Is it me or is it them? Factors that influence the passing of underperforming students.

CONTEXT: Research has found that clinical assessments do not always accurately reflect medical student performance. Barriers to failing underperformance in students have been identified in other vocational settings. Is 'failure to fail' an issue for medical educators in the UK, and, if so, what are its determinants? METHODS: We carried out a qualitative focus group study exploring the views of medical educators (general practitioners, hospital doctors and non-clinical tutors) from two different UK medical schools. To make sense of a potential multitude of factors impacting on failure to fail, we selected the integrative model of behavioural prediction to underpin our data collection and analysis. RESULTS: Ten focus groups were carried out with 70 participants. Using both theory and data-driven framework analysis, we identified six main themes relevant to the integrative model of behavioural prediction. These are: tutor attitudes towards an individual student; tutor attitudes towards failing a student; normative beliefs and motivation to comply; efficacy beliefs (self-efficacy); skills and knowledge, and environmental constraints. DISCUSSION: Many different factors impact on medical educators' failure to report underperformance in students. There are conflicts between these factors and the need to report competence accurately (i.e. duty to protect the public). Although some of the barriers identified are similar to those found in previous studies, using a theory-based approach added value in that it facilitated a richer exploration of failure to fail. Insights offered in this study will be used to plan a questionnaire study and subsequent intervention to support medical educators in accurately reporting underperformance in students.

Why people apply to medical school: implications for widening participation activities.

OBJECTIVES: This research aims to identify the influences contributing to students' decisions to study medicine and to apply the findings to the design and targeting of outreach activities aimed at widening participation. METHODS: Semi-structured interviews were carried out with 15 medical students at a UK medical school. Framework analysis was used to identify themes and subthemes and findings relating to becoming a doctor were analysed further in the context of a theory of career decision making. RESULTS: Five themes and subthemes were identified. We report the results for the 3 main aspects relating to becoming a doctor from the theme School to Medical School Transition: early motivation; inhibitory factors, and facilitating factors. Many students spoke about having always wanted to study medicine. Early exposure to the possibility of being a doctor allowed the idea to flourish and motivated students to achieve high academic goals. Inhibitory factors included discouragement from application by teachers on the grounds of not being 'doctor material'. Factors which facilitated access to medicine included the support of family members, particularly mothers, and other close friends, and having positive role models. CONCLUSIONS: Our analysis provides evidence of important factors in career decision making for medicine which can be used to inform widening participation interventions in 3 areas, namely, those of school support, home support and raising aspirations.

Doctors being up there and we being down here: a metaphorical analysis of talk about student/doctor-patient relationships.

This paper describes the metaphorical conceptualisations of student/doctor-patient relationships, as articulated by multiple stakeholders in healthcare. Eight focus group discussions with 19 patients, 13 medical students and 15 medical educators (comprising doctors, other healthcare professionals and non-clinical academics) were conducted in England and we subjected our transcribed and audiotaped data to a secondary level of data analysis i.e. systematic metaphor analysis. The analysis revealed six over-arching metaphors associated with the target domain of student/doctor-patient relationships i.e. STUDENT/DOCTOR-PATIENT RELATIONSHIPS AS WAR, HIERARCHY, DOCTOR-CENTREDNESS, MARKET, MACHINE and THEATRE. All of the metaphors (except theatre) emphasised the oppositional quality of student/doctor-patient relationships. Three of the source domains emerging from our empirical data (i.e. hierarchy, doctor-centredness, and market) relate to metaphors already employed in the non-empirical literature to discuss doctor-patient relationships (e.g. paternalism, patient-centredness, and consumerism). The three remaining source domains (i.e. war, machine and theatre) were novel in their conceptualisation of student/doctor-patient relationships, albeit that they have been reported in previous empirical literature to describe other target domains. In this paper, we discuss each of these metaphors and their associated entailments, including those found in our data and those absent from our data. We also differentiate between the unconscious use of metaphorical linguistic expressions by our participants and those serving a rhetorical function. Although analysing metaphoric talk is not without its difficulties, the construction of metaphoric models can help social researchers better understand how individuals conceptualise and construct student/doctor-patient relationships.

