Nu är det du som är doktor, nu är det du som bestämmer - Studier av yrkeskunnandets utveckling och manifestation hos studenter och läkare

Abstract

The overall purpose of this thesis was to contribute to the understanding of how doctors’ professional knowledge evolves during both their clinical training and professional life. In this thesis, this is achieved by describing the supervision of medical students and the professional approaches of active doctors when making clinical judgments. During supervision students are expected to develop professional knowledge and to become socialised into the profession. Professional knowledge is personal, is developed throughout life, and is infl uenced by the person’s education, experiences and generation group, and by organisational conditions. The profession’s culture and attitudes also infl uence what knowledge is focused on, considered valid and appropriate. The professional knowledge of a doctor changes continuously as he or she gains clinical experience. The overall theoretical perspective of the thesis is symbolic interactionism, meaning that professional knowledge and socialisation are described based on how they appear and create meaning for medical students and active doctors. The thesis is based on data from two separate data collection efforts. In studies I, II and III, the focus was on the supervision of medical students in a surgical training program. The empirical data consisted of fi eld notes from approximately 100 hours of observations and informal discussions. This group of ethnographic studies generated three separate thematic areas that were described: what was identifi ed as contents during supervision, attitudes conveyed in supervision and pedagogical strategies used by supervisors. In study IV the focus was on professionally active doctors’ clinical judgements and the study was based on interviews with nine junior and nine senior internal medicine doctors. This study made it possible to describe the way in which junior and senior doctors´ professional approaches vary when making clinical judgements. The four studies show that master-apprentice-like learning occurs both between supervisors and medical students and between more experienced and less experienced doctors. It emerges that it is not entirely clear what students are expected to learn and develop during the supervision. Moreover, the content is not adapted to the students’ level of knowledge and experience. The students are abandoned to structure and prioritise the contents according to the clinical situations encountered. The students are expected to cope with attitudes that sometimes may be perceived as demanding or demeaning, and which may be diffi cult to adapt to patient- and team-centred care. Both students and junior doctors are placed in diffi cult and challenging situations in relation to their experience and skills. Making clinical judgments is an important aspect of a doctor’s professional knowledge. This knowledge is complex and grows with the extent of the clinical experience and it varies depending on the context in which it has been gained. The level of professional knowledge and clinical judgment-making ability is also increased by observing how more senior and experienced doctors act and behave. Therefore, it would be of interest for both students and for the health care organisation at large to develop the pedagogical approach of both supervisors and active doctors.