In this section I describe how I approached the four analytical tasks of a Foucauldian discourse analysis. After a broad reading of the historical background, the analytical process continued through a deeper and more systematic reading of the policy documents, guided by the Foucauldian notion of archive (described in the chapter 3). Sets of documents were gradually grouped according to different (discontinued) series of rules regulating the discourse of general practice in medical education over a specific period. These groups represented an archive of the rules regulating general practice in medical education for that period. Each of these steps is described below.
4.1.3.1 Formation of the object: identification and characterization of the object of discourse
The characterization of the object of discourse involved identifying and analysing its particular features through the statements that defined it, looking for regularities and variances which differentiated it from other objects. It is clear in the analysis of the policy documents that this description of the
intimately related to general practice: these included general practice, family
practice and family medicine. Other keywords were closely associated with
general practice, such as community medicine, primary medical care, primary
health care and primary care. These all played an important role in naming,
describing, analysing, rectifying, re-defining, challenging or erasing this object. During the analysis process, I read the texts in full, noted the key presence or absence of the object under study, and identified broader ideas in the general discourse conveyed by the documents and their mission statements.
The following text from the Goodenough Report of 1944 exemplifies the characterization of the discursive object under investigation (general practice) as a medical field associated with the recognition of the effects of pathology on different dimensions of the patient’s life: personal, social and economic. Undergraduate medical education was, in this document, focused on medical conditions frequently faced in general practice. The assumption was that the graduating doctor should be prepared to act in general practice. Another important aspect of this text is the assumption that teachers involved in teaching surgery (most frequently surgeons) should also have an understanding of conditions treated by general practitioners.
“The training of an undergraduate in surgery should
be directed to the recognition, early treatment, personal, social
and economic effects of those surgical conditions commonly encountered in general practice…” (Goodenough, 1944, p. p.
29)
In the excerpt above, the object’s presence was directly identified through the keywords described. Its absence was recognized through the identification of other discursive objects characterized in the policy
specialties) characterized the object of this research (general practice) through direct comparisons described in the text or through a negative characterization, that is, by attributing characteristics to other objects that did not characterize general practice. The text below is an example of a negative characterization of the object. It reinforces the association between general practice knowledge and undergraduate education by implying that general practice is not a medical specialty requiring further (i.e. postgraduate) training. There is also an assumption that such specialists have superior educational status to that of general practitioners.
“All parts of teaching or of clinical practice that relate
only to the fields of work of the clinical or laboratory specialist
should be reserved for post-graduate education…”
(Goodenough, 1944, p. p. 125)
The selected documents therefore define general practice in relation to other discursive objects, especially medical specialties / consultants, medical schools, patients, medical students and health systems. Word-finding tools allowed me to check that I had identified all occurrences of these keywords in the text.
I used the concept of statement to identify different textual elements describing the characterization of general practice in medical education. Using the NVivo software, these elements were identified and grouped together in “nodes”. A node is a tool in NVivo that allows the researcher to group textual excerpts in order to identify a specific object of study. The node containing statements that characterized general practice had over 500 textual references for both Brazil and the UK. (Figure 8 – NVivo screen of UK policy nodes).
Figure 8. NVivo screen highlighting nodes of textual references from UK medical education policy that characterize general practice.
With the aid of NVivo nodes, I was able to focus on the most important passages for analysis without losing sight of broader discourses, which were grouped in separate nodes. The software also facilitated access to the original documents, meaning that selected passages could be studied in context rather than in isolation. The statements which played a vital role in delimiting my object of study are described in the results chapter (chapters 8- 12)
4.1.3.2 Formation of concepts: identify and analyse the important concepts used to characterize the object
Key concepts were identified as links between fields of knowledge and their definitions, allowing their use by participating institutions in medical education discourse to be analysed and compared (formation of concepts). In the current study, the key institutions were the national governments of the UK and Brazil, their respective departments of health (NHS, SUS), the committees responsible for evaluating and addressing the future of medical
GMC, CFM), other professional associations (i.e. BMA, AMB), and organizations representing medical schools, teachers and medical students (i.e. ABEM). Secondary documents produced by these institutions, such as the 1944 NHS White Paper, were referenced where they shed light on the use of specific concepts in different contexts.
Here is an example of how I approached the analysis of a concept category. The following quote is an example of the identification of key
concepts that characterize general practice. In the Goodenough Report
(1944) the concepts of health promotion and disease prevention were used to link the foundation of the NHS to the role medical education would play in delivering the medical workforce the new service needed. Students, it was presumed, would be willing to assume these responsibilities, which were directly attributable to general practice, and therefore to work in this part of the NHS.
“The importance of the promotion of mental and
physical health and of the prevention of disease is being
increasingly recognized by the medical profession and the general public. There is growing support for the view that a
general medical practitioner should become the health adviser of his patients and families and should participate to a
greater extent in the conduct of the health services of the country. The evidence received from student bodies discloses encouraging signs that many present-day students desire to
fit themselves for these tasks.” (Goodenough, 1944) p. 165.
