich and robust theoretical context for linking the self to others, structure and culture in ways that are useful in terms in then thinking about the social context and basis of health and medicine.
And look at the interesting new questions we consider: How about, for example, the implications of the adoption of an ethnographic position with all that entails about the importance of immersive, continuous, engaged involvement in the lives of others as a prerequisite for understanding them, for thinking about our vision of how doctors will be situated in, relate to and work with patients and communities?
A few final thoughts
I think there is interesting work to be done on the interface of positions of the kind that I have talked about here and consideration of students’ experience in the context of non-clinical community placements from the point of view of educational theory (principally, experiential learning). In particular, further elucidation and exploration of questions around if and how re-positioning of the student as ethnographer helps to shift the emphasis away from the learner as a cognitive entity at the centre of a process of intellectual and personal development and onto process of their interaction with community as a context in which culturally embedded and constituted ideas of personhood and role are being enmeshed and negotiated. Are the positions offered by experiential learning theory and ethnography compatible? If not how might they brought into rapproachment? Is this yet a further indication of the richness of theoretical resources that we can bring to bear to understand non-clinical community-based learning in medical education?
Russell, A.J. 2011. Interprofessional Healthcare as Intercultural Experience – Early Years Training for Medical Students. In Sociology of Interprofessional Health Care Practice: Critical Reflections and Concrete Solutions. Kitto, S., Chesters, J., Thistlethwaite, J. & Reeves, S. Hauppauge, NY: Nova Science. 139-153.
Mills, C, Wright. (1959), The Sociological Imagination, reprinted (2000), Oxford University Press, chapters 1-3 and 7, pages 3-75 and 132-143.