The construction of power in family medicine bedside teaching: a video observation study

Abstract

INTRODUCTION Bedside teaching is essential for helping students develop skills, reasoning and professionalism, and involves the learning triad of student, patient and clinical teacher. Although current rhetoric espouses the sharing of power, the medical workplace is imbued with power asymmetries. Power is context-specific and although previous research has explored some elements of the enactment and resistance of power within bedside teaching, this exploration has been conducted within hospital rather than general practice settings. Furthermore, previous research has employed audio-recorded rather than video-recorded observation and has therefore focused on language and para-language at the expense of non-verbal communication and humanmaterial interaction.METHODS A qualitative design was adopted employing video-and audio-recorded observations of seven bedside teaching encounters (BTEs), followed by short individual interviews with students, patients and clinical teachers. Thematic and discourse analyses of BTEs were conducted.RESULTS Power is constructed by students, patients and clinical teachers throughout different BTE activities through the use of linguistic, para-linguistic and non-verbal communication. In terms of language, participants construct power through the use of questions, orders, advice, pronouns and medical ⁄ health belief talk. With reference to paralanguage, participants construct power through the use of interruption and laughter. In terms of non-verbal communication, participants construct power through physical positioning and the possession or control of medical materials such as the stethoscope.CONCLUSIONS Using this paper as a trigger for discussion, we encourage students and clinical teachers to reflect critically on how their verbal and non-verbal communication constructs power in bedside teaching. Students and clinical teachers need to develop their awareness of what power is, how it can be constructed and shared, and what it means for the student-patient-doctor relationship within bedside teaching.power in education

Sociomateriality matters to family practitioners as supervisors

“…use of laughter, use of pronouns) and non‐verbal communication (e.g. body positioning, control of artefacts) 7 . For example, in this study 7 the role of the material world can be seen in the control of medical artefacts by learners as a way of constructing power in bedside teaching encounters in ways that do not necessarily follow accepted typical power asymmetries.…”

Social power facilitates and constrains motivation in the clinical learning environment

“…This research question indicates an assumption that trainees will be active in shaping their environment. Other studies within and outside medical education support this assumption, demonstrating that trainees engage in an assertive form of actor‐initiated, upward power . That is, they are active in influencing their environment from a low‐status position and use multiple strategies to try and improve both their learning and patient care.…”

“…Social power is a complex concept without authoritative definition; we understand it to be a ubiquitous feature of all social interactions that operates on both macro (structural) and micro (interactional) levels. Power both constructs and is reinforced through the hierarchies within which individuals interact.…”

Ethnography, methodology: Striving for clarity

“…Using a critical constructivist framework, they unveiled the role power plays in clinical knowledge, verbal and non‐verbal communication, trust and shared decision making. Power in medical education was also identified by Rees et al 11 through observational (video‐ and audio recorded) and individual interview methods (with students, patients and clinical teachers). Focusing on bedside teaching, their analysis concentrated on how power is constructed and contested within authentic doctor‐student‐patient interactions.…”

“…If the latter, then why do researchers use the term ‘ethnography’ (if not for legitimisation)? Other researchers in medical education, using the same methods as focused ethnography (eg, interviews, video‐recordings and audiorecordings of authentic activities), are equally successful in revealing these common elements of culture 11,12 . For example, Kuper et al 12 using the interview method, investigated the types of knowledge required to support medical students’ competence in non‐medical expert Canadian Medical Education Directives for Specialists roles.…”