Recognising, valuing and supporting clinicians who teach: a critical realist exploration

Abstract

This project set out to investigate an apparent contradiction in the published literature on recognition and reward of doctors who teach: while medical schools report a range of apparently successful interventions designed to recognise and reward their clinical teachers, teachers consistently report feeling under-recognised and undervalued.

Using a critical realist (CR) perspective, the project aimed to establish: a) why there is a widespread perception that clinical teachers and teaching are under-recognised / undervalued; b) why this persists despite the best efforts of medical schools to resolve it; and c) what, if anything, might be done to change this within existing organisational and societal constraints. A range of transdisciplinary perspectives were used to theorise potential causal mechanisms, and a critical pluralist approach was taken to methodology, combining case study research with critical discourse analysis, followed by application of a complex, adaptive systems (CAS) perspective to model the findings at the levels of ‘society’, ‘institution’, ‘organisation’ and ‘individual’.

Key findings of this study at societal and institutional levels were that the problem is underpinned by a primary tension between healthcare (high value) and education (lower value), and that this is compounded by structural factors such as lack of resources and heavy emphasis on quality assurance and accountability. Within the case study school, evidence suggested that: teaching was being ‘backgrounded’; communication was unidirectional, fragmented and liable to break down; the rewards being offered had high potential for adverse effects; and the reliance on implied contracts was contributing to a mismatch in expectations between teachers and medical schools.

Although this problem has multiple causes, the application of a CAS perspective to map the connections between these allowed the generation of a series of recommendations for change aimed at medical school managers and institutional policy makers. This project also makes a novel contribution to the medical education research landscape by demonstrating how critical realist metatheory can be utilised within the medical education domain and by illustrating how bricolage and iterative research designs can support a flexible approach to research, while still producing work which meets demands for theoretical and methodological rigour.