The Contribution of General Practice Placements to Medical Education: A Foucauldian Discourse Analysis of the construction of general practice placement knowledge in published medical education research

Problem

Fifty percent of the UK workforce is expected to enter general practice training, but recruitment is in crisis. Delivery of teaching in the general practice setting is reducing (Harding 2015), currently ranging 3-15% of undergraduate curricula. This study examines published, research literature about undergraduate medical education in the UK general practice setting 1970s - present, producing a map or topography of how general practice placements are characterised within this discursive field.

Approach

This study examines what is said to be taught and learnt in undergraduate general practice placements, using Foucauldian Discourse Analysis. This includes examination of how the object of general practice placements are characterised; what subject positions are produced; and the conceptual and strategic treatment of placements. This analysis examines what is made 'thinkable' within this influential discursive field.

Findings

Two 'gazes' are identified. The first is a 'gaze of discovery'. Here, the student-patient encounter is contemporaneous with the clinician. Placements are characterised as 'patient-based' and 'reality'. However, students are positioned as 'disruption' or 'intruder' to the 'normal' consultation. The second, is a 'gaze of deciphering'. Here, placements are characterised as knowledge compartments (e.g. chronic disease, interactional knowledge such as 'communication'). Patients are selected for teaching and the GP subject split between 'teacher' and 'clinician'. Conceptually, a discovery teaching encounter is treated as abnormal, producing different expectations for consent and practice. A deciphering encounter polarises teaching and service as competing activities. Strategically, generalist placements are treated as innovative (and thereby unestablished), different and supplementary to hospital-based education.

Consequences

Tensions exist within this discursive field between a generalist education and a pedagogic system which treats 'good learning' as pre-determined, and structured as short-term, disciplinary compartments. This positions general practice teaching as teaching what is not taught by the hospital or as 'early', 'basic' knowledge, challenging integration of service and teaching in this setting. Mapping the 'thinkable', enables consideration of the 'unthinkable': Might general practice placements (and their impact on future training and recruitment) be re-characterised as longer (positioning the student as 'acceptable' and the teaching encounter as 'normal') and the pedagogic system be more aligned with generalism (permitting space for patient-generated, rather than pre-determined disease frameworks, and integrating - rather than competing between - a GP’s role as teacher and clinician).