Essential workers? An institutional ethnographic lens on pandemic GP placements

ABSTRACT

Background

Clinical placements for medical students in the United Kingdom (UK) came to an abrupt halt in March 2020. The rapidly evolving Covid19 pandemic created specific challenges for educators, balancing safety concerns for patients, students and healthcare staff alongside the imperative to continue to train future clinicians. Organisations such as the Medical Schools Council (MSC) published guidance to help plan return of students to clinical placements. This study aimed to examine how GP education leads made decisions around students returning to clinical placements for the 20/21 academic year.

Method

Data collection and analysis was informed by an Institutional Ethnographic approach. Five GP education leads from medical schools throughout the UK were interviewed (over MS TEAMS™). Interviews focused on the work the participants did to plan students’ return to clinical placements and how they used texts to inform this work. Analysis focused on the interplay between the interview and textual data.

Results and Discussion

GP education leads actively used MSC guidance which confirmed students to be ‘essential workers’, an unquestioned and unquestionable phrase at the time. This permitted students to return to clinical placements by affording the GP education leads authority to ask or persuade GP tutors to accept them. Furthermore, by describing teaching as ‘essential work’ in its own right in the guidance, this extended what the GP tutors came to expect to do as ‘essential workers’ themselves.

Conclusion

GP education leads activated authoritarian phrases such as ‘essential workers’ and ‘essential work’ contained within MSC guidance to direct students’ return to clinical placements in GP settings.

KEYWORDS:

• GP
• general practice
• institutional ethnography
• pandemic
• undergraduate teaching

Background

The COVID19 pandemic has changed people’s lives throughout the world, from employment to education, from health to how to seek healthcare. Providers of higher education moved abruptly away from campus teaching towards an online curriculum and mode of delivery [1,2]. With health profession students in their senior years normally spending a large proportion of their time engaged in experience-based learning [3], their removal from clinical environments resulted in unique challenges for those leading Health Profession eEducation (HPE).

With the arrival of the pandemic, clinical environments were deemed to be highly contagious, and patients, students and staff in them vulnerable to transmission of this infection. Almost overnight in March 2020, UK medical students were removed from clinical environments including both hospitals and general practice (GP). In the months that followed, those holding educational leadership roles in medical schools embarked collectively on the formation of plans to return medical students to clinical environments for the 20/21 academic year. Leaders looked to bodies such as the General Medical Council (GMC) and the British Medical Association (BMA) for guidance on how to do this safely.

In May 2020, the Medical Schools Council (MSC) published guidance entitled ‘Statement on clinical placements’ [4] aimed at facilitating clinical leaders to make plans for return to clinical placements. A return to clinical placements in GP settings posed unique difficulties as practices varied widely with regard to available space, team size and ownership of premises. This further challenge came at a time when work and responsibilities in the clinical domain trumped other ‘non-essential’ duties.

The idea for this study came from our own experience as we, ourselves GPs and GP educators, were facing these challenges. We were curious about how others were making decisions and what they were using to inform these decisions. The pandemic provided the ultimate instance where leads for undergraduate education in GP had to make difficult decisions about what and how to prioritise for learning in GP settings, and how to lead, support and give reassurance to GP teams struggling to maintain the delivery of a service in disrupted and fragmented times. The consideration of where guidance might come from and the extent to which it might be used to navigate these uncharted waters was of utmost interest.

Whilst we do not often encounter the seismic disruption of a pandemic, an understanding of what influences GP education leads to make decisions on clinical placement at times of challenge matters to both on-the-ground educators, educational leaders, and to student experience. It matters because it forces us to question the value we ascribe to students learning in clinical environments. Contemporary educational pedagogy such as experience-based learning [3] reinforces the centrality of learning from and with real patients in practice contexts. Specifically in primary care, key curricular documents for GP [5,6] emphasise the importance of students being encouraged to consult with patients in order to meet the aim of item 11 in Outcomes for Graduates, ‘Newly qualified doctors must be able to carry out an effective consultation with a patient’ [7]. Do we consider learning from real patients in GP settings as ‘essential’ for these future colleagues? What can we discover that may support learning in GP in challenging times for the future?

