The social construction of teacher and learner identities in medicine and surgery

Abstract Introduction There are growing concerns about the quality and consistency of postgraduate clinical education. In response, faculty development for clinical teachers has improved formal aspects such as the assessment of performance, but informal work‐based teaching and learning have proved intractable. This problem has exposed a lack of research into how clinical teaching and learning are shaped by their cultural contexts. This paper explores the relationship between teacher–learner identity, educational practice and the workplace educational cultures of two major specialties: internal medicine and surgery. Methods This was a secondary analysis of a large dataset, comprising field notes, participant interviews, images and video‐recordings gathered in an ethnographic study. The lead author embedded himself in four clinical teams (two surgical and two medical) in two different hospitals. The authors undertook a critical reanalysis of the observational dataset, using Dialogism and Figured Worlds theory to identify how teachers and postgraduate learners figured and authored their professional identities in the specialty‐specific cultural worlds of surgery and internal medicine. Results Surgery and internal medicine privileged different ways of being, knowing and talking in formal and informal settings, where trainees authored themselves as capable practitioners. The discourse of surgical education constructed proximal coaching relationships in which trainees placed themselves at reputational risk in a closely observed, embodied practice. Internal medicine constructed more distal educational relationships, in which trainees negotiated abstract representations of patients' presentations, which aligned to a greater or lesser degree with supervisors' representations. Conclusions Our research suggests that clinical education and the identity positions available to teachers and learners were strongly influenced by the cultural worlds of individual specialties. Attempts to change work‐based learning should be founded on situated knowledge of specialty‐specific clinical workplace cultures and should be done in collaboration with the people who work there, the clinicians.


| INTRODUCTION
The widespread adoption of competency-based curriculums in postgraduate medical education (PGME) has greatly increased the expectations and responsibilities of clinical teachers. 1 In response, there has been an 'exponential' increase in faculty development (FD). 2 Despite FD efforts to professionalise clinical education, there remain worrying inconsistencies in the quality of clinical supervision and the adjudication of learners. Moreover, there are growing concerns that trainees are not being given sufficient opportunities to participate meaningfully in practice. [2][3][4] It is clear that the educational effects of credentialing teachers and providing standalone teaching skills workshops have neither transferred well into practice, nor proved sustainable. [5][6][7][8][9] This disappointing impact has been attributed to cultural and organisational factors features of clinical workplaces that undermine teacher development. 6,7 These problems are compounded by a lack of empirical research into how social and cultural contexts shape the practices of teaching and learning. 10,11 The relationship between teaching, learning and cultural context aligns better with sociocultural theory than the cognitive models that underpin much FD scholarship. 12 From a sociocultural perspective, clinical education is a process of participating in the shared activities of institutions such as hospitals and clinical teams, and 'becoming' 13 a person whose identity is forged in particular cultural contexts. [14][15][16][17][18] There has been little research into how identity formation, clinical supervision and the influence of cultural context relate to one another. 19 Self-report studies have shown how postgraduate trainees master shared practices, rules of thumb and embodied understandings, 20-24 but such methodologies have been largely insensitive to the implicit effects of cultural context. 25,26 Observational studies have shown how graduate learners seek legitimacy in clinical teams by reproducing socially sanctioned token behaviours, but not how social and cultural contexts shape the roles of teachers and learners. [27][28][29][30][31][32][33][34][35] In response, we launched a programme of research to develop a situated understanding of the relationship between clinical teaching, learning and social context. Our purpose was to develop a theoretical framework that would inform future contextually sensitive FD initiatives. An ethnography of four hospital teams (two internal medicine and two surgical) in two separate teaching hospitals over a period of 1 year (2016-2017) yielded a rich dataset. 19 We used Goffman's dramaturgical theory, to explore the relationship between teacher and learner identity, educational practice and ways of talking and acting that typify participation in clinical teams. This showed that clinical teachers embodied rather than articulated their teams' implicit curriculum of norms and expectations. Trainees responded by reproducing teachers' embodied standards to create impressions of themselves as capable team participants. 19 This methodology proved insensitive, however, to the shaping effect of specialtyspecific culture on teaching and learning. The aim of this paper was to reanalyse the observational data using a theoretical framework, Figured Worlds, to identify how the contrasting cultures of two major specialties, surgery and internal medicine (IM), influenced teachers' and learners' identity formation. The research question was as follows: How do the identities of teachers and learners interplay with one another in the cultural worlds of specialty clinical teams where the linked practices of working, learning and teaching are situated?

