Two overarching themes emerged as unintended and unpredicted consequences of AEE. These are: (i) mētis and the division between ‘real learning’ and authentic practice, and (ii) mētis and professional identity in AEE. Table 2 categorises four possible types of knowledge or meaning consequential to AEE. These have been generated from our analysis and summarise the overarching finding that AEE produces both intended and unintended consequences, which, in turn, may be either predictable or unpredictable. The content of each category emerged from data as we used the concept of mētis to bring coherence to our empirical findings.
Mētis and the division between ‘real learning’ and authentic practice
Students constructed meaning based on a disjuncture between authentic practice, as witnessed during AEE, and the ‘real learning’ that they perceived to take place in and be recognised by the medical school:
‘…[AEE] weren’t linked to what we were studying… only supposed to be really linking to our communication skills not to what we were studying.’ (S3)
Often their meanings involved the rejection of some knowledge, rather than its assimilation and refinement into a more nuanced knowledge base:
‘The experiential learning is quite different because we are not supposed to know any medical knowledge about the diseases.’ (S4)
‘I just want to be qualified really so it’s just I need to do this to get through… some of the placements are just a bit annoying… like you could have been doing work in that time…’ (S5)
As a result, students did not see authenticity as a current priority in either gaining content knowledge or transferring knowledge for refinement through experience. Instead, students reported that AEE was about only interpersonal skills, which they conceptualised as separate from the medical knowledge that constituted ‘the medical course’ and was defined by medical school assessments.
Students focused on differences rather than similarities between simulated communication skills sessions within the school and interactions with authentic patients in AEE. Simulated patients (SPs) were conceptualised as agents of the medical school. This student expressed the common view that SPs were obeying the orders of the medical school:
‘I think simulated patients try to do things a lot more by the book, whereas real patients… you wouldn’t normally go through confidentiality with them and then consent…‘cause they just... don’t see it as being important, whereas simulated patients will – that’s only probably because they’ve been told to… by the medical school.’ (S6)
The discrepancy in experience between interacting with SPs and authentic patients, respectively, made it possible for students to conclude that although knowledge of consent and confidentiality was important to the medical school, this did not mean that it was relevant in authentic settings. Alternative explanations such as that authentic patients might believe good practice in these areas to be a matter of routine and therefore not to require discussion were not considered.
The students concluded that professionals and patients in workplaces did not recognise or identify with the demands placed on them by the medical school. These conclusions created a need for students to handle an apparent dichotomy between practice and medical school-derived learning. Their solution to this need is an example of mētis: they handled the perceived conflict by constructing explanations that included beliefs that the school was out of touch with authentic practice, and concurrently sought to present to faculty staff what they perceived to be acceptable learning. This was exemplified in a common approach to reflective assignments for submission to the school following AEE. This student noted that these were easier to do once the student had worked out:
‘…what to expect – what they want us to write and things like that.’ (S7)
Other students reinforced this view, adding that they would not use any negative experiences in their reflections because they were concerned these might be interpreted as indicating a personal inability to cope and that any criticism of a workplace might have future repercussions. Another element in the students’ mētis here is the ‘knowledge’ that the best way to ‘get on’ with the medical school is to deliberately present only what the student believes the school wants to hear and to suppress any acknowledgement of alternative experiences or understanding.
The dichotomy constructed between the two realities led to the devaluing of AEE as a source of content learning. Students, such as S5 above, described how AEE could prevent them from doing ‘work’ that would be formally recognised by the medical school. Overall, despite the faculty members' intent that AEE would offer opportunities to remind students about why they were studying at medical school, the students perceived it as disconnected from learning medical knowledge. This student described her understanding of the place of pharmacology in AEE:
‘…with regards to pharmacology it doesn’t apply as much on placements… when you are talking about medication with patients they’ll just hand you a list of medications and… because I’m trying to focus on the patient, I don’t necessarily have the time to write down the list or really even pay very much attention to it, so I move on… Yes [laughs], they give me the list and then I look at it and go “Thank you” [laughs] and give it back to them.’ (S8)
This student’s attempt to apply the principle of patient-centredness (emphasised as necessary by the medical school) paradoxically resulted in her overlooking of something important to the patient and missing an opportunity to learn about medication use. Other students discussed developing skills to handle situations in which they were offered information that they did not perceive to be of current importance to them in the context of the course demands. These students were discussing how they acted when workplace supervisors attempted to share medical content knowledge that they thought was currently irrelevant:
‘You do almost park it [knowledge] at times and just kind of think “Right, this is something I need to know; it is important but it’s not relevant for the minute now” and you kind of just almost park it away knowing that you will come back to it later… you might even have notes on it that you’ve written that you just don’t look at them for the moment.’ (S7)
‘But how often do you park it and then never find the car again?’ (S14)
As the second student implied, AEE may have currently unrealised potential for content learning and for the development of better integration and transfer of knowledge. However, the students’ mētis held that it was best for students to publicly pretend interest while privately ‘parking’ knowledge they did not perceive as immediately relevant.
