Luminary Learning Gastrointestinal Disorder- Issue 1

Learning to Work Together Through Talk: Continuing Professional Development in Medicine •  55 questions to test the trainee’s assumptions of shared knowledge that emerge during case presentations. Thus, oral presentations reflect a “regular discursive meeting place” (p. S14) for medical trainees and supervising physicians that play an important role in how trainees develop and demonstrate evolving competence and thus earn progressive autonomy (Kennedy and Lingard, 2007). Further, a critical discourse analysis explored descriptions that both medical stu- dents and physician supervisors provided about their moments of interaction supplemented by follow-up student debriefing interviews (van der Zwet, de la Croix, et al., 2014). The authors iden- tified various discourses within the Question-Answer dynamic between physician supervisors and medical learners. These included discourses related to a ‘power game’, ‘distance’ and ‘equality and reciprocity’ between educators and learners. Importantly, this analysis revealed affordances of student-doctor relationships conceptualized as ‘developmental spaces’ that generate positive learning momentum for students and doctors and ‘developmental vacuums’, which stifle learning. Another study examining the audio diaries of seven general practitioners (GPs) during a 10-week- long clinical placement uncovered trajectories of developing relationships through evolution of dialogue (van der Zwet, Dornan, Teunissen, de Jonge, and Scherpbier, 2014). Doctors in the study used dialogue to define and shape their discourses of good medical practice, both influencing and depending on students’ learning trajectories. Supervising physicians often view their questioning practices as activities that serve both teaching and patient care. However, Goldszmidt and colleagues (2012) found that supervisors’ interruptions to pose questions or make teaching points led to detours from the standard case pres- entation format that disrupt critical information sharing (Goldszmidt, Aziz, and Lingard, 2012). There is also a form of questioning known in medical circles as ‘pimping’, which is a slang term (Kost and Chen, 2015) referring to the practice of posing a rapid series of ever-more difficult ques- tions (Brancati, 1989) in a manner that can be interpreted as intimidating or even humiliating to junior medical trainees (Martin and Wells, 2014). In ‘pimping’ we see an example of the ‘power game’ (van der Zwet, de la Croix, et al., 2014), which is, ultimately, pedagogically unproductive. Indeed, as a manifestation of inherent hierarchical structures within healthcare, ‘pimping’ may have negative impacts on medical students and junior doctors, such as fostering future disrespect- ful behaviour (as a doctor) towards nurses, trainees, colleagues, and patients (Leape et al., 2012). And, yet, both senior surgeons and resident physicians said that intimidation and harassment could have legitimate educational value (Musselman, MacRae, Reznick, and Lingard, 2005). Talk plays a central a role in learning, identity formation, and socialization of doctors(-to-be) as well as being a core mechanism of patient care. The dialogical nature of interactions within healthcare teams and with patients has numerous positive benefits and in many ways reflects the shift to ‘discourse work’ seen in other professions. Given the complexity of healthcare settings in which it occurs, however, talk also has the potential to amplify less favourable social structures and practices that impede learning and patient care. These insights highlight the need to under- stand the positive and negative impact of talk in clinical practice so that we can better design strategies to improve communication for patient care and learning.