Exploring competent professional practice : a social practice theory approach
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During a medical consultation, the right answer in terms of medical knowledge from evidence within clinical guidelines, may not align with the right answer for an individual patient. This can create tension within a medical consultation between the delivery of patient-centred care and externally imposed performance measures. This thesis illuminates a way to differentiate between unwarranted variation from a well-founded, mandated evidence base versus exercise of professional judgement and use of alternative sources of knowledge. This qualitative case study used a practice-based approach, and reflexive thematic analysis, to investigate how medical students use evidence-based knowledge within a consultation with an individual patient. This involved observation of teaching practice, and simulated consultations, then follow-up interviews with medical students, simulated patients and medical school tutors. This illuminated what is meant by competent professional practice and provision of patient-centred care. The thesis makes a methodological contribution by providing an alternative way of studying the complexity of implementation of evidence-based practice, as a social practice rather than a linear predictable practice. This study showed the value of considering ethical principles to support the patient to co-construct the performance. Patient-centred care could be demonstrated by the medical student being explicit about connecting with meaning from within the practice of the patient, to respect patient autonomy and epistemic justice. This required attention to which practice, and which elements within practice were attended to, from within the bundle of multiple practices within any context at each point in time. By teaching for connections, tutors support the competence of students to reflect on both the meaning element within the practice, and the material element within practice. The tutors can use feedback to support the students to use sociological imagination, to create a practice which is most meaningful for an individual patient, to provide patient-centred care within evidence-based medicine.
Thesis, PhD Doctor of Philosophy
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