Medical students’ views of power in doctor-patient interactions: the value of teacher-learner relationships

Medical Education 2010:44: 187–196Context  This paper aims to contribute to the important, and relatively underexplored, area of medical education research that seeks to illuminate the value and meaning of relationships in the undergraduate education

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  Medical students’ views of power in doctor–patientinteractions: the value of teacher–learner relationships Sara Donetto CONTEXT  This paper aims to contribute tothe important, and relatively underexplored,area of medical education research that seeks toilluminate the value and meaning of relation-ships in the undergraduate education of doc-tors. Here I present new empirical material in which I ground my reflections on some waysin which teacher–learner relationships can helpaddress medical students’ often uncritical viewsof professional practice. The views I illustrateare of particular significance as they contrast sharply with the participative models of practicepromoted by current policy, professional andeducational discourses. METHODS  My reflections stem from the anal- ysis of data I generated for a larger, broadly ethnographic study exploring students’approaches to their future role as practitionersin one UK medical school. I draw upon thislarger body of data and focus here on twoexamples in particular of the more generaluncritical readings of medical professionalism Iencountered at Sundown Medical School (aninvented name), namely: students’ oftenreductive views of medical power, and theirsimplistic formulations of patient education. DISCUSSION  I argue for the need to fosterricher and more critical understandings of professional power and knowledge among stu-dents and educators, and suggest here that teacher–learner interactions could have animportant role in fostering such richer under-standings. I argue that teacher–learner rela-tionships can model some of the dynamics of the practitioner–patient interaction and thusprovide useful opportunities for closer andmore critical analysis of power, education andknowledge in the medical school classroom as well as in the consultation room. CONCLUSIONS  I suggest that effective inte-gration of participative and critical pedagogicalstrategies in medical curricula and more struc-tured involvement of patients in the role of teachers may represent valuable strategies forthe development of learning relationships that better promote reflexive and collaborativeforms of professionalism. power in professional practice Medical Education 2010:   44  : 187–196  doi:10.1111/j.1365-2923.2009.03579.x Department of Education and Professional Studies, King’s CollegeLondon, London, UK Correspondence:   Sara Donetto, Department of Education andProfessional Studies, Franklin Wilkins Building, King’s CollegeLondon, Waterloo Road, London SE1 9NH, UK.Tel: 00 44 20 7848 3179; Fax: 00 44 20 7848 3182;E-mail: ª  Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010;  44 : 187–196  187  INTRODUCTION Teacher–student relationships in undergraduatemedical education are of paramount importance tothedevelopmentof future doctors. They arecentral toeffective content and skills learning by medical stu-dents and, by inspiring as well as sometimes discour-aging emulation, they also provide crucial role-modelling for the personal and professional develop-ment of clinicians. 1–4 In this paper, I focus on apotentiallymoretransformativefunctionthatteacher–learner interactions can have in undergraduate med-ical education: that of helping foster a more criticaland genuinely participative medical professionalism.Current policy and professional discourses on healthcare design and provision promote a shift away fromold-fashioned medical ‘paternalism’ towards more‘patient-centred’ and collaborative models of clinicalpractice. 5–11 The fundamental aims of this transfor-mation are more consistent practices of respect forpatient autonomy and shared accountability forhealth care decisions. Medical education guidelinesecho this broader trend and recommend that undergraduate curricula should nurture students’abilities to communicate effectively with patients and work in partnership with them. 6,12–14 I wish to argue that teacher–learner relationships canfruitfully contribute to this desired transformation inmedical professionalism. In support of this claim, Ipresent data from a broader study which sought toshed light on medical students’ critical approaches tomedical professionalism (‘Critical awareness inundergraduate medical education: an ethnographicstudy of one UK medical school’; S Donetto, unpub-lished PhD thesis, 2009). In this paper, I focus on twoimportant themes emerging from that dataset: stu-dents’ unsophisticated understandings of medicalpower, and their use of a ‘banking’ model 15 to discusspatient knowledge and education.In exploring medical students’ views on professionalpower and its effects, I adopt a broadly Foucauldianframe of reference. I understand power as beingdistributed in a network of relations, ‘something which circulates’, 16 a generative, productive forcethat does not act exclusively through coercion. My conversations with students at Sundown MedicalSchool (an invented name) sought to illuminatethe extent to which they could identify and reflect upon the power relations at work in medicalpractices. In particular, I paid special attention tostudents’ perspectives on ideological manifestationsof professional power such as the normative andtruth-producing effects of biomedical discourses. 