Interpreting educational evidence for practice: are autopsies a missed educational opportunity to learn core palliative care principles?
- SpR in Palliative Medicine, West Midlands Deanery and NIHR Clinical Lecturer in Medical Education, Keele University Medical School, Staffs, UK
- Correspondence to Dr Sarah Yardley, SpR in Palliative Medicine, West Midlands Deanery and NIHR Clinical Lecturer in Medical Education, Keele University Medical School, Staffs, ST55BG, UK;
Objectives UK policy requires undergraduate medical curricula to equip students to care for dying patients. The educational potential of autopsy attendance during authentic early experience to learn about the social context of death and dying has not been fully explored. In this paper the author: (1) explores how meaning is created from autopsies in authentic early experience; (2) compares views of students, curriculum designers and pathology supervisors; and (3) identifies actual/potential learning about death and dying.
Methods This paper is based on a qualitative study of authentic early experiences situated in a UK medical school. Semistructured interviews were conducted with students in year two (n=12), workplace supervisors (n=2) and curriculum designers (n=13). Narrative analysis was used to contrast empirical data with socio-cultural perspectives on learning. Language and metaphor were used as tools to interpret knowledge construction and meaning-making in addition to a thematic approach.
Results The autopsy enabled students to learn about death and dying in a social context. Variance between groups in perceptions of autopsy experiences may reduce educational value. Autopsies were considered by students to be opportunities for ‘meeting’ real people, albeit dead ones, and learning from them. Tensions between lay and medical perspectives influenced learning.
Conclusions Increasing communication and collaboration between medical school curriculum designers and disciplines such as Palliative Medicine as well as Pathology could address concerns regarding student/doctor competencies to deal with death and dying. Further research is needed to evaluate changes in curriculum design and to establish if similar concerns are found in other settings.
In the late 1960s, as Kübler-Ross was identifying problems in medical institutions from the perspective of dying patients,1 Cicely Saunders was pioneering the UK hospice movement.2 Their work can be considered a foundation for emergence of the concept of a ‘good death’ incorporating relief of suffering and acceptance. Perceptions of ‘risk to life’ in different contexts (eg, death from chronic illness in comparison with sudden deaths) affect how the concept of a good death is constructed.3 Although medicalisation and institutionalisation of death and dying continue to be debated, death and dying are an unavoidable part of practice for doctors in almost all clinical specialties. Equipping students and doctors to care for patients and families during the dying process is a necessary educational objective.4 ,5 Recently updated standards in ‘Tomorrow's Doctors’ emphasise this education should commence in undergraduate curricula.6
Despite this, a lack of meaningful exposure to dying patients during medical school has been postulated as explanation for newly qualified doctors feeling unprepared to care for patients at the end of life.7 This perception is echoed by palliative care teaching coordinators within medical schools.8 In contrast, commencing a foundation post in general medicine or general surgery brings a reality of patient death, commonly within a workplace culture which regards discussion of this as taboo.7 Integrated undergraduate curricula encourage students to link physiological, pathological and clinical learning, and may include ‘authentic early experiences’ in workplaces providing care for dying patients.9 ,10 Authentic early experience describes new medical students undertaking ‘human contact in a social or clinical context that enhances learning of health, illness or disease, and the role of the health professional’.9 Differences have been found between anticipated and actual experiences of interactions with dying patients, particularly the extent to which personal meaning plays a role.10 This finding is replicated in experiences of death in later years which impact on students’ identities as well as their future approach to patient deaths.11 Students are more strongly influenced by the workplace modelling of professionals than theoretical teaching about end of life care.12 Studies of the effects of exposure to dying patients on student attitudes have produced mixed results, with some reporting negative and some positive changes.13 ,14
While the educational potential of autopsy attendance has been debated in specialist pathology journals, it has not been fully investigated within clinical education. Where educational value has been discussed, it is commonly related to content such as anatomy knowledge, rather than social knowledge about the patients concerned.15 ,16 Talmon surveyed pathology educators about the use of autopsies. The majority of respondents used autopsies as a teaching tool for pathology, but only 10% reported discussing end of life issues.17 How and why students might create meaning from autopsy attendance earlier in undergraduate courses and integrate this into their clinical practice is unknown.