| Theoretical framework
Figured worlds is a critical theory that provides conceptual and analytical tools to examine relationships between identity formation and culture. 36 A figured (or cultural) world is a socio-historical context (e.g. membership of a clinical team) that affords particular experiences, ways of talking and acting and social possibilities. 16 Identity, within Figured Worlds, is not possessed; it is dynamic and evolving, constructed by speech and other symbolic acts, finding form in the interactions between individuals and the cultural worlds that they live and work in. 37 Drawing on Bakhtin's theory of Dialogism, Figured Worlds assumes that speech and other symbolic acts give individuals agency to self-author identities in cultural worlds. 15,16,38 In Figured Worlds, the term 'figure' refers to the identity possibilities that are embodied by, for example, teachers from whom residents learn. 36 The term 'figuring' superficially resembles role modelling but differs in how it places greater emphasis on learners' agency in forging their own identities, rather than assimilating roles. [36][37][38] In this account, when we use the term 'modelling', we are referring specifically to the actions of teachers in demonstrating skills or articulating thinking for learners. 39 We also differentiate between modelling and coaching where 'coaching' describes when teachers' observe learners' performances and provide feedback to support growth and development. 40 Figured worlds acknowledges that high-level institutional and sociohistorical discourses (which Gee terms big-D Discourses) structure cultural worlds, create social positions, and make those positions more or less available to people with different identities. 41 Importantly, Figured Worlds also allows scholars to reveal how the contents of everyday speech (little-d discourse) give people agency to resist the structuring effect of big-D Discourses. 36,41 In this way, the everyday use of (small-d) discourse constructs and reconstructs (big-D) Discourses. 41 In this study, we used Figured Worlds theory's linguistic concepts to make sense of our ethnographic observations of cultural worlds in action (e.g. the educational rituals particular to the cultures of surgery and IM) and everyday speech (discourse), which give individuals agency to navigate cultural worlds.

| Setting and sample
This article reports a secondary analysis of an ethnography, carried out to explore how clinical education is actualised in the day-to-day working and learning environments of a surgical and an IM clinical team, in each of two separate teaching hospitals in Ireland. The hospitals were of similar size covering largely urban populations in two adjacent Irish cities. We selected surgery and IM because they represent practices within the same profession whose socio-historical origins are very different. Although the sampling strategy was chosen for dramaturgical research, it was well suited also to exploring the influence of cultural factors on identity formation in medical education.
A 'gatekeeper' in each hospital distributed a leaflet giving information about the study amongst all clinical teams. The lead author (PC) then spoke about the study at medical and surgical grand rounds where most teams were represented. He invited offers to participate and included teams in the order they volunteered. Those included were typical of clinical team units in Ireland in that they were composed of one or more lead consultant specialists, one or two senior specialist registrars (senior residents) and two to four junior trainees (junior residents).

| Research ethics approval and protection of participant identity
The ethnographic design and its associated data collection methods were approved by the research ethics committees of the two participating teaching hospitals (references: C.A. 1150 and 062/16). All participating team members received an information sheet about the research including the intention to publish the results. All provided written consent to participate in the research. Any patients or health care staff who were incidentally included in video or image data received an information sheet with researchers' contact details, which they were asked to read before giving verbal consent to be included in the dataset. If such consent was not forthcoming, we deleted the relevant data segments.  Table 1. In practice, this meant reading and rereading field notes, interviews and video transcripts to identify meaningful acts, figured types (e.g. teachers in a particular specialty), culturally significant artefacts and other genres listed in Table 1. We regarded interpretive inferences as valid when linguistic evidence, symbols or behaviours present in video or digital images provided empirical support. 41 We used this evidence to examine how participants' communicative actions   note observations, excerpts of spoken language and video transcripts to synthesise a narrative summary of the cultural worlds of surgery and IM.

| Rigour and reflexivity
Sensitised by Figured Worlds, we used rich description, crystallisation and multi-vocality 44,45 to move from raw data to interpretation. We agreed interpretations between two people who had independently read the data. 44 We strengthened the trustworthiness of our interpretation by seeking evidence from more than one source: for example, field note and interview data repeated over time. 45 We applied the Figured Worlds concept of multi-vocality by seeking similarities and differences between different individual participants and different teams in the same discipline. 36  In keeping with best ethnographic research practice, 42 we used our insider (PC: general practitioner; TD: hospital specialist) and outsider (WdG: educational psychologist) perspectives to scrutinise otherwise taken-for-granted aspects of language and practice. PC kept a reflexive diary to ensure that the relationship between personal perspectives, observations and interpretations was available for scrutiny.