A more positive form of mētis was developed among students who adopted strategies that enabled them to meet challenges encountered in AEE, setting in motion a cycle of increasing confidence and willingness to attempt further challenges. For example, in the following excerpt, the student starts by acknowledging that an emotional patient presents a challenge to her, and that she has felt awkward and has not known how to respond. In the process of talking herself through the experience, however, she moves rapidly from a discourse of being ‘out of control’ to one of the experience ‘not being a big issue’, but, rather, a lesson in how to respond, and describes how her response produced the desired effect:
‘…on the second placement with the old lady – she became really emotional and… before I probably would have been like “Oh my God, what do I do?”…I’ve had actually that hands-on practice now, I’d be able to deal with it better in the future, I think, if I had an emotional patient in front of me who started to cry… and that’s what… that’s what I really will remember – how, like, how to react… I just remembered, you know, just give her a few minutes to compose herself and I didn’t bombard her with any questions or anything and then afterwards I said, you know, just talked to her in a comforting manner etc. And that’s how I dealt with it really, so it wasn’t a big issue.’ (S1)
This student’s meaning making can be conceptualised as a positive form of mētis; she had taken a risk and found that it ‘worked’ and was likely to reproduce this way of working in the future. However, not all students responded in this way and it may be the students who did not who should most interest educators. For many students, the survival of their current interaction is most pressing, not the potential to apply knowledge in the future. Survival may also be achieved by remaining passive when dealing with the unpredictable, which makes the student a ‘bystander’ in a potentially challenging or difficult situation. One student described a situation in which the doctor told a patient he would follow a particular management plan, but then apparently explained to the students after the patient had left that this was not his actual intention:
S2: ‘[T]he doctor basically just checked whether there’s any… infection and took, swabs or placebo swab and reassured the patient that everything will be fine… but, according to [the] doctor he comes in every few days… just because of this… wound.’
Interviewer: ‘Okay. And did the doctor tell you they were doing the swab as a placebo or was that something you thought?’
S2: ‘Later on. After the patient had went out. Because, the doctor – after taking [the] swab and reviewing the case or something – decided it’s a waste to send the swab off… for tests.’
Interviewer: ‘Okay. What did you think about that?’
S2: ‘[pauses] Well, I guess it’s a useful tool, in a way, but ethically I’m not quite sure.’
The student initially described this scenario using the term ‘placebo swab’. He then became ambivalent and distanced himself from the doctor’s actions. The meaning the student made was partly based on the doctor’s offering of access to a form of professional mētis about interactions with patients. Instances of the sharing with students of workplace (professional) mētis (whether these were controversial, as in the present case, or not) facilitated the integration of students into workplaces, moving them from outsider to insider status.
Table 2 shows that ‘real learning’ defined by the medical school was an intended and predicted consequence of AEE. Conceptually, however, it represented only one part of the knowledge construction and meaning making undertaken by the students. Authentic early experience also had desirable but uncontrollable consequences, such as the students’ difficulty in making links between what they perceived as necessary workplace knowledge and the demands of the medical school. In addition, it was neither intended nor predicted that students would interpret differences between communication skills training and practice in the ways that they did, such as with respect to their understanding of consent and confidentiality. The earlier example of the ‘placebo swab’ event illustrates a need for the medical school to discuss with students variance in practice if negative role modelling is to be converted into constructive learning rather than to remain as a form of mētis pertaining to the hidden ‘professional’ culture.