This paper is an interpretative data analysis that considers the possibility of potentiating opportunities to learn skills important to palliative care within integrated undergraduate curricula where teaching time for specialty specific education is at a premium. It draws on data generated in a larger empirical qualitative study of how and why students generated meaning and constructed knowledge following authentic early experiences. All data relevant to authentic early experiences in the form of autopsy placements were extracted for further analysis. These extracted data provide an evidence base for discussing how and why students interpret their experiences in contrast to the perceptions of workplace supervisors and curriculum designers. These findings are then considered in the context of clinical teachers working within palliative and supportive care settings with suggestions to develop their educational practices. A theoretical argument is developed for greater integration of learning about interacting with patients and their families across disciplines.
Qualitative research studies usually produce data which exceed that necessary for the researchers’ original purpose and which generate interesting findings beyond the specific research questions for which the study was designed. In addition, a marker of robust and rigorous qualitative analysis is to seek to interpret the data rather than simply to seek confirmation of expected findings. It is, therefore, important that if unexpected findings emerge that these are given due consideration. The social impact of autopsy experiences emerged as a central theme in the original study when it was noted that these particular experiences were spontaneously prioritised by students as significant events to discuss with impact demonstrated through their choice of language: colourful descriptions and vivid metaphors.
The results presented are drawn from a larger qualitative study of knowledge construction and meaning-making consequential to authentic early experiences.18 The study interpreted empirical data through contrast with socio-cultural perspectives on learning. In particular, both Situated Learning Theory19 and Activity Theory20 informed the methodological approach. In addition Scott's concept of Mētis21 was used to develop a cohesive perspective on how and why students construct knowledge and make meaning through interaction. A brief summary of these theoretical frameworks is provided here with references for interested readers to pursue.
Activity theory (concerning systems within which learning occurs) provides a model to consider learning outcomes as the product of complex processes contributing to the end outcome through interaction.20 There has been increasing interest in these processes within the field of medical education research along with emphasis on the importance of ‘situated learning’ with ‘legitimate peripheral participation’ for students. Lave and Wenger describe situated learning as contextualised vocational learning, providing an alternative to developing abstract knowledge for later transfer.19 Both situated learning and activity theory provide potentially fruitful mechanisms for considering variables in complex situations with a focus on social practices as objects of inquiry. Activity theorists have tended to focus on transformation through practical action while situated learning focuses on the social interaction between participants to negotiate change.22 Pragmatically, these differing approaches provide subtly different lenses through which to consider data. Mētis is a theory of how social processes work in ways more complex than schemata devised to map them. It provides a framework for considering how people create meaning and when and how they choose to use it, and value it, in relation to formally recognised knowledge. The relation between Mētis and formal schemes or recognised knowledge depends on participants’ conceptualisations of each other and institutional agencies.
To (1) explore creation of meaning from autopsy as an authentic early experience; (2) compare how autopsies are conceptualised by students, curriculum designers and pathology supervisors; and (3) identify actual/potential learning about death and dying.
The study was situated in a UK medical school with an integrated spiral curriculum incorporating authentic early experience and problem-based learning. A spiral curriculum is one in which students revisit topics in multiple years of study to sequentially build understanding and to consider common themes between topics. Second year students attended one autopsy placement as part of an experiential learning curriculum thread. They were expected to submit a reflective essay on their experience which was used for both appraisal and assessment purposes by the medical school. Within their research interviews students admitted a reluctance to report negative experiences in their reflective essays and a desire to prove themselves to the faculty. This lack of genuine reflection, alongside the focus of the research being on how and why students created meaning for themselves, justifies the decision not to use the reflective essays as research data.
