Clinician and education researcher: Ships passing in the night?

The papers by Valestrand et al.1 and Bearman et al. present the reader with a range of clinician voices, bringing us some insight into ‘medical humanity’ and their professional worlds. The candour, self-deprecating humour and directness of these voices are striking. Even more striking is the self-doubt and despair voiced by several participants. Valestrand et al.1 explore the views of four clinician mentors about their mentoring efforts, and the faculty development programme designed to support these. The mentors reflect on who they have become and wonder which aspects of their own professional and personal journeys to expose, as they try to provide something of value to their medical student mentees. This is interesting territory for clinical teachers, who typically tend their personal and professional boundaries with some care, especially when they are not speaking with colleagues. Medical students are not quite yet colleagues, and there are interesting power and self-presentation dynamics at play. Bakhtinian dialogism may have much to offer. Clinical teachers, who typically tend their personal and professional boundaries with some care. More concerningly, one participant characterises the clinical world that awaits students as a ‘coming disaster’ and comments that ‘time hurts all doctors in the end’. Two participants are openly dismissive of the mentoring program. This is interesting and disturbing stuff. There is surely some irony, however, that a mentor's description of the faculty development resources as ‘wishy washy and blah blah’ is interpreted by the authors as ‘rejecting liminality’, ‘manifesting explicit resistance’ and ‘being unaware of his own processes of professional identity formation’. This seems to be a case of ‘ships passing in the night’ (or, even worse, firing shots at each other across the bows). There is something unsettling about the disconnect between the two languages. One wonders how a more curious, respectful and compassionate conversation between practitioner and researcher, in which each found a way to acknowledge the other, might have unfolded, and what we might have learned from this. There is something unsettling about the disconnect between the two languages. My sense is that Bearman et al. undertake a more sympathetic exploration of medical humanity. They explore how trainees evaluate ‘how they are going’ in their clinical worlds. They find that surgical trainees have ready access to useful intra-operative information to self-evaluate their operative skills: from the ticking of the clock, the sighs of the theatre nurses and their own sinking feelings, to empirical patient outcomes which expose the success or otherwise of their work. Feedback from their supervisors is usually tacit and implicit—the less said, and the more autonomy given, the better. Coaching was also sometimes available in the operating theatre: characterised delightfully by one trainee as ‘The reason why you're lousy is this. … Now watch me’! Useful formal feedback conversations were rare (one in 8 years, one trainee tells us), and mandated conversations were sometimes harmful. The authors reflect that formal feedback conversations may be more useful in more ambivalent clinical contexts where patient outcomes are more difficult to measure and less clearly related to the quality of the clinician's work, and where there are fewer opportunities for coaching. This is important work and an interesting hypothesis. I am most familiar myself with the clinical world of general practice, where coaching is rare, much of our work is non-procedural, and the impact of our work on patient outcomes is often indirect and almost always evolving. We are constantly attending to scraps of information from and about our patients, and our teaching, often tacit but sometimes explicit, as well as our own internal sensing of comfort and discomfort with the job we are doing. The authors' metaphor of ‘patching these together’ to find out ‘how we are going’ rings true. As to the utility of forced feedback conversations and reflection to ‘enable meaning-making’ in clinical training, to my mind the question remains open. I am not sure whose problem these are intended to fix, and it seems quite likely that forcing may do more harm than good. The impact of our work on patient outcomes is often indirect and almost always evolving. Both papers highlight the importance of being curious about clinicians and clinical workplaces (although preferably by observing clinicians at work, as well as talking to them). Both highlight a divergence between education researcher and clinician professional worlds. The researcher's expertise in problematising, manipulating theory, mastering new discourses and making the tacit explicit and complicated, contrasts with the pragmatic, practical and more embodied directness of the latter, for whom less is sometimes more. For the practitioner, what is seen, felt and done, may be more salient than what is merely said. The flourishing of theoretical constructs relished by the education researcher, and the increasingly specialised language used to couch them, risk ‘decoupling’ researchers from practitioners, and indeed alienating each from the humanity of the other. It is undoubtedly important and compelling to build more and more sophisticated accounts of how learning and expert judgement emerge from our embedding in various complex social worlds. But these accounts should be useful as well as sophisticated, and at least ‘do no harm’. We should not be curious about clinical worlds merely to service one educational theory or another: we should actually care about these worlds and the people in them. For the practitioner, what is seen, felt and done, may be more salient than what is merely said. There are real and present problems in clinical workplaces which warrant our attention. One of these is clinician burnout. For practitioner, educator and researcher (both as people and as ‘professional identities’) to pull together in understanding how clinical workplaces can be places where both education and patient care flourish, and avert a ‘coming disaster’, we may need to reclaim a shared language. Otherwise we may simply pass each other in the night. There are real and present problems in clinical workplaces which warrant our attention. Nancy Jennifer Sturman: Conceptualization; writing—original draft preparation; writing—review and editing.