“It’s Not like This Back Home” Conversations and Conversation Analysis as a Tool to Consider the Family Medicine Consultation in India

Abstract

Introduction: This paper describes some of the features of family medicine consultations in one clinic in India. In the United Kingdom (UK) there is a significant difference in the success rate in the Royal College of General Practice postgraduate licensing assessment (MRCGP) between those doctors who graduated MBBS from overseas but who trained and work in the UK, and those who graduated in the UK. The reasons for this are not known, but are likely to be multifactorial. India is the country of origin of one of the largest groups of UK International Medical Graduates (IMGs) and some doctors from India feel that their difficulty in passing this exam is in part due to family medicine being performed differently in India. Methods: The reported experiences of family medicine trained doctors in India about contextual aspects of practice are explored through a thematic analysis of focus group and interviews. A conversation analysis of work done by talk-in-interaction in video recordings of actual family medicine consultations in India is also presented. Results and Discussion: The impact of family medicine training, or the lack of it, and Indian structural and societal norms in the practice of family medicine are considered. The Clinical Skills Assessment element of MRCGP (CSA) heavily emphasises talk as used in all three assessment domains - data gathering, clinical management and interpersonal skills. The phrase ‘interactional fluidity’ is coined for the marker of competence with talk that RCGP examiners seek. This has implications in a high-stakes, yet simulated, assessment for those consulting in a second language. Using a model that differentiates between ‘core business work talk’, ‘work-related talk’ and ‘small talk’, the talk from video-recorded real-life consultations in India will be analysed. The risk of UK examiners mistaking unfamiliar patterns of talk for lack of medical competence is discussed. Conclusion: The differential attainment of IMGs has been described for some time and this paper aims to move the discussion on to potential training interventions in response.