Ethical approval was received from the School of Medicine Ethics Committee and an NHS Local Research Ethics Committee. The study was advertised through lectures and email. Recruitment occurred via medical school administrators. Participants gave written informed consent. An arbitrary sample of students from year two (n=12) participated by contacting the researcher to volunteer. The term ‘arbitrary’ refers to the process of sequentially interviewing consecutive volunteer students in the second year of their studies with no further inclusion or exclusion criteria. Students did not have to have attended an autopsy placement in order to be included. In the larger study, purposive sampling of medical (hospital and community) and non-medical (social and voluntary) workplace supervisors (n=20) was undertaken. This included the two pathologists supervising the autopsy experiences. All authentic early experience curriculum designers (members of the medical school faculty directly responsible for these experiences) were invited, and consented, to participate (n=13, including four who were clinically qualified). Participants were interviewed at their place of work. For students and curriculum designers this was the medical school. For workplace supervisors this was a variety of hospital-based and community health, social and voluntary settings. Data saturation was reached in all three groups. Semistructured individual interviews were conducted by Sarah Yardley. She was known to the participants as a full time researcher, although they were not blinded to her medical qualification. Participants were not told that she had worked in Palliative Care. The interview schedule was designed to cover expectations, processes and consequences of experiences. This was achieved through a sequence of topic areas including stories of experiences, and areas of frustration in medical education such as the learning of content knowledge, achieving functional knowledge and transfer of knowledge. Iterative changes were made on the basis of previous interviews for sequential participant groups.23 Participants were asked to provide examples and encouraged to explain their interpretations of these.24 The larger study from which this paper reports only the specific findings related to autopsies was designed to answer two research questions: ‘How and why do students construct useful knowledge and meaning-making from authentic early experience placements?’ and ‘How and why do students make authentic early experiences work for them?’. No student or curriculum designer was asked specifically about autopsies but students (n=12, with even those who were still awaiting this experience wanting to discuss its significance) who gave this placement as an example were then engaged in a further discussion related to it. Workplace supervisors were asked to discuss authentic early experience placements for which they had direct responsibility within their workplace. This is the most likely explanation for no workplace supervisor other than the pathologists choosing to discuss autopsies. Last, two student discussion groups (one consisting of year two students who been interviewed previously (n=8) and the other of year two students who had not been interviewed previously (n=3)) were undertaken to discuss and refine emerging findings.25 Interviews and discussion groups were audio-recorded and transcribed verbatim. Sarah Yardley maintained field notes and a reflective diary throughout the study duration.23 A complete copy of the interview guide can be obtained by contacting the corresponding author of this paper.
The theories discussed above give no guidelines for practical data management. Therefore, an iterative analysis based on theoretical principles was developed while allowing the data itself to partially shape the framework. It must be acknowledged that interviews are socially constructed encounters presenting subjective perspectives; for this reason, the findings are necessarily based on personal representations of reality.
NVivo 826 facilitated the analysis by Sarah Yardley alongside hand-written field notes. An iterative thematic framework, initially developed in vivo from the student interview data, was used to code other data, adding new codes when necessary. Narrative analysis23 provided a methodological approach to access knowledge and meaning construction. Caragh Brosnan and Richard Hays reviewed the coding strategy and analytic framework incorporating multiple qualitative methods. In addition, Caragh Brosnan undertook a more detailed coding check on two of the student interviews resulting in consideration of only minor refinements. Three additional researchers Caragh Brosnan, Richard Hays and Jane Richardson were involved in generating and refining themes and interpretations.
Findings from each of the three participant groups are presented in turn before discussing comparisons between the groups. Student interactions with workplace supervisors and curriculum designers were based on student perceptions of what was expected of a ‘medical student’.
Students conceptualised their experiences as meeting and learning from real, albeit dead, people. Example narratives are provided in box 1. Significant language has been highlighted in bold. The identification of significant experiences can be made through listening to what is memorable and described in detail by participants, alongside the language, tone and manner (including metaphors) in which the story is told.27 ,28 Some of the participants’ stories can be classified as ‘significant incidents’—a term which itself has different meanings depending on the context. It is used in this context to describe examples of experiences which have, or perhaps should have, had a significant impact on the interviewee.28
‘… quite a scary experience ‘cause there was a lot … more blood... ‘Cause we've been doing dissections since the first year but… it was a bit different to do that because it was just completely real, I think … I'm not that squeamish … a lot more thorough and rough in a way, so … it was just a bit more gory… I think it's hard if just a layperson came in and saw that, I think they'd think that they weren't showing any respect, so... but they've got so much to get through that they've got to be thorough, so it's just trying to keep that in perspective, I think.’ (Y2I1)
‘We have to write a reflective summary on it so I think the medical school will then be able to take from that if anybody has been affected profoundly by it they can sort of follow it up... it seems to be... especially on television... it's glamourised... it's sort of whitewashed a bit… it's sort of made to be a bit prettier than it is... and then you're actually there and you see what has to happen in a post mortem.... and it has to happen because so many patients you don't know the cause of death, you need to know the cause of death… I think it was just a bit of realism, I think.’ (Y2I2)
‘You're used to... seeing a dead person... but you're not used to seeing a fresh dead person... I know it sounds terrible to say but I mean these people have died, say, the night before and... this was someone who was alive yesterday and to see all her organs just out on the bench... Massive carving knife, just doing sections through and then it all gets whacked in a bag and put in the cavity and sewn up... I suppose it's going from something... someone that was alive yesterday to basically a piece of meat the next day... ‘cause that could be me, tomorrow... It was a good experience. I mean... You get used to it but I was a little... nauseous … to start with. But the more and more you experience it, the less and less that gets and then you walk into a situation and it's just normal.’ (Y2I11)
Y2, year two; I, interview.
