The Medical School as Multiple Communities of Practice: analysis of a longitudinal GP placement
In 2017, GKT School of Medical Education introduced a year-long, one-day-a- week longitudinal placement in General Practice for all 371 second-year medical students. This was introduced to address the need for early integration of clinical experience and basic medical science, align with shifts in healthcare towards community settings, and provide longitudinal support for students. This innovation aligns with international trends towards longitudinal undergraduate medical placements, supported by pedagogical benefits of continuity elements.
Such placements aim to develop students’ professional identities through becoming part of a Community of Practice (CoP), but research applying this theoretical framework to longitudinal placements is limited. We sought to use CoP as a sensitising theory to further explore student and tutor experiences of the placement.
The programme was researched using a case study methodology, with student and tutor experiences explored through routine evaluation questionnaires, focus groups and field notes from a tutor training event. The entire student (n371) and tutor (n54) cohort were surveyed, with respective response rates of 64% and 41%. Seven tutors and 47 students participated in focus groups. CoP was used as a sensitising theory for inductive thematic analysis of the qualitative data.
Four key themes emerged: role legitimacy, identity trajectories, perceived curriculum congruence and continuity of relationships. Student role legitimacy was enhanced by engaging authentically in clinical care and feeling welcomed into the clinical environment. The placement supported inbound professional identity trajectories, positively influencing conceptions of a career in General Practice. Tutors delivered course content with varying degrees of fidelity to the explicit curriculum, and divergence was often experienced by students and tutors as disallowed. Educational priorities of the placement were sometimes felt to conflict with those of Faculty, challenging student (and tutor) loyalties. These themes were supported and influenced by the continuity elements of a year-long longitudinal placement; with tutors, peers, learning environment and patients.
Data sources were triangulated during analysis, data saturation was met across the modalities, and the authors were mindful of continually maintaining researcher reflexivity; all of which contributed to the trustworthiness of the findings.
CoP theory contributes to the conceptualisation of the outcomes of an early years longitudinal GP placement, and provides a framework for understanding professional identity formation through legitimate peripheral participation. It can also elucidate tensions between the explicit and informal curriculum. Our findings support adopting the following measures: explicit introduction of CoP theory to students and tutors; supporting students to negotiate dissonance at the boundaries of CoPs through reflective practice and the development of boundary processes between disciplines delivering teaching; orientating CoPs toward clinical care to tackle interdisciplinary and hierarchical divides; encouraging legitimacy through providing students with narrow areas of clinical responsibility and promoting welcoming clinical environments.