Explaining how medical doctors learn about and understand the approach to the end-of-life in the workplace
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Date
27/07/2020Item status
Restricted AccessEmbargo end date
27/07/2021Author
Qureshi, Shaun Peter
Metadata
Abstract
Background
For patients approaching the end-of-life, treatments with life-prolonging intent can be
futile, wasteful, and harmful. Equally, harm may be caused by prematurely treating
patients as if they are dying. In order to provide a high standard of care, and align
with clinical guidance, doctors must appropriately discern when a patient is
approaching the end-of-life. This thesis takes the necessary and novel step of
developing an explanation for how medical doctors learn about and understand the
approach to the end-of-life in the workplace.
Research aims
1. To examine how the approach to the end-of-life is conceptualised by medical
doctors;
2. To explore experiences and understandings of doctors learning to care for patients
at the approach to the end-of-life, including factors which provide barriers to
learning;
3. To develop a theoretical explanation of the learning of doctors about the approach
to the end-of-life.
Methodology and methods
Taking a critical realist ontological position, this thesis considers what causal
mechanisms influence doctors learning about and understanding the approach to the
end-of-life. Data were generated through complementary methods:
• Scoping study and qualitative content analysis (QCA) of medical literature (2006-
2016) to examine established conceptions about the approach to the end-of-life
among UK medical doctors;
• Thematic analysis (TA) of data from semi-structured interviews with newly
graduated (foundation) doctors to explore development of understandings of the
approach to the end-of-life, and influences on this development and learning;
• Examination of the findings through the lens of a socio-material epistemological
framework – Cultural Historical Activity Theory (CHAT) – to theorise how interacting
factors influence the learner/practitioner in a complex environment.
Results
QCA of two hundred and sixty-nine included documents identified that there is no
single shared understanding of the approach to the end-of-life among doctors. TA of
data from fifteen interviews with foundation doctors indicates that care of the patient
approaching the end-of-life is a central aspect of their role and is learned about after
leaving medical school, beginning practice, becoming integrated into the workplace.
Both the literature and interview data indicate the approach to the end-of-life is not
understood as a discrete entity but is constructed dynamically in relation to the
patient, their disease, potential treatments and implications of these treatments, from
the perspective of the practicing doctor. CHAT allowed for consideration of this
practice-based learning as systems of activity, and identification of where
contradictions within and between each activity system act as barriers to learning and
practice.
Discussion and conclusions
The results have significant implications for educators and policy makers:
understandings of the approach to the end-of-life are not gained in advance of
practice (i.e. in medical schools). Instead, understandings are dynamically
constructed by doctors in their practice. Improving the doctor’s workplace by
overcoming tensions and challenges identified in this thesis should be focuses for
intervention to improve learning and care for these patients in the future.