Mapping the thinkable: ways of characterising and researching general practice placements

Problem

There has been increasing political debate surrounding recruitment of trainees into general practice, thought to be related to students’ undergraduate experiences; and recruitment of GP tutors in the context of service demand. Research texts are one important artefact of academic work, and one influential way in which discursive rules shape legitimate ways of thinking about placements and research. This project examines how it is thinkable within research texts to characterise placements and justify research, producing particular power relations between hospital and general practice placements; and related subject positions for patient, student, GP and researcher. Making visible these discursive rules and making curious currently ‘unthinkable’ ways of researching and characterising placements, can inform future approaches to address challenges recruiting and retaining trainees and GP tutors.

Approach

Foucauldian discourse analysis (FDA) makes visible how each utterance is made within specific discursive boundaries, to which certain rules of acceptability apply. These rules produce particular power relations: treating as normative certain ways of seeing or being, and marginalising others. This project analysed texts about general practice undergraduate medical education in the UK, dating from 1960s to present. An approach to FDA was used to categorise objects, subject positions, concepts and strategies within texts. This built a map of ways in which texts characterise placements and produce particular ways of being for students, patients, and GPs; how these link with ways of conceptualising learning; and how particular ways of claiming the legitimacy of research shape how placements are characterised and limit available positions for researchers and practitioner-researchers.

Findings

Two ways of characterising placements are identified. A ‘gaze of discovery’ views placements as opportunistic experiential learning with patients, producing possibilities for patients as ‘educator’ and ‘contextualised disease’; GP-teacher as ‘facilitator’; and student as ‘participatory learner’ or ‘intruder’. A more dominant ‘gaze of deciphering’ treats placements as pre-determined curricula compartments using mind-body and knowledge-skills-attitude distinctions to imagine different learning in different spaces. Placements are treated as basic, early, or filling gaps in hospital-based curricula. This produces patient as ‘subject with x’; student as ‘learner of curriculum’; and GPs as ‘teacher or clinician’ and ‘not knowing’.Evaluation is the dominant way of justifying research, positioning placements as innovative (and thereby un-established) and researcher as ‘evaluator’, distinct from clinician-teacher. Other texts justify researcher as ‘making voices heard’, some legitimising co-construction of knowledge and an integrated position for researcher-practitioner.

Consequences

Overall, strategies position placements as supplementary and different to hospital teaching. Justifying research as evaluation produces challenges for the field’s legitimacy in relation to other research. While teaching is treated as exchange of existing knowledge, research is positioned as informing teaching practice, legitimising its value through production of new knowledge.