| RESULTS
Becoming a surgeon or a physician was shaped by culturally valued ways of knowing and acting peculiar to the cultural worlds of surgery and IM and was inextricably linked to their specialty-specific practices.   • Internal medicine knowing was valued in terms of its quantity, (knowing lots), its quality (logical and evidence-based) and its applicability (flexible implementation). For example, a medical consultant uses a role model narrative to figure internal medicine knowing: 'He seemed to know everything. He was just a genius. He knew everything about every speciality. He would hold the grand rounds every week and bring in these really exotic, complicated cases that had great clinical signs and he was a real master of general medicine' (H2T1 Consultant interview). • Knowing like an internal medicine doctor enabled physicians to create coherent abstract representations of complex patient presentations that informed subsequent diagnostic, therapeutic and prognostic decisions. • Abstract representations of patient presentations were judged in terms of their internal consistency, their logic and their alignment with the existing evidence base. 'I would say two or three interactions with a junior doctor will tell me their knowledge, their ability to assimilate information, the right information …. and it is quite obvious the ones who do not. There is no overall picture forming, it's like they are check listing questions, but they do not know what to do with the information, they are not collating it' (H1T1 Consultant 2 interview).

Seeing
• A surgical way of seeing privileged surgical practice by focusing on the functional outcomes of surgery rather than the scarring or disfigurement associated with surgical intervention. 'This woman has a lovely stoma for us to look at' (H2T2 Field note Resident talking to medical students). • A surgical way of seeing marginalised delicacy or embarrassment about bodies, odours, discharges etc. 'Nobody squeamish? We are all clinicians here and we are not afraid of bodies!' (H2 T2 Fieldnote Consultant talking to surgical team).
• An internal medicine way of seeing privileged clear-sightedness and gestalt in the context of complex patient presentations. 'This man was sent in by his GP with what he thought was a lower respiratory tract infection. However, when I talked to him it became clear that his problem was not cough, but shortness of breath, particularly at night. He needed a lot more pillows and found it very hard to lie flat … Now, you will never really get a clearer history than that of paroxysmal nocturnal dyspnoea' (H2T1 Field Note Consultant talking to his team at the patient's bedside). • An internal medicine way of seeing privileged the ability to identify salience in a mass of patient historical and investigative detail.

Talking
• Surgical talk was unadorned, pragmatic language that conveyed identification with a surgical perspective. For example, a surgical resident figures a surgical way of narrating a case: 'She had a big ovarian cyst. When we were trying to remove it, it burst scattering crap all over the abdomen' (H1T2 Field notes Resident talking). • Surgeons used 'hero' disaster-deliverance narratives to position themselves as capable: 'She came to us with an abdominal fistula. She was shedding raw faeces all over her abdomen wall and it was getting very excoriated. We decided to have a go at fixing this. We went in and eight hours later we closed up. A few days later a new fistula opened above the old one. However, this was a lot less painful and problematic than the old one' (Fieldnote H2 T2 Resident talking).
• Physicians talk foregrounded precision, logic and coherence to present compelling and satisfying abstract models of patient cases for a physician audience. 'You know if someone is capable … There are different ways in which people present cases for example. So you come in to do a post call ward round and somebody says "this patient came in, and they presented with shortness of breath, and they had a cough, and this is the x-ray." Or "this patient came in with exacerbation of COPD, and we have done the following and this is the chest x-ray." You know from their way of managing things' (H1T2 Consultant 3 interview). The climate of these conferences was more formulaic and discursive than in surgical grand rounds. For example, junior residents always presented cases using a standardised structure.

Prudence
• Being prudent like a surgeon meant navigating the tension between caution and action. For example, a surgical resident self-authors as a prudent surgeon when discussing therapeutic options with a patient. 'I think you have a hernia there. These are a very common thing that happen after major surgery like you have had. They are weaknesses in the belly wall and sometimes the gut pushes through like this. Yours has a wide neck and is quite small. I do not think it's going to get into any trouble …. Surgery would mean opening up your belly again and putting in gauze like stuff to hold it together -I do not think you want any more surgery do you?' (H2 T2 Video transcript or Resident OPD consultation).
• Being prudent like an internal medicine physician meant being reflexive and circumspect in relation to extant ideas, as well as new information or data. For example, an internal medicine physician figured internal medicine prudence as follows: 'There are many ways to skin a cat, and medicine will make a liar of you because you do not know the right answers. It's not a science. So much of it is how the story is told [and] whether you have the ability to go back and readdress what you did on the first day. Was it the right thing to do and are you prepared to change your plan?' (H1T1 Consultant physician interview).
• Being resilient was highly valued in surgical team culture. Surgical resilience meant being capable of normalising postoperative complications, justifying actions and attributing poor outcomes to factors other than self. 'Complications happen; they just happen, and I feel that you cannot get too bothered by it, because if you get too bothered by it, the next patient is affected. You process it, leave it in that room and you move on …. I have had to go away pretend nothing has happened' (H2T2 Resident interview). • Being resilient as a surgical trainee meant deflecting reputational threat by choosing to interpret critical comments from supervisors as coaching interventions rather than attacks on personal capabilities.
• Being self-directed was highly valued in internal medicine team culture. Being a self-directed learner meant observing and absorbing supervisors' practice and being motivated to learn for oneself. • An internal medicine emphasis on self-directedness favoured a modelling approach to clinical education as opposed to the more coaching orientated approach prevalent in surgery. Here an IM consultant figures the modelling teaching approach of IM: 'You lead by example, and you hope that people will watch what you do and if you do it well they will derive a positive experience from it. I do not think doctors need to be spoon fed. You're relying upon self-directed learning' (H2T1 Consultant interview).
Consultants and supervisors did most of the talking in IM case conferences sharing perspectives in back-and-forth exchanges while residents listened.
The conversation jumped to and fro between the consultants who discussed the management of aspergillo-   to each specialty and culturally anchored. 31 Teachers and learners negotiated their identities within cultural worlds characterised by specialty-specific ways of knowing, talking and being.

