Before moving on to later narratives, it is perhaps useful at this point to demonstrate how the transformation of a short data extract into poetic form allows the data increased openness and encourages reader engagement beyond the scope of verbatim data.
As described in Chapter 3, poems were formed from data which I felt of particular significance by reducing words I believed unnecessary to conveying the meaning of the
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data. This transformation of Helen’s data in Table 2 in which she spoke of difficult relationships on her ward, produced a more concise and powerful iteration in which her isolation and emotional distress appear in sharper relief.
In these few lines Helen’s distress was evident; isolation, fatigue, imprisonment, and all the time trying to perform her duties. A single spark of humanity lingered in a simple kindness from a solitary person who offered support. In poetic form a reader is drawn closer to her emotional distress and, for those who have in some form been there, personal memories connect with her inescapable struggle.
Housedog
Terrible
didn’t sniff fresh air for three months bullying nursing staff
bullying consultants no rest exhaustion just shat on really
awful
crying in the treatment room making up the IVs
so tired the pharmacist
only friendly person on the ward gave me a cuddle
bought a box of jelly babies
112 Tools in a machine
I remember the on-call stuff; classic stories
I was just going through a process
wasn’t making any diagnoses or decisions just a tool in a machine
Within that machine were people I just disliked;
snakey, challenging, hierarchical people who wanted to prove me wrong.
To say to the consultant ‘He has done this and he has forgotten to do that, and thank goodness I rescued it
and can I now get a foot on the ladder, please?’
No patient-centred attitude; it was about a diagnosis
And I was tired;
I used to stay on nights off do all the clerking and the filing
People were falling off with stresses and breakdown;
one ended up in a psychiatric hospital
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From George’s data this facing poem traced a similar process through aspects of his job and poor interactions with colleagues
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Tools in a machine
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The separation George felt from ruthlessly ambitious colleagues was abundantly clear and soon he was reduced to simply finding a way through. He was vulnerable, engaged in a game he did not wish to play and with people whose ambitious, doctor-centred approach he did not share. Recognising how severely it could impact on his own health, his options were limited.
By making a transition to poetic form, this section of data draws together the difficulties of both his job structure and negative consequences inflicted on him by the aggressive competitiveness of others. There is space for him to reflect that their style of medical practice appeared to focus on themselves and their brilliance leaving patients in the crossfire while they fought their way to eminence. This poem also has capacity to recognise casualties in the system; to register this without fine detail, appears sufficient.
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When working and learning were fun
Six months there was good fun; loose on the wards,
working with people you know registrars that had taught us. Living in the hospital
I would stay some nights because there was a social thing to it. It was fun, exciting,
learning a lot,
in an environment that you were comfortable with. The surgeons let you get on with the medicine, and you would call for help as you needed You would help them do the surgery bit, which was fun,
but the novelty wears off
and you would rather be back on the wards; thinking and
doing things for patients It wasn’t too onerous;
by mid-afternoon you tidied things up, could play pool.
Not too busy but you can rack up 100 hours There really was a community,
camaraderie spirit.
Nights off, you would all go out together You really did feel a valued member It was an experience,
an expedition that you all did together
It was good fun. And you learned a lot you were more independent could do things
could do it as a junior
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By contrast Graham’s recollections were of positive experiences; fun engagement, supportive colleagues, friends on and off the wards;
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When working and learning were fun
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Socialisation and support marked Graham’s carefully chosen posts, maximising a supportive camaraderie and friendship between colleagues and taking advantage of opportunities to acquire practical skills and exercise a degree of autonomy. The headline total of hours was tempered by an ability to have relaxing ‘time-out’ and the sheer joy of performing as a doctor after years of preparation. Use of verbatim quotes normally attempts to avoid undue repetition, but in a poem repetition, bounce and rhythm of the wonder of learning in a collegial and supportive environment lends an ongoing momentum to the piece. There remains a sense of endless possibilities, of his/their adventure, and of progress towards building a satisfying career.
Generating poems encouraged me to engage again with data and through presenting them to different audiences to hear the depth with which they were understood and realise how powerfully listeners reacted to expression of feelings or were reminded of past experiences and at times identified strongly with the narrator. For these reasons, poems continue to carry data throughout subsequent chapters often contributing a more rounded picture of what was important in the context of the quote. Since some data does not readily transfer to poetics and at times pertinent quotes are more appropriate, data is included in both forms.
116 4.4 Neo-professional; a provisional status
As discussed in section 2.9 many sources agree that a sense professional identity and understanding core characteristics inherent in medical professionalism undergo significant development from the point of qualification (Niemi, 1997, Weaver et al., 2011, Helmich et al., 2010). Stories revealed several examples during this period when doctors’ developing professionalism was nurtured or challenged.
Hilton and Slotnick have termed young doctors as ‘proto-professionals’, but I propose a more fitting choice could be that of ‘neo-professional’ (Hilton and Slotnick, 2005). At their graduation there may be variation in the degree to which individual doctors have progressed to firmer identity definition and embraced the duties, responsibilities and attitudes which are recognised as characteristics of medical professionalism (Kahn, 2013), but by obtaining a medical degree and entrance to the GMC register they are already correctly termed ‘professionals’.
Identifying this group as neo-professionals takes account of the learning processes which are in progress while the doctor enacts a professional role within limitations imposed by supervision. Cognisance can also be taken of their inexperience in enacting these roles, of vulnerability in hierarchical structures, and of a degree of malleability in what they will come to accept as normal practice and whether they may be at risk of adopting practices at variance with what they have been taught once these are observed (Cottingham et al., 2011). Indeed concern has been voiced that while medical educationalists have been teaching a bioethical based medical professionalism, an alternative sociologically favoured approach to adequately address relationships between clinical autonomy granted to the profession in expectation of returns such as altruism, morality and integrity, has been neglected (Cruess and Cruess, 2008). Once more rigid concepts have been established in a doctor’s thinking and become tangled in complex notions of clinical mentality and a defence
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of autonomy, unhelpful links between these concepts have been found more resistant to modification (Armstrong and Ogden, 2006).
As these experienced clinicians narrated their neo-professional experiences, they did so in knowledge of understandings of professionalism which have matured as their careers advanced. In their stories they demonstrated constraints of authority due to their lowly position. Clinical autonomy was limited and where granted could lead to contrasting positions of satisfaction with innovative work or distress through having had sufficient latitude to make an undetected error. Orientation towards caring for patients and skills to listen required more time than was available in some pressured posts. Socialising with likeminded colleagues contrasted with attrition of cut-throat competitiveness. Despite long hours of work their efforts could go unrecognised or receive unwarranted criticism and they encountered many instances when senior colleagues displayed behaviour which fell below standards to which they aspired.