Revealing implicit understanding through enthymemes: a rhetorical method for the analysis of talk.

BACKGROUND: Everyday talk is characterised by implicit information that the listener is required to infer. We introduce a method of analysis based on theories from semiotics and classical rhetoric that enables the researcher to reveal unspoken beliefs that underlie such talk. OBJECTIVE: This paper aims to provide a detailed description of the process of unveiling the hidden elements of logical inference within narrative. We wish to enable other medical education researchers to utilise this method in their own field of interest. OVERVIEW: We begin by giving an overview of the concepts of the enthymeme in rhetoric and opposition in narrative analysis. We then demonstrate the steps required in order to undertake such analysis by using examples from our own data. Strengths and weaknesses of this approach, including the problem of inference, will be discussed. CONCLUSION: We identify a number of current domains in which the investigation of enthymemes has been fruitful. We suggest that this method might also be utilised successfully within the domain of medical education research and encourage other researchers to consider this approach.

"From the heart of my bottom": negotiating humor in focus group discussions.

Reporting and analyzing interactional data collected during focus groups can be a significant challenge for qualitative health researchers. In this article, the authors explore the use of humor among focus group participants as one area of interaction and negotiation that is methodologically interesting and theoretically insightful. They explore discussions about service user involvement in medical education across eight focus groups consisting of medical educators, medical students, and service users. The findings suggest that humor can be used among focus group participants to maintain solidarity, navigate coping strategies, and negotiate power. Not only is humor useful when exploring new concepts, it can also be an indication of wider views that might not be explicit in an analysis of focus group members' comments alone. The authors urge qualitative health researchers to examine interactions among focus group participants, and their analysis of humor illustrates how this can be achieved.

The trouble with assessing students' professionalism: theoretical insights from sociocognitive psychology.

The academic literature on professionalism assessment in medical education is burgeoning, and its focus has primarily been on the assessment of professional behaviors. Consequently, the attitudinal elements of professionalism have largely been ignored in the literature. As a result, educators chiefly rely on professional behavior alone as the primary measure for professionalism without giving proper consideration to students' underlying attitudes. Using theoretical insights from sociocognitive psychology, this viewpoint article begins by discussing the relationship between attitudes and behaviors. It suggests that attitudes are poor predictors of behavior when external constraints, such as social pressure to behave in a particular way, are strong. It continues with a critical examination of the phenomenon of "faking it"--students faking professional behaviors to garner positive reactions from observers. This practice is contrasted with students who at times behave unprofessionally in response to social pressures or other contextual components, despite having professional attitudes. So, in using behavioral assessment alone, we may pass students with professional behaviors but unethical attitudes and fail students with unprofessional behaviors but ethical attitudes. Guided by a sociocognitive model of behavioral explanation, the article ends with some practical recommendations for coupling observation with conversation to assess students' professional behaviors and their attitudes more fairly.

Physicians' perceptions of clinical teaching: a qualitative analysis in the context of change.

BACKGROUND: Change is ubiquitous. Current trends in both educational and clinical settings bring new challenges to clinicians and have the potential to threaten the quality of clinical teaching. OBJECTIVE: To investigate hospital specialists' perceptions of clinical teaching in the context of change. DESIGN: Qualitative study using in-depth semi-structured interviews. SETTING: Three hospital trusts in the United Kingdom associated with a new medical school. PARTICIPANTS: A purposive sample of 15 clinicians from each of the three participating hospitals was approached. A total of 13 participated in the in-depth interviews: three from hospital A, six from hospital B and four from hospital C. RESULTS: The two main themes of 'Characteristics of Good and Bad Teachers' and 'Clinical Teaching Approaches' emerged. These were underpinned by a number of sub-themes; including some seen by participants as potential barriers to teaching and learning, for example, organisational and personal issues. CONCLUSIONS: Potential barriers to teaching and learning, including why good clinical teachers may at times seen to be intimidating or to cause humiliation and problems of engaging with new educational practices, can be understood within the context of change resistance. Knowing more about how clinical teachers think about their task as educators is essential and this should underpin staff development and training programmes.