Techne or Artful Science and the Genre of Case Presentations in Healthcare Settings

This paper presents a qualitative study that investigated the role of case presentations in the socialization of medical and optometry students. Using the debate from classical rhetoric around the term techne (art or science), we observed that genre theory helps explain the way case presentations mediate the development of professional identity through the interaction of certain knowledge (techne 1), “savvy” knowledge (techne 2), and ethical reflection (phronesis). We noted that these mediated scenes of learning are necessary but problematic because they can lead students to yearn for certainty and to exclude outsiders (other healthcare providers, patients). Finally, our research challenges the binary opposition that exists between art and science especially for professions that bring their disciplinary knowledge into practice

The Rhetoric of Patient Voice: Reported Talk with Patients in Referral and Consultation Letters

Referral and consultation letters are written to enable the exchange of patient information and facilitate the trajectory of patients through the healthcare system. Yet, these letters, written about yet apart from patients, also sustain and constrain professional relationships and influence attitudes towards patients. We analysed 35 optometry referral letters and 35 corresponding ophthalmology consultation letters for reported \u27patient voice\u27 coded as \u27experience\u27 or \u27agenda\u27 and we interviewed 15 letter writers (eight optometry students, six optometrists, and one community ophthalmologist). There were 80 instances of reported \u27patient voice\u27 in 35 letters. The majority (68%) of the instances occurred in referral letters, likely due to differences in both \u27letter function\u27 and \u27professional stance.\u27 Reported \u27patient voice\u27 occurred predominantly as \u27experience\u27 (81%) rather than \u27agenda\u27 instances. Letters writers focused on their readers\u27 needs, thus a biomedical voice dominated the letters and instances of reported \u27patient voice\u27 were recontextualized for the professional audience. While reporting \u27patient voice\u27 was not the norm in these letters, its inclusion appeared to accomplish specific work: to persuade reader action, to question patient credibility, and to highlight patient agency. These letter strategies reflect professional attitudes about patients and their care

Working off the Record: Physicians\u27 and Nurses\u27 Transformations of Electronic Patient Record-based Patient Information

BACKGROUND: Electronic patient records (EPRs) are increasingly being used in health care, but little is known about how EPR-based patient information is used in daily care activities, nor about its potential influence on novice training. METHOD: Seventy-two physicians and nurses participated in an eight-month study on a single pediatric ward. Eighty hours of nonparticipant observations and 20 interviews were conducted. Data were analyzed using constructivist grounded theory and visual rhetoric. RESULTS: Three main features of participant interactions with EPR-based information were identified: (1) EPR-based information was routinely transformed into paper documents; (2) these transformations were organized by profession-specific guiding principles; and (3) transformation strategies were learned through an informal curriculum. CONCLUSIONS: This study describes how and why health care professionals work around EPR-based patient information, and suggests that an EPR\u27s visual organization may be incompatible with professional activities. The study addresses the socializing implications of these activities, and highlights their educational potential

Working off the Record: Physicians\u27 and Nurses\u27 Transformations of Electronic Patient Record-based Patient Information

BACKGROUND: Electronic patient records (EPRs) are increasingly being used in health care, but little is known about how EPR-based patient information is used in daily care activities, nor about its potential influence on novice training. METHOD: Seventy-two physicians and nurses participated in an eight-month study on a single pediatric ward. Eighty hours of nonparticipant observations and 20 interviews were conducted. Data were analyzed using constructivist grounded theory and visual rhetoric. RESULTS: Three main features of participant interactions with EPR-based information were identified: (1) EPR-based information was routinely transformed into paper documents; (2) these transformations were organized by profession-specific guiding principles; and (3) transformation strategies were learned through an informal curriculum. CONCLUSIONS: This study describes how and why health care professionals work around EPR-based patient information, and suggests that an EPR\u27s visual organization may be incompatible with professional activities. The study addresses the socializing implications of these activities, and highlights their educational potential

Look Who’s Talking: Teaching and Learning Using the Genre of Medical Case Presentations

