Possibility and agency in Figured Worlds: Becoming a ‘good doctor’

Context: Figured Worlds is a socio-cultural theory drawing on Vygotskian and Bakhtinian traditions, which has been applied in research into the development of identities of both learners and teachers in the wider education literature. It is now being adopted in medical education.

Objective: The objective of this paper is to show what Figured Worlds can offer in medical education. Having explained some of its central tenets, we apply it to an important tension in our field.

Application: The assumption that there is a uniform ‘good doctor’ identity, which must be inculcated into medical students, underlies much of what medical educators do, and what our regulators enforce. While diversity is encouraged when students are selected for medical school, pressure to professionalise students creates a drive towards a standardised professional identity by graduation. Using excerpts from reflective pieces written by two junior medical students, we review the basic concepts of Figured Worlds and demonstrate how it can shed light on the implications of this tension. Taking a Bakhtinian approach to discourse, we show how Adam and Sarah develop their professional identities as they negotiate the multiple overlapping and competing ways of being a doctor which they encounter in the world of medical practice. Each demonstrates agency by ‘authoring’ a unique identity in the cultural world of medicine, as they appropriate and re-voice the words of others.

Discussion: Finally, we consider some important areas in medical education where Figured Worlds might prove to be a useful lens: the negotiation of discourses of gender, sexuality and social class, career choice as identification within specialty-specific cultural worlds, and the influence of hidden and informal curricula on doctor identity.

Emotions and identity in the figured world of becoming a doctor

CONTEXT: There is little room in clerkship curricula for students to express emotions, particularly those associated with the development of a caring identity. Yet it is recognised that competence, alone, does not make a good doctor. We therefore set out to explore the relationship between emotions and identity in clerkship education. Our exploration was conceptually oriented towards Figured Worlds theory, which is linked to Bakhtin's theory of dialogism.

METHODS: Nine female and one male member of a mixed student cohort kept audio-diaries and participated in both semi-structured and cognitive individual interviews. The researchers identified 43 emotionally salient utterances in the dataset and subjected them to critical discourse analysis. They applied Figured Worlds constructs to within-case and cross-case analyses, supporting one another's reflexivity and openness to different interpretations, and constantly comparing their evolving interpretation against the complete set of transcripts.

RESULTS: Students' emotions were closely related to their identity development in the world of medicine. Patients were disempowered by their illnesses. Doctors were powerful because they could treat those illnesses. Students expressed positive emotions when they were granted positions in the world of medicine and were able to identify with the figures of doctors or other health professionals. They identified with doctors who behaved in caring and professionally appropriate ways towards patients and supportively towards students. Students expressed negative emotions when they were unable to develop their identities.

CONCLUSIONS: Critical discourse analysis has uncovered a link between students' emotions and their identity development in the powerful world of becoming and being a doctor. At present, identity development, emotions and power are mostly tacit in undergraduate clinical curricula. We speculate that helping students to express emotions and exercise power in the most effective ways might help them to develop caring identities.

The thinking doctor: clinical decision making in contemporary medicine

Diagnostic errors are responsible for a significant number of adverse events. Logical reasoning and good decision-making skills are key factors in reducing such errors, but little emphasis has traditionally been placed on how these thought processes occur, and how errors could be minimised. In this article, we explore key cognitive ideas that underpin clinical decision making and suggest that by employing some simple strategies, physicians might be better able to understand how they make decisions and how the process might be optimised.

It's good to be queen: classically eusocial colony structure and low worker fitness in an obligately eusocial sweat bee.

Lasioglossum malachurum, a bee species common across much of Europe, is obligately eusocial across its range but exhibits clear geographic variation in demography and social behaviour. This variation suggests that social interactions between queens and workers, opportunities for worker oviposition, and patterns of relatedness among nest mates may vary considerably, both within and among regions. In this study, we used three microsatellite loci with 12–18 alleles each to examine the sociogenetic structure of colonies from a population at Agios Nikolaos Monemvasias in southern Greece. These analyses reveal that the majority of colonies exhibit classical eusocial colony structure in which a single queen mated to a single male monopolizes oviposition. Nevertheless, we also detect low rates of multiqueen nest founding, occasional caste switching by worker-destined females, and worker oviposition of both gyne and male-producing eggs in the final brood. Previous evidence that the majority of workers show some ovarian development and a minority (17%) have at least one large oocyte contrasts with the observation that only 2–3% of gynes and males (the so-called reproductive brood) are produced by workers. An evaluation of the parameters of Hamilton's Rule suggests that queens benefit greatly from the help provided by workers but that workers achieve greater fitness by provisioning and laying their own eggs rather than by tending to the queen's eggs. This conflict of interest between the queen and her workers suggests that the discrepancy between potential and achieved worker oviposition is due to queen interference. Comparison of relatedness and maternity patterns in the Agios Nikolaos Monemvasias population with those from a northern population near Tübingen, Germany, points to a north–south cline of increasingly effective queen control of worker behaviour.