We chose to use an Institutional Ethnography (IE) informed approach in this research, cognisant of how the tensions we were exploring started from our own experiences. IE is a critical sociological approach which has been widely used in healthcare settings [8–10]. It is borne out of the life work of Dorothy Smith [11–13] based on her reading of Marx and her involvement in the feminist movement. As a theory/methodology in itself, the approach fundamentally ‘starts from people’s everyday local experiences and explores the trans-local that is present in and organizes their everyday’ [14]. With roots in activism and social justice issues, it is common (though not essential) for IE studies to start in the ‘on-the-ground’ experiences of the researchers themselves before the inquiry moves to look at where and how these experiences are shaped, sometimes abstractly referred to as the ‘system’. IE locates at the interface between the ‘ground’ and the ‘system’, an interface where we found ourselves at that time.

An understanding of the IE concepts of ‘work’ and ‘texts’ will aid in the reading of this article. In IE, work is considered in a generous sense, ‘The concept of work is extended here to what people do that requires some effort, that they mean to do and that involves some acquired competence’. [11] This goes beyond what people do as employees, often encompassing caring or advocacy work. Whilst many qualitative approaches analyse texts, in IE textual data sits alongside other sources data such as interview or observational of data. Texts are defined as ‘definite forms of words, numbers or images that exist in a materially replicable form … across time and space and among people variously situated’ [15]. Texts are considered to carry the message of the ‘system’ and organise what happens on the ground, but only once activated by people in their work; they have no agency without people.

Whilst IE has been widely used as an approach in research into healthcare settings, this is not yet the case in (HPE) research. Advocates have suggested it as an important addition for the field [16]. This argument is in part due to the strand of IE research which focuses on that which is coined ‘new public management’, described by Griffith and Smith as, “the adoption and adaptation of strategies and textual technologies that revolutionised corporate management during the 1980s and 1990s “ [17]. New public management ideals such as efficiency, standardisation and accountability are becoming increasingly more visible in health care and health professions education; using an IE lens, our objective was to see how these ideals played out ‘on-the-ground’.

One likely reason for slow uptake of IE as a research lens in HPE is the length of time required both to learn this complex approach and to apply it unequivocally. A number of publications in health and HPE have adopted and demonstrated the merits of a pragmatic ‘IE-informed approach’ to data collection and analysis, to guide rather than rigidly dictate data collection and analysis in a way that is useful and usable [8,18]. We have therefore focused on ‘work’ and ‘texts’ in a pragmatic way, keeping social organisation at the core. We have not utilised other recognised IE principles such as ‘problematic’ and ‘standpoint’, and tried where possible not to use IE terminology such as ‘ruling relations’ where we can explain without potentially off-putting jargon. [See 16 for explanation of these terms]

Aims of this research

The aim of this study was to examine how GP education leads made decisions on students returning to GP clinical placements for the 20/21 academic year, what texts they used to support their decisions and how these texts informed and shaped their decision-making processes. We specifically looked at how they engaged with the text, the MSC guidance, using the discursive concept of ‘essential workers’ within it to achieve their aim, with reference to accountability. Using an approach informed by IE, we focused on what the GP educational leads actually did as their ‘work’ and the role that ‘texts’ played in this ‘work’. A secondary aim of this article was to exemplify the use of an IE-informed approach in Primary Care research, demonstrating how this illuminating lens can be used in a pragmatic way.

Method

An IE-informed approach

This qualitative study was grounded in the traditions of IE. We applied the concepts of IE to inform data collection and analysis, which took place in an iterative fashion. By this we mean that analysis began before the initial interview with textual analysis, and continued throughout and beyond the interviews. While we will describe them separately, they were not linear processes.