17–21 This lens of ‘critical awareness’ – as I called it – wasborrowed, and adapted, from educationalist PauloFreire’s work on ‘critical consciousness’. 15  Alongsidestudents’explicitcommentsonprofessionalauthority, their observations on the value of patient education and on the role of doctors in supporting it offer further, indirect, examples of their often unso-phisticatedviewsofmedicalpower.Thissecondthemeis of particular relevance here because of my focus onteacher–learner relationships and their influence onthe education and information-sharing approaches of future doctors. Underlying my analysis is an assump-tion that, in an institutional milieu which endorsesprofessional development paths geared towards moreparticipative models of health care, it makes sense to wonder whether and how students interpret therelationships between professional knowledge, power,discourse and expertise. Although my research is informed by the classics of ethnographic work in the medical education litera-ture, 22–24 my argument is fundamentally practical inintent. The discussion of this paper therefore focuseson arguments for and concrete suggestions about how the interactions between medical students andtheir educators could better support more genuinely collaborative clinical work. The qualitative nature of the study findings necessarily limits their generalis-ability, but, I would suggest, the arguments that Idevelop here have relevance to medical educationacross the UK. METHODS This paper draws upon data I generated for my PhDresearch (‘Critical awareness in undergraduate med-ical education: an ethnographic study of one UK medical school’; S Donetto, unpublished PhD thesis,2009). This consisted of a broadly ethnographic 25 study that aimed to explore medical students’  critical  approaches to their future professional roles asdoctors. I carried out my fieldwork in a city medicalschool which I refer to as Sundown, which I chose forpracticality of access and for its academic character-istics. Sundown Medical School offers a 5-year MBBS(Medicine Bachelor and Bachelor of Surgery) course(with an optional intercalated BSc) as well as grad-uate-entry 4-year and extended 6-year courses. Although detailed information on the curricularstructure cannot be reported here for reasons of  188  ª  Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010;  44 : 187–196 S Donetto  confidentiality, it is important to point out that, at Sundown, critical awareness is not in itself an explicit curricular aim and that problem-based learning(PBL) has limited room in the official curriculum.My fieldwork covered a total period of two academic years (November 2005 to August 2007). As a fullethnography of medical student cultures was not only unfeasible in view of time and resource constraints,but also potentially over-informative for the scope of the study, I entered the field for discrete events suchas specific observations, teaching and meetings withgatekeepers (e.g. year coordinators), students andeducators. I observed a total of 87 teaching sessions(Table 1). Although I attended a few whole-yearlectures, I focused on small-group, interactive teach-ing formats as I was interested in hearing students’spontaneous comments on the topics they werestudying. Because of my specific interest in students’understandings of and critical insights into social andideological aspects of medical practices, the bulk of my data consisted of individual semi-structuredinterviews. I interviewed a total of 30 students (meanage 22.5 years, range 18–28 years) with a view toeliciting their reflections on their future role asdoctors and, in the late stages of the fieldwork, toexploring their opinions (loosely applying thenotion of participant validation 25 ) on the analyticalthemes I was developing for the thesis (see Appen-dix). The gender ratio of the student sample (male,9 : female, 21) broadly reflected that of the MedicalSchool population (data available from 1998   ⁄   99 to2005   ⁄   06) and, with the exception of two studentstaking the extended medical degree, all studentsinterviewed were enrolled on the standard MBBScourse. Eleven students were from Year 2 or equiva-lent (one student had completed Year 2 and was onthe intercalated BSc and one was on the Year 2equivalent of the extended degree), 11 from Year 5 orequivalent (one student was re-sitting Year 5), andeight were from other years (Table 2). Self-reportedethnic background labels were harmonised with thelabels used by Sundown Registry and added up to 16students from the ‘White’, six from the ‘Black’ andeight from the ‘Asian’ grouping categories. I alsointerviewed some of the educators in the MedicalSchool (11 in total; Table 2) in order to obtaincollateral information on broader trends amongstudents