In a pediatric teaching hospital, the authors examined 16 novice medical case presentations that were classified as instances of a hybrid apprenticeship genre. In contrast to strict school and workplace genres, an apprenticeship genre results from the sometimes competing activity systems of student education and patient care. The authors examined these novice case presentations for the amount and patterns of time devoted to student learning and expert teaching, the difficulties created for participants, the sometimes misunderstood implicit messages delivered by experts, and the opportunities to address educational objectives. This study offers professional communication researchers a model that combines quantitative and qualitative methodologies to assess the effects of competing activity systems in the development of communication expertise

Tensions in the Field: Teaching Standards of Practice in Optometry Case Presentations

PURPOSE: Professional identity formation and its relationship to case presentations were studied in an optometry school\u27s onsite clinic. METHODS: Eight optometry students and six faculty optometrists were audio-recorded during 31 oral case presentations and the teaching exchanges related to them. Using convenience sampling, interviews were audio-recorded of four of the students and four of the optometrists from the field observations. After transcribing these audio-recordings, the research team members applied a grounded theory method to identify, test, and revise emergent themes. The theme reported herein pertains to communicating standards of practice. RESULTS: Faculty optometrists demonstrated three ways of communicating standards of practice to optometry students during case presentations: Official Way, Our Way, and My Way. Although there were differences between these standards, the rationale for the disparities was rarely explicitly articulated by the instructors to the students. Without this information, the incongruity among the standards was left to the students to interpret on their own. CONCLUSIONS: The risk created by faculty not articulating the rationale underlying standards of practice was that students misinterpreted the optometrists\u27 ways as idiosyncratic. Thus, opportunities were missed in the educational setting to assist students in making responsible decisions, locating their position in practice, and shaping their professional identity. Competing responsibilities of patient care and student education left instructors with little time to articulate rationale for standards of practice. Therefore, educators must reflect on innovative ways to bring into relief the logic behind their actions when working with novices

What Healthcare Students Do with What They Don\u27t Know: The Socializing Power of \u27Uncertainty\u27 in the Case Presentation

Healthcare students learn to manage clinical uncertainty amid the tensions that emerge between clinical omniscience and the \u27truth for now\u27 realities of the knowledge explosion in healthcare. The case presentation provides a portal to viewing the practitioner\u27s ability to manage uncertainty. We examined the communicative features of uncertainty in 31 novice optometry case presentations and considered how these features contributed to the development of professional identity in optometry students. We also reflected on how these features compared with our earlier study of medical students\u27 case presentations. Optometry students, like their counterparts in medicine, displayed a novice rhetoric of uncertainty that focused on personal deficits in knowledge. While optometry and medical students shared aspects of this rhetoric (seeking guidance and deflecting criticism), optometry students displayed instances of owning limits while medical students displayed instances of proving competence. We found that the nature of this novice rhetoric was shaped by professional identity (a tendency to assume an attitude of moral authority or defer to a higher authority) and the clinical setting (inpatient versus outpatient settings). More explicit discussions regarding uncertainty may help the novice unlock the code of contextual forces that cue the savvy member of the community to sanctioned discursive strategies

Towards Embracing Clinical Uncertainty: Lessons from Social Work, Optometry and Medicine

Summary: The oral transmission and transformation of client information in an apprenticeship setting provides a rich environment in which to observe students and their expert supervisors managing uncertainty. In this Canadian-based study, we examined the communicative features of 12 social work supervisions involving social work students and their supervisors and enriched our observations with subsequent interviews of the participants. Findings: Social work students viewed the acknowledgement and examination of uncertainty as a touchstone of competent social work. This observation contrasted with our past study of medical and optometry students who focused on personal deficit and a distrust of acknowledging uncertainty. Our observations and interviews revealed a unique professional signature to the novice rhetoric of uncertainty (seeking guidance, deflecting criticism, owning limits, showing competence) that suggests differing professional identities and contextual settings. Applications: An attitudinal shift toward accepting and trusting uncertainty in medicine and optometry may facilitate an enriched educational environment for students and a more open dialogue with patients about uncertainty. The unique professional signatures of this rhetoric offer insights into how professional identity shapes attitudes and behaviors toward uncertainty and suggest a source of tension within interdisciplinary healthcare teams