Research ethics

Full ethical approval for this study was granted by Queen’s University Belfast’s Faculty of Medicine, Health and Life Sciences Research Ethics committee (Ref MHLS20_90_A1).

Research team composition and reflexivity

The research team consisted of three academic GPs, who were themselves involved in the planning for return to GP clinical placements within their own institutional context. All three were working clinically as GPs throughout the period of interest, thus had their own ‘on-the-ground’ appreciation of the challenges and realities of GP practice at various stages through the pandemic. GK and NH have extensive prior expertise in IE research and HR is a highly experienced educational researcher with particular expertise in qualitative methods. The lead researcher (GK) carried out all the interviews, including one with another member of the research team, NH, in his role as a GP education lead. Within the IE approach, it is common that the experiences of those involved in the research form part of the data, as described above. In addition, NH is a member of the Society for Academic Primary Care’s GP Heads of Teaching (HoTs) (comprising a senior member of the GP Teaching team in each UK medical school) from which the participants were recruited.

Study setting and participant recruitment

The study setting was UK medical schools. An invitation to participate in this study was extended to those with senior educational leadership roles in GP education teams of each medical school; this invitation was sent to those who sit on the HoTs group described above. The vast majority of the UK’s medical schools (approximately 30) are represented at this group. NH introduced the study to this group at a meeting and the request was followed by a formal email invitation including a Participant Information Leaflet. Members of the group were requested to cascade this invitation to other academic GPs with significant responsibilities for teaching and coordination of teaching, especially in the event that they were unable to take part themselves. All respondents expressing interest in the study were interviewed.

Data collection

As previously described, the data collection and analysis took place in tandem and simultaneously informed the other. For ease of explanation, we will describe them here separately. Gathering of texts began at the point where the idea for the research came about and continued throughout the study. For the interview data, GK interviewed five GP education leads from medical schools throughout England, Wales and Northern Ireland. Interviews were conducted via Microsoft (MS) TEAMS™. The focus of the interview was on the work that the GP education leads did to plan students’ return to clinical placements and how they used texts to inform this work. A preliminary interview guide was devised containing broad questions with more prompting questions to get the detail of what people actually did and importantly, to ask where their work was organised from. As with other qualitative approaches, the interview guide was developed iteratively as the interviews proceeded (see Figure 1).

Figure 1. Example prompts questions in the developing interview guide.

During the interviews, the researcher orientated participants to what the IE approach focused on – what they actually did, in their work specifically, as opposed to abstract concepts, e.g. how they thought about who they needed to contact to discuss return to placements as they exercised at the weekend or drove home from work. To consider the role that texts had played in shaping their work, the researcher and participants explored, during the interview, participant-identified texts. These included, but were not limited to, the MSC guidance [4] which the researcher had referred to in the study information circulated to participants as part of the recruitment process.

The five interviews were conducted between June and September 2021 and ranged in duration from 18 to 45 minutes. With participant written consent, interviews were audio-recorded and transcribed within MS Teams. GK listened back to the recordings with the transcripts to ensure accuracy of transcription. Within the IE approach, there is no ideal number of interviews required for sufficiency, the aim for the research team is to have an understanding of the work and where the work is organised from. With the ongoing pandemic meaning relentless pressure on potential participants, a pragmatic decision was taken within the IE-informed approach to conduct no further interviews. Additionally, interview data forms only part of the dataset, alongside the textual data considered so important in IE.

Data analysis

The research team analysed the texts and transcripts as data collection was ongoing; initially, this was a process of familiarisation with the data. Analysis in IE involves ‘writing accounts’ [19]; initially identifying and highlighting (indexing) transcript excerpts relating to what was happening on the ground, writing the ‘work’ of the participants into accounts. The analytic interest then moved to consider from where this work was determined or ‘socially organised’, i.e. what organising forces, likely in the form of texts, prompted them to do what they did, what Rankin refers to as ‘the account of the institution’. [19] Discussions within the research team about the data, including both the interview data and textual analysis of documents mentioned, were a fundamental part of the analytical process: the interplay between the interview and textual data was the focus for the analysis. These accounts of what the GP education leads did and how texts organised this work, were presented to the HoTs Educational Research Special Interest Group, providing an opportunity to check whether the findings chimed with the wider group of GP education leads.