Mētis and professional identity in AEE
Students enter medical school with lay perspectives about the roles of doctors, which differ from how they perceive themselves. They want to show they are capable of developing into a doctor (and are seeking access to the mētis they require to achieve this) while feeling closely aligned with patients during AEE. For example, this student, who had been sent to take a history from a patient in clinic unexpectedly, described the experience as one in which she and the patient shared a common sense of vulnerability:
‘I explained to the patient, that I’d got no experience at doing this… introduced myself and explained what I needed to do and would she be happy to talk to me… she was very supportive… she felt very vulnerable as well, obviously, because of the sensitive nature… of the reasons why she was there… I think she felt… quite comfortable with me and disclosed quite a lot…’ (S10)
The identity of ‘medical student’ was described by students as one that meant they were no longer able to take a lay perspective; however, they reported experiencing discomfort with their new professional role. Discomfort arose in the course of conducting conversations that broke the boundaries of lay norms for everyday social interactions but in which the students perceived themselves as ‘spare parts’ without purposeful workplace functions. Comparing AEE with previous experiences of health care work, some students argued that their current status was actually a hindrance:
‘…if you’ve got a job on a ward, it’s entirely different… and you’re part of, you’re accepted but if you’re a medical student, you’re not.’ (S11)
Students felt required to accommodate others’ perceptions of what it meant to be a medical student although they did not yet feel legitimate in the role:
‘You will be professional and you will be polite and you will speak to people in a certain way and people will react to you in a certain way… whenever you mention you’re a medical student to anybody… you’re not a person anymore.’ (S12)
Initial experiences involved observing others at work or asking patients about their experiences of health care or illness, rather than making medical enquires focused on seeking information to facilitate disease management. Students found it difficult in practice to discuss patients’ perceptions of, for example, lifestyle risks such as smoking or diet, and patients’ experiences of interactions with health care professionals regarding these topics:
‘You’re sort of asking all these lifestyle questions that really… you can ask them one or two, or maybe three, but you don’t want to go… you sort of feel it’s a bit intrusive almost, some of the detail you have to go into.’ (S13)
The students’ difficulty referred not to appreciating patients’ perspectives, but to understanding how to retain this appreciation whilst simultaneously developing a professional identity. They did not overtly display the cynicism and loss of caring attitudes reported to develop amongst students in later years of medical school.34–36 Nevertheless, they believed that, in order to become insiders, they needed to deliberately set aside lay perspectives and suppress personal views. This was despite the discomfort they experienced with the professional perspectives they felt it necessary to personally adopt. The paradoxical meanings discussed here were neither intended nor predicted consequences of AEE (Table 2). The mētis which arose out of these tensions, rather than developing an understanding of ‘being professional’ that incorporated the use of judgement, referred to the development of a sense of a ‘homogeneous’ professional persona that required them to set aside the notion of ‘being a person’.
In addition, some students developed ‘chameleon identities’ to handle repeated transitions, thereby side-stepping any attempt to reconcile differences between the demands of their two sets of masters (the medical school and faculty staff, and workplaces and health care professionals) and to meet the requirements of each setting. Students discussed their expectation that the ‘tailoring’ of ideas for different interactions with different people in different settings was necessary:
‘I just suppose that you have to tailor it to whoever you’re speaking to.’ (S15)
Knowledge of these differences was developed into mētis as students found that avoiding reconciliation ‘worked’ as a way to handle conflicting ideas. Students would choose when to declare learning in future interactions and how to present themselves according to their constructs of learning recognised by the school or their usefulness in workplaces. This held even when there were clear opportunities to make connections.
If, as our results suggest, the concept of mētis can be applied to AEE, the student learning that goes unnoticed or is at least unattended to by placement providers and faculty staff will equate to the very practical knowledge with which students make choices about how to interact and present their learning. Student mētis encompasses all that the students made use of to ‘handle’ AEE to make it ‘work’ for them. In this context ‘work’ describes the outcome of students’ negotiation of their experiences in ways they deem useful for serving current goals. Knowledge incorporated within student mētis guides how and why individual students choose to interact with others (in the medical school and in the authentic workplaces in which their AEE is situated) to suit their immediate needs and purposes, as well as educational goals. An extreme interpretation reveals a paradox whereby AEE results in consequences that are opposite to those intended by educationalists in terms of how students themselves experience the intervention: they do not see themselves as legitimate participants, however peripheral, within the workplace, which fundamentally differentiates their educational experience from that envisaged by Lave and Wenger.37 Our students did not experience placements as part of integrated learning within the curriculum because they were unable to resolve for themselves the different and often contradictory knowledge presented to them by medical school faculty staff and placement providers.