as well as feedback on my ideas from thedata analysis.In the time available I focused mostly – although not exclusively – on the second and final years of theundergraduate course. These represent important moments of transition (from pre-clinical to clinicalstudy and from student to qualified practitioner) inthe academic career of medical students and aretherefore more likely to prompt the type of reflectionthat I was seeking to observe or elicit in interviews. Allinterviews were semi-structured and were guided by broad question areas that were reviewed and refinedover the course of the project. Formal ethical approval was obtained from the ethics committee of the insti-tution in which my studies were registered; I managedpossible ethical concerns carefully and took steps toensure the anonymity of participants, who were eachgiven a pseudonym for use in all subsequent writing.I maintained a reflexive stance throughout the study,bearing in mind the effects that autobiographicalelements, identity management issues and involve-ment in the field may have on the analysis of data.Data analysis was closely intertwined with data gener-ation; it involved close examination of field notes,audio-recordings and transcripts of interviews, as wellas reflections on more general impressions from thefieldwork. I produced extensive analytical notes onthemes that emerged from the fieldwork throughout thestudy.Interviewsweredigitallyaudio-recordedandtranscribed by myself and by two trusted professionaltranscribers under a confidentiality agreement. I useda combination of manual and software-assisted coding(NVivo 7; QSR International Pty Ltd, Doncaster, Vic, Australia) for the interview transcripts. I borrowedprocedural analytical tools – such as open coding –from grounded theory. 26,27 More precisely, I pro-ceeded through a first round of coding of transcriptsand progressively clustered the codes obtainedaccordingtooverarchingthemes,re-analysingselectedcodesaspossibleanalyticalthreadsdevelopedthrough Table 1 Participant observation summary  Participant observationTotal sessions  n   =  87 Course yearYear 2 31Year 5 45Other years 11Session typeMostly interactive 69Mostly didactic 18Fieldwork period: November 2005 to August 2007 ª  Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010;  44 : 187–196  189 Medical students, power and pedagogy  the ongoing drafting of chapters. I shared my codingand discussed my data analysis at several stages of theresearch with a range of fellow researchers, includingpeers in a data analysis group and more experiencedacademics. As I mentioned earlier, I also sought andobtained feedback on my early analytical consider-ations from a number of research participants. RESULTS In the following sections I report data illustratingmedical students’ often unsophisticated understand-ings of professional power. In particular, I report students’ comments on medical authority and patient empowerment and their views on the more subtlepower relations involved in the education of patients for more informed decision making. I focuson these two examples of students’ views for two mainreasons: because they capture the generally uncriticalattitudes towards professional practices that I encoun-tered at Sundown, and because they point to concrete ways in which the interactions between students andeducators could help challenge these attitudes. Medical students and professional power  From the interviews and interactions I had withmedical students and educators during the 2 years of my fieldwork, it emerged that simplistic views of medical power and poor awareness of the normativeand ideological implications of medical science andpractice were commonplace. In general, the word‘power’ rarely cropped up in students’ conversations.Other than references to the ‘empowering’ effect of patient-centred practices, students made very littlereference to medical power unless directly askedabout it. Occasionally, the term, when suggested by me, was frankly rejected, as in the case of final yearstudent Davina:‘It’s not about power [ … ] because you’re not tellingsomebody ‘‘I want you to do’’, you’re suggesting it. And it’s their thing whether they take it or they don’t take it. You’re there to give the advice in my opinion.It’s more advice than power. But it’s not, it’s not power, I can’t find a word to describe it but I don’t think it’s power.’ (Davina, Year 5 re-sit)By contrast, Year 2 graduate student Jonathan, whocame from a social science background, observed that in medicine ‘power is immense, but  …  never decon-structed’. He explained:‘Everyone knows …  on the course, I think, knows thedoctors are in a powerful position, both with patientsand in society, but that’s never …  talked about, I Table 2 Interview summary  Interviews Total no. of people interviewed 41No. of students interviewed 30 Total recording time: 41.7 hours(interview length range 29–116 minutes)Course yearYear 2 11Year 5 11Other years 8No. of second interviews with students 7Course yearYear 2 2Year 5 4Other years 1No. of tutors interviewed 11 Total recording time: 13.3 hours(interview length range 31–80 minutes)No. of second interviews with tutors 1Fieldwork period: November 2005 to August 2007 190  ª  Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010;  44 : 187–196 S Donetto  suppose. And, whether that power is appropriate evenis never really  …  talked about.’ (Jonathan, Year 2)More frequently the students I interviewed at Sun-down Medical School talked about power indirectly,in terms of the professional’s ‘authority’ in thecontext of the clinical consultation. More precisely,this ‘authority’ usually referred to the issue of whohad the most influence in determining the outcomesof a consultation and, in particular, the decisionsregarding further investigation for or management of the clinical circumstances in question. In this sense,students at Sundown were, for the most part, inclinedto conceptualise medical power and authority interms of decisional assertiveness or even inadvertent coercion. Aiming for concordance, as prescribed by the patient-centred model of health care endorsed by the School’s curriculum, was seen by undergraduatestudents as a ‘new’ way of practising medicine, asopposed to the more traditional paternalisticapproach of ‘doctor knows best’. Studentsdescribed the clinical encounter as an occasion forcollaborative interaction between the doctor andthe patient, referring to the greater space forpatient contribution to the decision-making processas a desirable improvement in medical practice.However, they often proved puzzled – if not sceptical– about the terms of this collaboration. Not infre-quently, the patient’s right to choice translated intoan ‘it’s up to them’ formulation (see also how Davina referred to ‘their thing’ in an earlier quote),of which the following extract is the most dramaticexample:‘I don’t want to say they [patients] think they know  what’s best for them [laughs] because obviously insome cases they do and you have to respect theirdecisions, but I just feel that sometimes you have togive and take with the doctor’s opinion. As in like …  we do have an opinion, we do have a professionalopinion and … and if you go against it, that’s entirely up to you, but don’t come back [laughs] and blameus at the end of it all.’ (Barbara, Year 2)Students considered patients ultimately responsiblefor all important choices regarding the management of their care. They viewed this autonomy, andpatients’ greater involvement in medical decision-making processes more generally, as representingforms of ‘empowerment’. This empowerment seemedto hinge upon access to medical knowledge, which inrecent years had been made more available to thegeneral public by the media in general and theInternet in particular. More precisely, the demystifi-cation of medical knowledge to which the mediacontributed was seen by students as one of the factorsthat detract power from the profession:‘I think there will always be a respect because of theamount of work that you’ve had to do to achievebecoming a doctor. But, in terms of, the profession,because now it’s, ehm, a lot of the power has beentaken away from doctors I think, via politics andthrough the media and stuff like that, so, basically,sort of, medicine has been a bit de-mystified.’(Louise, Year 5)In general, wider access to medical information wasseen to make people more ‘health-savvy’ (Milele, Year2), to represent the gateway to more informed choiceand therefore to ‘empower’ patients:‘ … nowadays the patient is more empowered … [ … ] with more information on the Internet and withmore, erm …  and they know that they have morerights nowadays. So first of all they have more right tomaking a decision, and second of all, they have moreinformation. So in that way, that empowers them.’(Liang, Year 4) As the last two extracts show, power was seen almost as being a fixed quantity, some of which had beenpartially subtracted from medical professionals andappropriated by patients, although too often ininadequate and counterproductive ways. A Year 5student commented that the new trend in patients’approaches to medical knowledge was affecting theprofession on a broad level:‘I think to a certain extent society has more impact on …  the medical profession than the medicalprofession has on society. Like I said, the wholeInternet revolution and the patient coming inclutching a whole sheaf of papers going ‘‘I think I’vegot diabetes … ’’ ehm …  I think …  that’s made adifference to the medical profession and I think that it is the medical profession being pushed becausepeople are more likely to seek out  …  you know, moreabout stuff than we do.’ (Alison, Year 5)Far from linking power to networks of relations that underlie the production and circulation of certain ways of understanding health and illness, students’ views on medical power focused on its more concretedimension of ‘authority’. Power seemed to be closely linked to scientific knowledge and was viewed asbeing in the process of being redistributed because of the greater accessibility of scientific informationbrought about by the Internet. Students’ perspectiveson patient education illustrate this view further. ª  Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010;  44 : 187–196  191 Medical students, power and pedagogy
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