The first student, (A), contrasts her autopsy experience with experience of embalmed cadavers in dissection practicals. The ‘reality’ of the autopsy impacted on her. She wants to demonstrate her ability to cope and acceptance of the necessity of the procedure being carried out. Tension between the desire to self-align with the witnessed behaviour of professionals and a still-held lay perspective is shown as she expresses concern that a layperson would perceive a lack of respect.
The next student (B) uses the metaphor of ‘whitewashing’—covering up reality—to describe previous understanding gained from television. He frames the autopsy as a test of ability to become a doctor, expecting anyone who cannot cope to be identified and followed up. Students were pleased if they had proved they could handle the interactions required during this experience. They conceptualised this as surviving a challenge. This may lead students to seek to demonstrate their ability to cope, regardless of how they feel. As with student A, evidence of acceptance of the professional imperative to undertake autopsies is offered, perhaps to show that student B is willing to take on such a viewpoint.
The last student narrative (C) uses the metaphor of butchery. The impact on this student cannot be missed, as he describes ‘seeing a fresh dead person’ and relating to this person as an individual. He is challenged by the realisation ‘it could be me’—forming a personal connection to the potential fragility of health.
A switch is then made from describing ‘someone’—a person in the past tense, to ‘a piece of meat’—an objectification of what is no longer a person. This description stands in contrast to the assertion that it was a ‘good experience’. Whether this assertion is made to demonstrate an ability to cope or to simply mean ‘good to know what an autopsy is like’ is unclear. The narrative is brought to a close with the recognition that repeated exposure brings familiarity and acclimatisation. As normalisation of the autopsy is accepted to be necessary for the student's medical identity, he begins to move from outsider to insider of the medical world.
Student C had also visited a patient with colorectal cancer during an authentic early experience placement set in General
Practice. He describes this experience with language comparable that of the autopsy detailed above:
‘…it was a bit of a jump in the deep end—but it was very eye-opening, really good to...get it under my belt because obviously I'm going to see that throughout my career...I didn't know what the hell to say to him at all...I don't
know how to say this but unnerving...when you get onto the...aspect of him actually facing his own mortality and getting upset
about it and just hoping for one more Christmas with the grandkids before he kicks the bucket—his words not mine...it sticks with you...you're a little bit down for the rest of the day...but it's one thing you've got to cope with I suppose when you're coming into what we're doing...you try to distance yourself as much as you can from the patient but there's inevitable
transference...(year two interview (Y2I)11)
As with the autopsy, the student is challenged by the reality of someone facing their mortality but he reasserts the belief
it was a ‘good’ experience. Giving the reason that it will be a recurring experience in his career (suggesting that, perhaps,
therefore, he should see it as normal) he remains keen to demonstrate an ability to cope, while at the same time suggesting
it is necessary to do so by creating distance between himself and the patient. The need for distance or detachment was also
expressed by other students as evidence that they were forming a professional identity:
‘Whenever you go on placements you're always seeing ill people. The history taking I took was someone who was terminally ill—they had, a few months to live...so I think it's given me an opportunity to get used to hearing bad news and then, you know, dealing with myself so that I'm not making the patient feel bad.’ (Y2I4)
In this example, the student is emphasising that she has the capability to deal with distressing situations. There is also evidence that she is seeking some justification for this: her reluctance to describe herself as hardened, and the use of patient considerations as support for the benefits of developing less emotional reactions rather than self-protection.
The two pathologists supervising autopsies were interviewed to gain their perspective on these experiences (box 2).
The pathologists wanted the students to learn that autopsies had a purpose and for students to know how to be ambassadors of this message. Their agenda included: (i) students’ learning ‘factually correct’ information which could be used to explain to bereaved relatives that the procedure was performed without compromising patient dignity and (ii) understanding of the uncertainty of clinical diagnoses. This agenda arose amidst a perceived vacuum of specific objectives from the medical school. Recognition of how students still related to lay rather than professional perspectives was variable. For example, workplace supervisor B uses the same metaphor of butchery as the students but with the opposite intent.