| Informal identity work in teacher-learner interactions
These observations align strongly with current descriptions of workplace learning where identity formation is characterised as a negotiation between learners' engagement with the affordances of the workplace, and its demands of them. [46][47][48] Our work suggests that clinical teams should be conceptualised as cultural worlds in which agency is negotiated dialectically in relation to the socio-historic norms and expectations of the team as well as the parent specialties. 49 Learning in specialty-specific cultural worlds not only limits learners' agency but promotes the reproduction of culturally sanctioned practices and dispositions. 13,50 Becoming a surgeon or an internist is therefore situated in a contested space between the demands of workplace contexts, specialty cultures and the aptitudes and aspirations of individual learners. 48 Contextual threats to learner centredness and the perpetuation of dominant culturally scripted teaching practices and identities represent important challenges for faculty developers who wish to address the deficiencies of clinical education. There is good evidence, for example, that learners who can exercise agency to harness the available dialogue and practices in working or learning contexts can greatly enhance their learning experiences. 51 Our work suggests that the solutions to the acknowledged problems of clinical education need to be founded on well informed constructions of the particular discourses that apply in specialtyspecific cultural worlds.
Becoming a specialist represents a form of identity work shaped by participation in clinical teams and the alignment of self with the historical values, practices and traditions of a particular discipline. 32,34 Identity work describes how individuals create, claim, discard and negotiate social and role identities in relation to others in social contexts. 52 In this study, we found that learners in formal and informal clinical learning contexts used strategies of narrative positioning and self-authoring to discursively make identity claims as surgeons and IM physicians. They did so in relation to discipline specific cultural back-

| Recommendations for faculty development
Given the profoundly situated nature of the curriculum of the workplace, and the particularities of teaching and learning in different specialties, faculty developers could greatly enhance their effectiveness by shifting emphasis from attempts to 'improve' clinical education using solutions derived from educational orthodoxy, toward facilitating change founded on contextual understandings. To achieve this, faculty developers need to work with clinical teachers, (using action research approaches for example), to observe and make sense of the workplace settings and teaching practices that they hope to change. Faculty developers should collaborate with clinicians to develop contextual curriculums that are customised for the politics and realities of the places where clinicians work. 54 Video reflexive ethnography, (VRE) has been shown to be a very effective approach in helping clinicians to appreciate cultural, taken for granted aspects of context and practice. 55 Technologies such as VRE could be used to resource participatory action research designs whereby clinicians collaborate directly in building understanding of workplace contexts and therefore solutions to the educational problems that pertain there.

| Limitations
Although these findings could help design faculty development programs that are better suited to the realpolitik of workplace education, there are some limitations to their applicability. Whereas this study was strengthened by gathering data from two clinical teams in each of two separate teaching hospitals, features such as team structure, hierarchy and training curriculums were particular to one country. To

| CONCLUSIONS
In clinical education, teacher and learner identity and the associated practices of teaching and learning are all shaped by, and contingent on, the sociocultural contexts in which clinical learning is situated. Participation in social structures such as specialty-specific clinical teams, informs not only what is learned, but how it is learned. Clinical education is not, as it is sometime portrayed, a linear process of acquiring knowledge, but is instead a complex process of becoming, through mutual engagement in situationally specific curriculums of the workplace. 53 Our work suggests that faculty development should move away from its current focus on expert led credentialing approaches to 'fix' clinical education and consider instead a more facilitative approach, founded on constructing shared understandings of workplace curriculums with the people who work there, the clinicians.