As is conventional in an IE-informed approach, in the following section we present the results and discussion of the study together, as they are inextricably linked. Participants have been given a pseudonym to give the reader a sense of each as an individual and to show how their standpoint is ‘coming though’ in the analysis.

Results and discussion

In the interviews with the GP education leads, the MSC guidance (arguably unsurprisingly) appeared to be the important text in their work. Whilst they spoke abstractly about looking to other sources such as the BMA, GMC and local governments, the MSC guidance was the only one spoken about concretely. All but one of the GP education leads actively described engaging with it. This active engagement with a particular text means that (in the language of IE), participants ‘activated’ the MSC guidance. This document contained a very specific and directive phrase for the work of these GP education leads.

Whilst it is possible to support some learning online and through simulation, … clinical placements must be made available to students.

One participant, Oliver, described how they were focused on one particular phrase.

The only bit that I think I probably ever read in detail and thought was important for me at that point was the essential workers.

Essential workers

The GP education leads specifically discussed this phrase contained within the MSC guidance of ‘essential worker’.

The Medical Schools Council (MSC) welcomes the confirmation from the Department of Health and Social Care in England that medical students are deemed to be ‘essential workers’.

The MSC text confirmed to the GP education leads that students were included in those deemed ‘essential workers’ at a time when this previously unfamiliar phrase had become a part of everyday language. Molli described the ‘relief for all of us’ this phrase brought; Charlotte reflected similarly.

That was a huge relief because we were sitting there until we had that … there would be no doubt, they had to be on the wards, they had to be in practice ‘cause they are essential workers.

Andrew described more concretely what this phrase entitled students to do.

At that time, it was what you …, essential workers could drive to work, essential workers could travel around, essential workers would get PPE [personal protective equipment].

The MSC guidance specifically makes reference to these details that Andrew mentioned – PPE, travel etc.

As the GP education leads activated this guidance, the powerful phrase ‘essential workers’ was the discursive concept, the green light they needed to get students back into clinical placements. Oliver spoke of actively waiting for the publication of this guidance, anticipating the inclusion of this phrase, the catalyst to allow them to press ahead with plans.

Really I just needed the document with an official title saying confirming they would be essential workers so that we could get on planning for September.

This unquestioned and unquestionable phrase permitted the GP education leads the necessary authority to ask or persuade GP tutors to accept their plans.

As already stated, all but one of the GP education leads spoke of actively engaging with the MSC guidance when planning return to placement. This GP education lead did use this guidance in time, but stated they initially found it difficult to apply in a Primary Care setting. Interestingly, this lead, whilst responsible for a part of the Primary Care Curriculum in their institution, was now making the overall decision about return to placements.

The ‘essential work’ of teaching

GP education leads discussed how the MSC guidance went further than establishing students as essential workers. It went on to state,

… teaching and supervising medical students on clinical placements should be seen as essential work within the health service.

GP tutors’ clinical work during the pandemic meant that they themselves were considered to be essential workers, fulfilling this role from the outset of the pandemic; their clinical work was regarded as ‘essential work’. This guidance extended what is considered under the banner of ‘essential work’ to necessarily include teaching; their teaching work was elevated to ‘essential work’ in the way that they (and the public) had come to consider their clinical work during the pandemic. As a derivative of the unquestioned phrase ‘essential workers’, the phrase ‘essential work’ assumed the same authority.

When GP education leads activated the MSC text, stating that teaching by GPs was ‘essential work’ in its own right, this gave them the authority to ask GPs to resume this important work. Andrew explained, in incontestable terms, the power it gave them.