Workplace supervisor (WS) narratives
‘… used to teach anatomy... to understand... just what happens in a post-mortem, so... students can answer a question, to a relative about what's going to happen in a post-mortem… and to see some basic pathological processes in action. I ask them what they know about the coroner – I obviously expect them to know nothing at all about the coroner, so I explain a little bit about that… then I also demonstrate any pathology to them, which they haven't had much exposure to at that time and… we sort of indicate the system whereby we might arrive at a cause of death and, obviously I let them ask any questions at any time, and most importantly I... insist that they see the body after it's been sewn up to indicate that it's quite reasonable for the relatives to see a body after a post-mortem.’ (WS10)
‘I want them to learn that we're not going to butcher them – after the PM [postmortem] they just look like before...’ (WS14)
Only four (of whom only one was clinically qualified and therefore had this experience himself) of the curriculum designers mentioned autopsy placements in their interviews, with even these faculty members viewing the autopsy experience as essentially non-problematic. One mention was simply about the logistics and administration needed to organise the experiences. The possibilities of learning additional anatomy or pathology or perhaps the experience prompting students to think more about classroom teaching on sudden death were mentioned but in ways that were dismissive or lacking recognition of the impact autopsies might have. The examples in box 3 illustrate their perspectives. Curriculum designer B conceptualises the ‘experiential’ aspect of the autopsy as an ‘extra’ which might (or might not) add a dimension to inhouse teaching. This, combined with the dismissal of autopsies as a routine long-standing placement in medical curricula, and a focus on ‘evidence’ of attendance and assignment completion as expressed by curriculum designer A suggests there was little expectation of a contribution to student knowledge or recognition of the potential impact on student meaning-making. The exception to this was curriculum designer C, who was the only member of the medical school to report discussing the personal impact with a student.
Curriculum designer (CD) narratives
‘…that's been running for years and so what we're expecting the student to do is see a post mortem, be shown some gross anatomy and morbid anatomy and they also write a reflective piece about it for their portfolio... well, we've got evidence that they've attended and we've got evidence that they've at least thought about it.’ (CD6)
‘They may also, learn something about the... psychological and social impact of a post mortem... the implications for the relatives and so on. And this fits into... a case where, there is a bereavement – a sudden death.’ (CD5)
‘…she had been struck by the fact that if that had been her father she would have thought the indignity of the examination...would have been intolerable.’ (CD9)
Medical students are known to need the support of experienced clinicians to make links between learning in different contexts and to integrate their learning from different disciplines.29 The findings presented in this paper show the potential educational opportunities arising from attendance at autopsies, and so can inform how clinicians develop their teaching practice when dealing with novice learners.
These students provided their autopsy experiences as examples of knowledge and meaning created from authentic early experiences. The autopsy was an opportunity to learn about death and dying in a social context, considering future interactions as doctors with dying patients and their families. Clinical teachers need to be explicit about identifiable similarities in order for students such as these to transfer what they have learned from the mortuary to clinical practice.
Students struggled with desires to align themselves with professional views while still experiencing the autopsy from a lay perspective. A previous comparison of student attitudes (to autopsies) with attitudes in general society found many similarities, including a discomfort and unease related to attending autopsies or considering the potential of one after their own death.30 However, as students progress in their medical careers there is some evidence these emotions are suppressed in favour of supporting the ‘medically acceptable’ view that this is a necessary medical procedure.31 McNamee et al32 report that fourth year medical students believe attendance at autopsy demonstrations is a way to develop ‘clinical detachment’ and equip themselves to ‘deal with’ death.
For the pathologists providing supervision the experience created an opportunity to ‘sell’ a different narrative to what they considered misconceptions of their own roles and the horror of autopsies. The professional views they presented were based on the premises that autopsies are a valuable scientific tool and that there is no intrinsic disrespect to the deceased if performed and explained in the correct manner. They were, perhaps, not aware that students’ acquiescence to these views was motivated by a desire to prove their worth as potential doctors.
The lack of specific and explicit understanding of potential learning outcomes for autopsy placements by the curricula designers left a vacuum to be filled by negotiation between the students and workplace supervisors. Students did not generally acknowledge the extent of content knowledge that placement providers wanted them to gain.
These findings resonate with socio-cultural theories of learning as the students constructed their knowledge and created meaning through interactions (with the deceased as well as their workplace supervisors and curriculum designers). If we accept that learning occurs through experience, then we must acknowledge that past experience and pre-existing knowledge will affect future experiences and, therefore, future learning. Comparison of the conceptualisations of autopsies among students, workplace supervisors and curriculum designers demonstrates the necessity to understand how and why attendance at an autopsy will impact on immediate learning, but also, perhaps even more importantly on future learning in different contexts.
