Communities of clinical practice and normalising technologies of self: learning to fit in on the surgical ward

Abstract

This paper reports observational research of Fourth Year medical students in their first year of clinical training doing their surgical attachment. Previously, the authors have argued that medical curricula constitute normalising technologies of self that aim to create a certain kind of doctor. Here, they argue that a key mechanism through which these normalising technologies are exercised in the workplace is Etienne Wenger's communities of practice. In the clinical environment the authors identify communities of clinical practice (CoCP) as groups of health professionals that come together with the specific and common purpose of patient care. Fourth Year medical students join these transient communities as participants who are both peripheral and legitimate. Communities of clinical practice are potent vehicles for student learning. They learn and internalise the normative professional values and behaviours that they witness and experience within the disciplinary block of the medical school and teaching hospital; specifically, the authors suggest, it is through their participation in communities of clinical practice that medical students learn how to ‘be one of us’.

Keywords:

• medical anthropology
• qualitative biomedicine

Acknowledgements

This research was funded by a University of Otago CALT Research into Teaching Grant. Ethical approval was granted by the University of Otago Ethics Committee (ref. 03/10/114). The authors are grateful to the Department of Surgery at the Dunedin School of Medicine for opening up the teaching ward rounds and clinical tutorials to the critical gaze of the authors in this exploration of the clinical learning environment, and for their engagement with the perspectives that arose out of it.

Conflicts of interest: none.

Notes

1. Issues of professional socialisation are far from simplistic. Many medical curricula, including that of the authors’ medical school, attempt to counter negative informal and ‘hidden’ professional socialisation processes with formal professional development courses. How successful they are in practice is debatable (Osterman and Kottkamp 1993; Stern 1998; Herbert 2003). Similarly, the authors’ previous research has shown that clinical teachers may deliberately role-model behaviours and values in order to counteract negative processes in professional socialisation (Jaye et al. 2005).

2. Although the authors are superimposing the ‘team’ over the CoCP for simplicity's sake, there are important differences. Both the surgical team and the CoCP consist of a core group of consultant surgeons (in this case either two or three). There are varying degrees of transience in both the team and the CoCP; medical students may be attached to the team for a few weeks at most, house surgeons for three to 12 months, and registrars may be relatively stable members over a period of one or two years. However, what distinguishes the team from the CoCP is that the surgical team is a formal institutional structure and represents a professional group. It is clearly centred on the consultant surgeons who lead it, and endures beyond the patient stay. There are other teams on the ward, notably the nursing team – again a professional and formal institutional structure. CoCPs, on the other hand, are relatively informal groupings that tend to form around the requirements of particular patients and in this sense are centred on the patient. While patients are necessary participants in CoCPs, they are not members of the team. Another key distinction is that while the CoCP has a very specific purpose in providing the necessary care for a particular patient, the team is more ambiguous – having much broader responsibility and jurisdiction. A corollary distinction is that while the team is comprised of members, it is participation that defines the CoCP.

3. The surgery attachment is popular with medical students. Contributors to a Dunedin School of Medicine Fourth Year student website in 2005 gave the surgery run a four-star rating (out of five) and advised students yet to experience this attachment that it is a tough environment but not to take this personally (Anonymous 2005).