[The text] gives us an assurance that that we could face down any resistance to having medical students in the clinical environment.

Many of the GP education leads were themselves working on the front line as GPs during the pandemic, receiving huge numbers of emails on a daily basis about how to configure and adjust clinical services during the pandemic. Despite this, many of the GP education leads chose to send the MSC guidance onto the GP tutors by email. Andrew stated,

There’s the tsunami of communication emails and all the rest … when you see something like that you go well, this is actually really important, so we should share it and we should refer to it … They knew what we were working to and what we were answering to.

Molli brings these two points together, where on explaining that they also included the MSC guidance in their newsletters to GP tutors, she stated how the tutors on receiving this guidance ‘didn’t argue the point’.

Arguably, the GP education leads were sharing this to reference that this call for return to placements came from a higher authority that they themselves were also answerable to. The text explicitly refers to guidance from the regulatory body for doctors in the UK, the GMC, in reference to a document used by each medical school.

In order for medical students to meet the standard required by the General Medical Council in Outcomes for Graduates 2018, before graduation they will need to be able to see and take part in the treatment real patients under supervision.

In new public management terms, this is the textual reference of the standards the work of the GP education leads would be judged against. This text, once activated by the GP education leads, named a higher authority to which all this work was accountable to. It played on both the GP education leads’ and the GP tutors’ unquestioned need for all their work, to include the essential work of teaching, to be accountable in a regulatory sense, in a way they were accustomed to with their clinical work. Use of the IE lens to inform this study underlines how accountability played out on the ground for GP education leads and how it provided the ideology that focused how GP educations leads carried out their work. It is interesting to note that medical schools were not answerable (or accountable) to the MSC as such, elevating the authority their guidance created authority once activated as a text.

But essential to whom?

Despite its powerful phrasing, some of the GP education leads acknowledged tensions around the term ‘essential workers’. Some critically questioned the phrasing; to whom is the work essential or what is it essential for? Some specifically mentioned that the essentiality of this work was for the running of the National Health Service (NHS), rather than the learning experience of individual students. The MSC guidance specifically stated the need to, ‘graduate students for the NHS’, and later referred to graduating students ‘in order that they start their professional lives in the NHS’. Hana reflected tensions gleaned from GP tutors about more junior students being in GP settings.

There’s always a kind of an imbalance between … our GP teachers’ perception and patients’ perception of the the, the use and value of students in practice compared to you know, actually, an essential worker. Like I think a fifth year, that’s about to qualify then that’s very different, isn’t it, from being a fourth year who still basically needs a lot of hand-holding and teaching and so on. The teachers were fairly torn if that makes sense.

This GP education lead was clearly sceptical of how ‘essential’ all students really were in clinical practice, offering their opinion on the difference between an about to graduate student, soon to start work for the NHS, as referred to in the MSC guidance above and a fourth year student, whom they suggest is far from realising this goal.

Conclusion

This IE-informed approach examined the work of GP education leads in planning for return to clinical placement for students during a pandemic and how they used texts in this work. GP education leads activated the Medical Schools Council (MSC) guidance, bringing into action authoritarian phrases such as ‘essential workers’ in referring to the students placed in clinical environments and ‘essential work’, referring to teaching as part of the work of GP tutors. These phrases enabled them to ask (perhaps persuade) GP tutors to have students return to clinical placements in GP settings. This study is an example of IE-informed research, where the concepts of work and how texts organise this work can be used in the approach to data collection and analysis in Primary Care research, in an informed yet pragmatic way.

Acknowledgments

We would like to acknowledge all the participants who gave up their time to be involved in this study.

Disclosure statement

As stated in the article, NH is a member of the Society for Academic Primary Care’s GP HoTs and the HoTs Exec, from which the participants were recruited. NH was interviewed as part of this study.

Additional information

Funding

The authors reported there is no funding associated with the work featured in this article.