Autopsies and palliative care: implications for practice
Doctors are required to be able to competently explain to relatives why an autopsy is requested, what will happen and what the body will look like afterwards. The aims of palliative care educators are remarkably similar to the pathologists in this study, including the transition from student to doctor with respect to providing care for dying patients and support for their relatives.8 Autopsies may be underutilised for educational purposes. Actively linking clinical specialties such as Palliative Medicine to these experiences could have several benefits. The medical knowledge that can arise from an autopsy if the cause of death was unknown might be recognised as relevant to students if stronger links were made between clinical disciplines and pathology teaching. Expertise within Palliative and Supportive Care, alongside other clinical specialities, might be utilised to provide support for students as they make the transition from a ‘lay’ (ie, general public) perspective to developing a professional perspective on healthcare. Achieving this aim could also include more imaginative alternative approaches, for example, as suggested by one of the reviewers of this paper, encouraging students to attend funeral directors to see how they take care of and present bodies for viewing before encouraging discussion of these experiences within teaching on bereavement and after death care.
If clinicians considered autopsies to be a relevant teaching tool for communication skills within their clinical specialties then this could create new educational opportunities for undergraduate students to develop integrated learning relevant to peoples’ experiences of healthcare. The data show that students experience and construct knowledge and meaning from autopsies in a comparable way to their interactions with ‘alive’ patients. Potential learning, for example, how to interact sensitively with patients and their families in distressing situations and the importance of being able to explain procedures to the public, may be lost if teaching clinicians do not understand how students make sense of these experiences and support students in creating links that allow them to transfer learning from one setting to another. Arguably all doctors need to know how to care for dying patients and/or interact with bereaved families and friends in a professionally caring way. Important elements for these activities include an understanding of the physical, social, psychological and spiritual issues related to death and dying in addition to understanding of specific legal frameworks such as the role of the coroner in relation to medical practice. It is important that as students become doctors and so are inevitably enculturated into medical practice that they retain awareness of, for example, the concerns of ‘the public’ with respect to death and dying.
Strengths and limitations
The methodological approach was guided by theory and sought to integrate multiple qualitative methods in order to increase the rigour of the findings. Taking participants from three groups and contrasting these using socio-cultural theoretical perspectives to inform clinical teaching practice has not, to my knowledge, previously been done in this area of Medical Education. These findings provide evidence of the importance of doing so if the influence of interactions between people on learning is to be understood. This study was conducted in a UK medical school and so it is possible that elements of the findings relate to this particular school or country. It should be noted that during the study period the school was, however, receiving praise by regulatory bodies for its approach.
The data in this study demonstrated that students already reflect on and construct knowledge and meaning in these learning domains following postmortem placements. Capitalising on this spontaneous process with, for example, structured discussions and clinical teachers demonstrating links to their own practice offers a mechanism to develop important skills for both general and specialist palliative care.
Increasing communication and collaboration among curricula designers, clinical speciality teachers and pathologists to integrate knowledge-based and patient-centred education could address concerns regarding competencies to deal with death and dying. This would contribute to fulfilling the standards of Tomorrow's Doctors6 and ultimately improve patient and family experiences of healthcare. Further research is needed to evaluate changes or interventions based on the findings and theoretical argument developed in this paper and to establish if issues raised by these interviewees apply to other settings.
Caragh Brosnan, Richard Hays and Jane Richardson are thanked for their supervision of the doctoral thesis and helpful comments on earlier versions of this paper.
Collaborators Richard Hays; Caragh Brosnan; and Jane Richardson.
Contributors SY is the guarantor of the paper and the sole author. She conceived, designed, and conducted the doctoral work on which it is based. She has written the article and the arguments contained within are her own.
Funding Funding for the research on which this paper is based was received from Keele University Medical School and Keele Research Institute for Primary Care and Health Sciences. In addition, the author received a small grant for transcription from the Association for the Study of Medical Education.
Competing interests None.
Ethics approval Keele University School of Medicine Ethics Committee and NHS South Staffordshire LREC.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data on which this study is based are available on request from Keele University Library in the form of a completed PhD thesis. In addition, the raw data have been archived at Keele University, but it is not publically available.
- Received 16 July 2012.
- Revision received 28 September 2012.
- Accepted 19 November 2012.
- Published Online First 14 December 2012
- Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions