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Talking the talk': school and workplace genre tension in clerkship case presentations Lingard L, Schryer C, Garwood K, Spafford M, University of Toronto, Canada. Medical Education 2003;37:612 - 620 Reviewed by: Bruce Z Morgenstern, Mayo Medical School


Talking the talk': school and workplace genre tension in clerkship case presentations

Lingard L, Schryer C, Garwood K, Spafford M, University of Toronto, Canada. Medical Education 2003;37:612 - 620

Reviewed by: Bruce Z Morgenstern, Mayo Medical School

This article addresses the socialization of the medical student into the academic medical community, focusing on learning this community's "sanctioned ways of talking." The authors break down this talking into two broad categories, talking with patients and talking about patients. This study focused on the latter. The study is based upon genre theory, the genre being case presentations. In this case, the genre is used for dual purposes: patient care and for student evaluation.

To answer the question how (and how well) does the learning facilitated by the case presentation genre socialize the novice into the values and goals of a health profession discipline, the authors used a convenience sample of 11 students and 10 faculty. They observed and recorded16 oral case presentations and the teaching exchanges related to them, and conducted interviews. The interviews consisted of scripted open-ended questions about the nature and purpose of case presentation and two video clips of presentations, one of which was early and flawed and the 2nd was later and more sophisticated.

Not surprisingly, the students viewed the presentation as both an opportunity for learning, but also as an exercise on which they were to be evaluated. Students described the ideal presentation as one that did not get interrupted. Three strategies by students were identified: proving competence, seeking guidance (i.e., asking the staff how to proceed through a presentation), and deflecting criticism.

The faculty, on the other hand, felt that the presentation was a way to construct shared knowledge about a patient case, and to facilitate care. Faculty feedback was often explicit and comprehensive. Five important dimensions of an ideal presentation were uncovered: access to necessary information, reliability, relevance (or pertinence), evidence (as in EBM), and managing the probabilities (described as the "connection between populations and indices of diagnostic suspicion").

The different expectations of students and staff add to the tension between the need for a comprehensive presentation of all the information obtained and the need for an efficient presentation for diagnosis and management. Faculty often provided feedback on the presentation as a workplace genre, while students are often presenting as a school genre.

The authors conclude that "school and workplace iterations of the case presentation genre may be at cross-purposes," and that "when students and teachers perceive a genre differently, a ‘gap' is created in their interactions." As a solution, the authors suggest that faculty review with students the multiple uses for the case presentation and explore with students the significance of these uses.

Comment: This study is an excellent example of the use of qualitative research to address an issue. One of the advantages of this form of research is that subject numbers can be small. Another is that a research question for a prospective study can be determined. This study opens many doors to improve the teaching and learning of an important skill.

The results are not surprising, but the data have not been obtained prior to this, nor have the competing perceptions of students and staff been addressed. The authors' solution requires some integration between clerkships. Students need to be able to be skilled in presentations for all clerkships, but the target (i.e., the "ideal") needs to be made obvious and relatively consistent. Is this a feasible goal?

(Do you have consensus among your faculty and residents on what makes a good presentation? Do you have an explicit template for the components of a presentation that go beyond "SOAP"? Steve Miller)

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