In the text above, there is an assumption that medical education is supportive of the foundation of the NHS through the training of doctors who are prepared, as general practitioners, to prevent diseases and promote
health. However, the connection between the use of these concepts in
different fields of knowledge was difficult to discern, as the example above illustrates. There were no references to other documents that conceptualized
health promotion and disease prevention and very few to areas of knowledge
beyond the medical field. This could be seen as an attempt to insulate medical discourse from the influence of other knowledge areas or to stake a particular claim to the creation and use of these concepts. The few connections that do exist with other fields of knowledge are examined in the discussion chapter (13).
4.1.3.3 Formation of strategies: identify and analyse the strategic choices and how these choices shape the object
The consolidation of different choices in the production of a discourse reveals the strategy implemented by the authorities responsible for the documents reviewed (formation of strategy). The identification of these strategies involved three areas of focus: equivalent-incompatibilities, economy
of discursive constellation and the authorities involved (previously discussed
in chapter 3). Some practitioners of Foucauldian discourse analysis do not formally describe this phase of analysis (although they may follow it intuitively). I certainly profited from making discursive strategies explicit in the form of a mind map structure (see Figure 9).
Figure 9. Example of a mind map of the analysis of discursive strategies and equivalent incompatibilities. The balloons in green represent characteristics attributed to general practice. The lines connecting the balloons are labelled with the number of the references so that they can be identified easily in the NVivo nodes and in the original documents. The balloons in light blue are equivalent statements and the ones in red are incompatible statements.
Following the identification of statements (section 8.2.3.1 – formation of objects), I used the structure of mind maps, like the one above, to analyse the formation of strategies and how these regulate the formation of the object. As the statements were plotted on the map, their equivalences and
incompatibilities could be perceived more clearly than through the linear
presentation of the text. Statements regarding equivalences of each object were given a specific colour on the map (light blue). The regrouping of
equivalent statements that characterized the object of analysis exposed the
underlying assumptions of truth that enabled the object’s features. These assumptions of truth legitimized the occurrence of the compatible statements and the homogeneous characterization of the object. The incompatibilities of each object were gradually identified and given a different colour (red) on the mind map (Figure 2). These were the main indications of a heterogeneous account of the same object (formation of object). Mind maps such as the one above proved exceptionally useful in recognizing strategies of inclusion and exclusion of the discourse and object of the current study (general practice). This was particularly evident when other objects (i.e. “specialties”, “hospital”, “primary care”, “medical schools”, “teachers”) were defined and the “general practice” object was absent and/or excluded.
An example of discursive strategy identified in the analysis was the assumed dependency of the NHS on medical education.
“Properly planned and carefully conducted medical
education is the essential foundation of a comprehensive health service…We think it is advisable to stress the dependence of a successful health service on medical education, partly because current discussions show signs of a
tendency to concentrate prematurely on the detailed structure of such a service to the neglect of its essential foundation…”
In return for government funding, medical schools and teaching hospitals were expected to provide a medical workforce (general practitioners) for NHS primary care. But despite this new relationship between medical education and the public health system, university hospitals would be responsible solely for teaching and research and would not provide services to the population as a whole. This division between teaching and non- teaching services created a hierarchy of services in the discursive practice of medical education policy, with the task of educating medical students presented as having higher value than that of caring for the overall population. General practice surgeries were excluded from student teaching. The quote below illustrates the independence of teaching services and the primacy of their educational role:
“The number and variety of patients in the wards and
out-patient departments of the teaching hospitals should be
adequate to provide the students with such clinical experience in the various branches of Medicine…The admission
of patients to it must be selective and controlled in the interests
of teaching.” (Goodenough, 1944, p. p. 14)
This represented an incompatibility in discourse which helped to identify, through the analysis, the discursive strategy of hospital-based teaching as superior to other settings.
Identifying the authorities involved in the production of policies was greatly helped by the public nature of the documents. Names of authors and details of their professional background were readily accessible via the internet, mostly through governmental, medical or academic websites. Institutions had also posted documents offering a historical account of their foundation and development: these provided additional context for the
discussion of the results of the analysis (chapter 13). It was much more difficult to find critical (non-institutional) accounts of these organizations; indeed, during this research, none at all were found concerning the role played by these institutions in academic medicine or health practice, highlighting their seemingly unassailable status within the medical arena.
4.1.3.4 Formation of subject position: identify and analyse the subject positions available to the object
The characterization of the object produces different subject
positions presented by authorities involved in the production of policy
documents (formation of subject positions). Throughout the analysis, changes in the subject positions relating to general practice/general practitioners and other objects indicated a discontinuity in discursive strategy (i.e. the general practitioner as both learner and teacher). The policies reviewed, assigned particular subject positions to the actors involved in undergraduate medical education. The following example characterizes doctors involved in general practice as “practical in nature”. This characterization is later used to justify the exclusion of general practitioners from teaching and research roles and from academic departments within hospitals (chapter 6).
“Such (refresher) courses should be specially
designed for general practitioners, should be practical in nature,
and full use should be made of out-patient departments.”
(Goodenough, 1944, p. 34)
This discourse / discursive practice produces a subject position of “eternal learner” for the general practitioner: the recipient of continuous “refresher” training from specialist teachers engaged in theoretical and scientific work in a university hospital setting (chapter 6).
The following section describes the writing-up process, which can be seen as the final phase of discourse analysis.