Looking back to move forward: Using history, discourse and text in medical education research: AMEE Guide No. 73

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Practice points

Making meaningful change in medical education requires questioning taken for granted assumptions about what medical education currently is and what it should be. Historical, discourse and text analysis approaches, which are widely and successfully used outside medical education research, can enhance our field by helping us to ‘make strange’ things heretofore accepted as ‘normal’ or ‘natural’. History is not a singular linear development towards progressive improvement but rather a fluid construction incorporating multiple contextual perspectives. Discourse analysis enables researchers to understand the effects and relations of language, practices and power in our current assumptions about medical education. Text analysis, while often used in conjunction with discourse analysis, can also be useful for conducting many other types of qualitative research.

Box 1 Overview of Parker's framework

Criteria for distinguishing discourses	Description
Discourse is realized in texts	As the world around us is textual, we need to treat objects of study (e.g. documents) as texts which are described and put into words
A discourse is historically located	Discourses are embedded in history and should be considered in relation to time. We need to explore how and where discourses emerge and describe how they change
A discourse is a coherent system of meanings	Discourse is made up of groups of statements that present a particular reality of the world. The task of the analyst is to map the world as discourse represents
A discourse is about objects	Using language means referring to objects and representing them in particular ways. Hence, we unpick what objects are referred to and how they are talked about
A discourse contains subjects	As discourse addresses us in particular ways and allows us to perceive ourselves in certain roles, we need to identify the rights we have to speak in relation to any discourse
A discourse refers to other discourses	Describing discourses necessarily involves the use of other discourses. Contrasting different ways of speaking helps to disentangle this
A discourse reflects on its own way of speaking	Each discourse comments upon the terms it employs, referring to other texts to elaborate. Hence, there is a need to reflect on the terminology used
Discourses support institutions	Discursive practices involve the reproduction of institutions. Analysis involves identifying institutions that are reinforced or subverted when a discourse is used
Discourses reproduce power relations	Discourse and power are intimately related so we need to look at which categories of person gain and lose from employment of a discourse
Discourses have ideological effects	Different versions of how things should proceed can coexist and compete within discourse. Hence, there is a need to show a discourse connects with other discourse to sanction control

Note: Parker (2002) as presented in Shaw and Greenhalgh (2008). Reproduced with permission.

Box 2 Discursive changes in the good doctor in medical education

The good doctor as a Flexnerian scientist: The discourse of the scientist physician formed the basis of Abraham Flexner's proposals for reform. Flexner's scientist was an erudite and incisive thinker, who incorporated various forms of knowledge into his approach to his care for his patients. Flexner's scientist was generally socially well-placed, white and male

The good doctor as a man of character: Flexner's notion of the scientist physician was not adopted with the changes to medical schools that followed his report. Instead, science became curricular content and the discourse of the good doctor as a man of character became prominent

The good doctor as a compilation of characteristics: In the late (1950s) the discourse of the good doctor shifted from character to characteristics. Psychometric measures were increasingly used to dissect the medical student into his component parts

The good doctor as roles-competent: This discourse considers the good doctor as competent in the performance of various roles. Discourses of production combine with competency language to depict a manufacturing model of medical training

Note: Material derived from Whitehead (2011).

Figure 1. The CanMEDS diagram. Copyright © 2009 The Royal College of Physicians and Surgeons of Canada. http://rcpsc.medical.org/canmeds. Reproduced with permission.

Box 3 A discourse analysis of a graphic design: the CanMEDS daisy

This discourse analysis examined the CanMEDS diagram (Figure 1). Textual documents used in this analysis included the archives from the Educating Future Physicians for Ontario (EFPO) project (University of Toronto, Thomas Fisher Rare Books Library). The EFPO project developed a series of roles, which were modified by the Royal College of Physicians and Surgeons of Canada and organized into the daisy-shaped CanMEDS diagram. The discourse analysis aimed to understand the graphic design by identifying the discourses at play during roles development The EFPO project began as a response to a strike by physicians in Ontario, Canada. Project leaders aimed to better align physician education with societal needs by defining a series of roles that physicians ought to play. The project involved extensive public consultations with physicians, educators, students, other health care professionals and members of the public, including representatives from multicultural groups, disabled persons groups, women's groups, AIDS groups and seniors’ groups The principal author examined all documents in the EFPO archive. One prominent discourse identified was a discourse of threat (to physician expertise, status and authority) and need to protect the profession from these threatening forces. A second discourse was that of societal need. The discourse of societal need was repeatedly invoked in the discussion of roles. The proposed use of ‘roles’ appeared in the earliest EFPO documents as the way to achieve societal needs. However, nowhere in the archive was the relationship between roles and societal need explained. Instead, the two were placed side by side in sentences, and their connection rhetorically assumed by their direct and recurrent juxtaposition Visual images are not simply aesthetic, but convey messages that are value-laden (Zibrowski et al. 2009). The visual structure of the CanMEDS Framework is an innocent daisy, in which medical expertise is surrounded and encased by petals. Understanding the discourse of threat and a need to protect the profession's expertise that pervaded the EFPO documents, one possible interpretation of the graphic design could be that the ‘petal roles’ are functioning to ‘armour’ medical expertise

Note: Material derived from Whitehead et al. (2011a).

Table 1.  Boundaries that may be considered in selecting particular texts for analysis

Boundary	Examples of what might be specified	Examples of selected texts
Time	• Weeks • Months • Years • Centuries, etc.	• The medical charts produced on a ward over a 6-week period • The programmes of a health professions education conference over a 10-year period
Place	• Neighbourhood • City • Region • Country, etc.	• The reports about health care from a city's newspapers • The government regulatory documents related to a country's nursing education policies
Institution	• University • Medical school • Hospital • Hospital ward • International non-governmental organization • Committee, etc.	• The diversity committee documents from a university • The policy documents governing clinical work on a ward
Language	• Dominant international languages • Minority languages • Language(s) known to the researcher, etc.	• The academic journal articles written in English about the globalization of medical education • The academic journal articles written in Chinese and Arabic about the globalization of medical education
Content	• Subjects • Theories, etc.	• The blog postings about the medical school application process from Canadian and British websites • The academic journal articles about professionalism in the nursing education literature
Genres	• Prose fiction • Poetry • Academic journal articles • Academic books • Blog posts • Popular press articles, etc.	• The memoirs of medical school experiences published as mass-market paperbacks in English since 1970 • The poems published in the arts sections of high-impact general medical journals
Authors	• Educators • Learners • Clinicians • Patients • Researchers, etc.	• The stories written by patients for an online literary health care journal • The reports written by medical school Deans during accreditation reviews
Intended audiences	• Educators • Learners • Clinicians • Patients • Researchers, etc.	• The patient-information leaflets about the presence of medical trainees within a hospital • The grant applications about knowledge translation submitted to a national health research funding body

Table 2.  Questions to keep in mind when analysing texts

General question	More specific questions that may be important depending on the text, the theory/methodology being used and the research question
What is the text?	Is it a book, journal article, blog post, letter, dairy, photograph, painting, film, etc?
Who wrote the text?	What is his/her/their gender, age, ethnicity, country of origin, country of residence, socio-economic status, class, educational level, profession, job, etc?
When was the text written?	In what century, decade, year, etc?
Where was the text written?	In what country, city, type of institution, specific institution, etc?
How was the text written?	In what language, genre, form, etc? Using what key words, metaphors, symbols, etc? Making what key arguments?
Why was the text written in that way at that place and time by that person/group?	Was it commissioned, submitted, self-published, secret, paid for directly by a funder, funded indirectly, a plea for funding, supported, a plea for support, required, forbidden, authoritative, contested, transgressive, etc?
How does the text relate to the research question?
How does the text relate to other primary texts already analysed?
How does the text relate to secondary texts relevant to the study as a whole?

Parker I. Critical discursive psychology. Palgrave Macmillan, Basingstoke 2002

 Google Scholar

Shaw SE, Greenhalgh T. Best research – for what? Best health – for whom? A critical exploration of primary care research using discourse analysis. Soc Sci Med 2008; 66(12)2506–2519

 PubMed Web of Science ®Google Scholar

Whitehead CR. 2011. The good doctor in medical education 1910–2010: A critical discourse analysis. Dissertation, University of Toronto. [Accessed 30 March 2012] Available from http://hdl.handle.net/1807/32161

 Google Scholar

Zibrowski EM, Singh SI, Goldszmidt MA, Watling CJ, Kenyon CF, Schulz V, Maddocks HL, Lingard L. The sum of the parts detracts from the intended whole: Competencies and in-training assessments. Med Educ 2009; 43: 741–748

 PubMed Web of Science ®Google Scholar

Whitehead CR, Austin Z, Hodges BD. Flower power: The armoured expert in the CanMEDS competency framework. Adv Health Sci Educ Theory Pract 2011a; 16(5)681–694

 PubMed Web of Science ®Google Scholar