Displaying professional expertise in medical case history presentations in PBL tutorials: a discourse analytic study

Abstract

BACKGROUND AND OBJECTIVE: Case history presentations play a major role in medical work and are consequently a key feature of clinical education and an indicator of professional expertise. Throughout their medical training, students interview and examine patients and present their histories to medical tutors. One aspect of the case presentation that has seen little research is its role in problem-based learning (PBL), notably from a discourse-analytic perspective. In this paper I make use of the notions of activity type, unequal or asymmetrical roles, and front stage / back stage activity to generate an analytic framework to illuminate how the educational and professional demands of case presentations are continually managed discursively within the PBL tutorial. Through analysis of the discourse, the performance of participants in different roles provides cues to the nature of expertise. METHOD: This paper draws on data taken from a small corpus of audio and video recordings of eight final year undergraduate PBL tutorials in clinical medicine, amounting to sixteen hours of recording time. The tutorials were observed and recorded in side rooms off the hospital wards in which the students had interviewed the patients. The recordings were transcribed and partially coded to identify focal themes, and then analyzed using the above-mentioned analytic framework. FINDINGS: Through the analysis of the asymmetrical dynamics of the tutorial and the shifting foregrounding and backgrounding of participants‘ educational and professional roles, a complex picture emerges of how professional expertise is constructed through questioning from tutors and peers, the giving of explanations for diagnostic hypotheses, and the management of uncertainty. IMPLICATIONS: This study makes a contribution to our understanding of the communicative challenges of medical education where expertise may rest not only in knowledge of the subject but also in management of the discoursal demands of overlapping educational and professional contexts.