Our subjects demonstrated that they felt part of a wider medical CoP and specifically that they were legitimately peripherally participating in a CoP with the GPs that they had weekly contact with. The 5 major themes drawn from analysis of the results, hereon referred to as facets, allowed the development of a new model to understand LPP and the processes that are involved in the PIF of our cohort of students. This is visually represented in Fig. 1 below. The term facet was used as it captures the complexity of PIF and the notion that its development occurs through engaging with multiple processes in a non-linear fashion.
Facet 1: Awareness
Many students at Stage 1 interviews understood their learning in clinical practice as an extension of small group teaching. They were not yet appreciating that the clinical environment gave them the opportunity to contextualise their classroom learning and offer a real-life perspective on it. These students were categorised as being in a state of pre-awareness.
Some students however conveyed a sense of awareness. They discussed how the clinical environment offered them a different view of medicine. Their narratives describe them being challenged by their experiences and in turn their questioning of existing primary sources of knowledge like lectures and textbooks. This conscious realisation, an awaking, is a necessary aspect of LPP and a key process in PIF. It demonstrates that the lived experience of talking to GPs and being immersed in the clinical environment offers a richness to the learning experiences of our students that is not realised through classroom learning alone. It thus supports the importance that early exposure of medical students to clinical practice has in both contextualising learning and in PIF. This is illustrated in the quote below:
[clinical practice] ‘is bringing totally different concepts that I’ve not even thought of being linked and new ideas that people haven’t mentioned in lectures and that aren’t necessarily written in the textbooks………when we [other medical students] talk to our ladies with breast cancer………..you don’t really understand how it [illness] impacts on someone’s life until you see it in front of you…..it makes it so much more real’. (Student – Elizabeth – Stage 1).
Facet 2: Collaboration
Engagement in clinical practice and talking to both GPs and patients in the community appears to enable our students further consider their classroom learning. They are looking to the GPs as knowledgeable others in the CoP [11]. Their narratives suggest coherence through mutual engagement, establishing collective norms, and expectations resulting from a re-examination of importance and meaning. Through this co-operative participation relationships are built, and connections are made that bond members of the community together. Students are, in this sense, legitimately peripherally participating in the GPs CoP and in doing so are developing a sense of how their classroom learning will be used in the real-world. They are aligning themselves with the GPs that they are talking to and in this sense their PIF is occurring.
‘It’s all very well reading something in a book…when you see patients, you kind of get their priorities…I have a list [of priorities] in my head and it just rejigs when I have a conversation with the GP’ (Student – Rachel - Stage 2 interview).
‘When a GP says that never happens in GP practice…….that is so off the mark I [appreciate that and]……..I’m going to re-evaluate where I put that and prioritise that in my knowledge’ (Student – Alice – Stage 3 interview).
Facet 3 – Negotiation.
In negotiating a shared understanding of the common purpose of the group, the group’s joint enterprise. Both stage 2 and 3 interviews have students that demonstrate knowledge formed in action, where meaning is negotiated in the context of the CoP and what is important to the CoP is considered. It is this appreciation of reality that appears to be important to them and further aids their legitimacy within the CoP. LPP within the GP’s CoP thus allows students to develop get a sense of who they may be in the future which is an important aspect of their PIF.
[In the clinic you have] ‘the opportunity to try things out…..a phrase or kind of explanation and seeing what response you get back [from patients]…it’s like refining your efficiency and also your way of connecting with that person [the patient]’ I think the GP practice almost gives us a lengthy amount of time to refine what we’re going to go on to be….potentially experts’. (Student – Fiona – Stage 2).
Negotiating meaning is key in this process and being part of the CoP provides a safe environment from which to do this. In terms of LPP this creates mutual accountability integral to both Jane and GP.
‘if you have any…worries or concerns I find our GP’s very good at reassuring us that we’re where we should be at this point and everyone actually feels like that….you can’t ask other people in the same way that you do them’ (Student – Jane – Stage 3 interview).
Facet 4 - Evaluation
Through mutual engagement and joint enterprise students develop perceptions on practice. Students may show a mismatch between their peripheral practice and GPs full participation in the community. Reflection is a way of making sense of this and allows students to consider how they may be both part of the CoP whilst maintaining their own sense of agency. Emma comments on her GP’s practice and depicts reflection-in-action [27]. Emma’s viewpoint is evidence of her developing engagement within the CoP and an evolving PIF.
‘You can look at them [GP] and think well that’s a really good way to do it but you can also think well that’s their way of doing it, but I wouldn’t do it like that. I would maybe do something different. That’s OK to think that.’ (Student - Emma – Stage 2).
Rachel’s trajectory, past and future participation, exemplifies knowledgeability, and a collective becoming. Rachel’s integrated understanding of her world suggests an increasing awareness of PIF and of her LPP within a medical CoP.
[Feeling different] ‘it is like a really slow transition…just accumulating knowing really slowly… progressing into being a doctor…it’s really a kind of subconscious thing it just kind of filters into you……your vocabulary and demeanour, it does change’ (Student – Rachel – Stage 3)
Facet 5 – Realisation
Peripherality is complex to interpret, it is not a physical place within a community [10]. Philip, understands his current knowledge as ‘idealistic’, perhaps acknowledging his current participation as peripheral. His vision of future practice, of other people in full participation who will make his knowledge more ‘realistic’, will occur ‘in the world and in practice’. This exemplifies an identity trajectory generated through a history of practice and a vision of future professional identity [11].
‘I get the impression that our knowledge.... it’s probably still very idealistic and we will be meeting people in A&E who will probably make it much more realistic and bring it much down to what it’s like in the world and in practice’. (Student – Philip – Stage 3 interview). He understands that his participation within the CoP is peripheral and that he needs further experiences to fully contextualise his learning.
Our students are not only learning ‘from talk’, they are learning ‘to talk’ [10]. This is a key part of a student’s learning trajectory within a CoP and is important to identity development. John now explicitly recognises the complex importance of language and of having a shared repertoire of practice within the medical community, which were not evident in the proceeding interviews. He is thus signalling his conscious participation within the CoP and his developing sense of being a part of that CoP. He is demonstrating his PIF in the use and understanding of language as a shared repertoire within the CoP of medicine.
‘I’m talking to a patient and I’ll actively go ‘oh that’s jargon, I won’t use that. I think it’s important to have two modes [of talking] the more technical mode, [and] a less technical mode’ (Student – John – Stage 3 interview).