Exploration of clinical learning in general medical practice: a case study

Abstract

This thesis tells a story of a single year in the life of a primary care teaching practice from the multiple perspectives of clinical learners and those supporting learning. This story involves many people from junior medical students to nurses and doctors with twenty years of experience. It explores how they learn as clinicians. The research takes the form of a single descriptive case study based within a purposefully chosen GP teaching practice in West Yorkshire, England. The case study comprises interview, observational and documentary data collected over a single academic year in 2008/9. Interview data from 33 subjects were transcribed and analysed using thematic analysis within a modified grounded theory approach. The evidence from interview data was strengthened through direct and indirect observation and from documents relating to learning and teaching. I present a theory of how clinical learning occurs within the chosen practice, and on the nature of being a teaching practice. The findings are presented in the context of the existing literature of learning in this setting and within a theoretical framework of literature on social learning and communities of practice. Clinical learning appears to occur through engagement and opportunity. Engagement in learning is made up of four elements; recognition, respect, relevance and emotion. The elements are remarkably consistent across learner groups. Opportunity includes the availability, authenticity and immediacy of patient encounters; and the opportunity to learn with and from peers and professional colleagues. The research findings are consistent with existing work on social learning from other settings, but add to the literature. Engagement appears possible through recognition, relevance and respect and in the absence of meaningful participation, belonging or a clear trajectory of learning. Meaningful opportunities for clinical learning include those where patient encounters are made powerful through the authenticity that arises from the social and personal context of illness, and from the immediacy of hearing patient narratives de novo. The teaching practice studied in the case study is not dissimilar to others described in the literature of primary care learning, but this case study offers a far more detailed exploration of the elements which contribute to learning in the practice. These elements include strong whole practice support for learning, a skilled and committed clinical and educational workforce and a more indefinable additional element which is best summarised as a passion for education.