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

Peter Cantillon,Willem De Grave,Tim Dornan

doi:10.1007/s10459-020-09993-8

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.

Highlights

There has been growing disquiet about the quality of graduate clinical education (Irby 1995; Parsell 2001; Spencer 2003; Kennedy et al 2005; Swanwick 2008; Norman 2012; Steven et al 2014; Wiese et al 2018)
Informal learning in all four of the clinical teams that we observed was shaped by an implicit curriculum of establishing two related, but distinct individual impressions: the impression of being a capable team player at interfaces between the team and the hospital and the impression of being a capable team member at interfaces within the team
In so doing we have shown how an implicit curriculum that applies within clinical teams dictates much of what is learned and how it is learned

Summary

Introduction

There has been growing disquiet about the quality of graduate clinical education (Irby 1995; Parsell 2001; Spencer 2003; Kennedy et al 2005; Swanwick 2008; Norman 2012; Steven et al 2014; Wiese et al 2018). Clinical education has been characterised as inefficient (Bolster and Rourke 2015) and ineffective due to tensions between education, the safe provision of clinical services, and research (Kennedy et al 2009a; Goldszmidt et al 2014; Patel et al 2018; Wiese et al 2018). These shortcomings have been further highlighted by the widespread adoption of competency-based curriculums in graduate medical education (Ten Cate and Billett 2014). The perceived inefficiencies of graduate clinical education have led to increased calls for action, driven largely by enhanced scrutiny of clinical education by professional training and accreditation bodies (Dornan et al 2019)

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Discussion

Conclusion