Following an ethnographic approach, observations and informal interviews were used as the general data collection methods [18]. With a traditional ethnographic approach, the researcher invests considerable amounts of time in fieldwork. In this study, we adopt an ethnographic approach described by Jeffrey as a selective intermittent time mode, in which the key criterion is depth of study, entailing progressive focusing for a sustained period [19]. Data were analysed by identifying meaning patterns among similarities and differences [20] in what was identified as content during supervision.

Setting, realization and participants

In Sweden, all medical education takes place in state-governed public universities, and all clinical education is completed at university hospitals. The undergraduate medical education lasts for 11 semesters (5.5 years), at the end of which the student graduates with a master of medicine. To become a registered doctor, the student must also undergo clinical training, including 18 months of clinical work and studies after graduation. The supervision covered by this study took place at a surgical clinic in a university hospital in Sweden during 2004-2005. This university hospital is one of Europe’s largest, and encompasses three separate hospital sites, including three separate Surgical Clinical Education Wards (CEW). The head of each department, the health care directors and the director of the medical school all granted permission to carry out the study and facilitated access to the ward and participants. The observations were carried out mainly during medical rounds (n=21). Observations were also carried out at surgical outpatient clinics (n=3), in operating rooms (n=2) and during clinical seminars (n=1). Data were collected on a total of 27 occasions during a four-month period (see Table I), and comprised about 100 hours of observations.

Figure 1

List of observations, participates, settings and observer.

Field notes [18] were made according to a previously used model [21] including documentation of the setting, the participants, on the nature of their clinical education but also on the attitudes of the participants and on the pedagogical/communicative atmosphere observed during supervision. To deepen and broaden our understanding of what had been observed, informal interviews were conducted during coffee breaks or at other occasions and were documented in the field notes. Informal interviewing was performed without any predetermined questions and was used as a form of validation to ascertain that the researcher had interpreted the situation in an acceptable way. More complete documentation from observations and informal interviews was noted immediately after the observations [18] and field notes were transcribed after each observation.

For this study, nine fourth year medical students (two male students and seven females, aged between 23 and 37), attending a surgical course during their second year of clinical practice (i.e. the fourth year of their education), volunteered to participate in this study after a general inquiry to all students in the course. When observing participating students in clinical practice, 12 different supervisors (surgeons) (Table II) were involved. Of the twelve supervisors, eleven were men. The supervisors´ ages varied between 36 and 65 years. The distribution of ages and sexes of the participating students and supervisors was representative of the whole population of students and surgeons at the clinic.

Figure 2

Teachers age, clinical experience, title and experience as supervisor.

The participants were fully informed about the study. It was emphasized that participation was voluntary and that a participant could withdraw at any stage without any fear of repercussions. All participants gave their informed consent in accordance with the Declaration of Helsinki [22]. At the time when this study was planned and conducted, no approval by an ethics committee was required for this type of study. During some observations, patients were present. In such cases, the patient was informed of the purpose of the study and was assured that the researcher was bound by professional confidentiality.

Data collection and data analysis were, according to the ethnographical tradition, conducted simultaneously. In figure 1, the analysis process is illustrated. It will be described in greater detail in the text below.

Figure 3

Description of the analysis process.

The first step of the analysis consisted of making analytic notes [18] about the area of focus by supervisors when interacting with the medical students. These analytic notes were used as working hypotheses, e.g. communication is identified as a focus or identifying data is identified as a focus and guided further observations (I). By applying an iterative process in which working hypotheses were used to make sense of data, and new data were used to confirm or change preliminary hypotheses, the analysis advanced [18] (II). The constant comparison with previously collected material, the understanding of the phenomena in focus was widened and deepened [23] (III).

The final step in the analysis was performed when all observations were complete. Meaning units, which represented the phenomena in focus, were detected in the data text (field notes) and given a code describing their content, e.g. judging clinical situations, identifying physical phenomena, treating patients, communicating with patients. These meaning units were used to build up patterns describing the focus in supervision. As the analysis advanced, the working hypotheses were given meaning and were reformulated, and when all text material had been analysed and consistency had been ensured, the final construction of the result was obtained (IV). The analysis was discussed within the research group until agreement was reached and six topic areas were identified.

Problem-solving and decision-making were the most frequently observed topic areas during preparations prior to meeting patients, when the students were expected to solve medical problems in order to make a diagnosis or come to a decision. When solving medical problems, the students used information from medical reports, tests and nurses, together with information from the supervisors.

Supervisors encouraged students to reach a decision by applying a problem-solving approach. The students used both educational and clinical knowledge in their decision-making processes. By pointing out on what to focus and what to exclude, the supervisor guided the students in their problem-solving (Field note F, Appendix I). Sometimes supervisors demonstrated techniques used in solving a particular problem, for example, in dialogue with the student or the nurse. Supervisors could, for example, ask the nurse for specific information and thereby demonstrate how to proceed in solving the problem. They also pointed out and described approaches useful in problem-solving, such as focusing solely on the medical problem or not prescribing unnecessary blood tests when these would not contribute to the choice of further actions. Supervisors underlined the use and value of scientific accounts for decision-making

Supervisor: “There is evidence that it heals better if he moves about, although not so that it hurts. (19) (Field note G, Appendix I).

Handling treatments of disease concerned the management of care and treatment during inpatient hospitalisation, as well as planning of future treatment. Supported by the supervisor, students were expected to make decisions regarding the treatment of patients during rounds. To handle such situations, students used both educational knowledge and propositional knowledge, describing rules and guiding principles. Supervisors also contributed propositional knowledge, e.g. rules concerning which blood tests are usually carried out under certain conditions, which liquids should be prescribed in postoperative care, or which examinations are most appropriate for certain conditions. Supervisors even quoted research results to support decisions concerning treatments.

Supervisors used concrete examples to illustrate how to deal with treatments and diseases. Such management was mostly based on the supervisor’s personal background and practical experience. The field note below describes when the supervisor demonstrates experience-based knowledge when explaining how to manage a clinical case.

During the sit-down round the supervisor identifies the most important blood tests. Supervisor: “For now, the electrolytes are the most important in this situation. Tomorrow we shall take Hb and EVF and then we shall monitor the fluid balance”. (16)

Supervisors also presented experience-based approaches used to decide on a patient’s treatments.

Supervisor: “It is not sure things will improve just because one fires away with major tests and measures, which could also frighten the patient completely needlessly”. (6)

Supervisors and students discussed routines and procedures, such as how to manage certain conditions and illnesses, or how to manage specific clinical situations and how to support patients in their future care. The field note below shows a doctor providing examples of ways to manage a patient post-operatively

The supervisor joins the discussion and asks the student: “For how long should the patient be made to fast” The student does not answer the question but reflects: “The patient is not in pain...”/ The supervisor once again raises the matter of fasting and starvation during the round, when another patient’s prescriptions and continued treatment is being discussed. (21) (Field note H, Appendix I).

In the situations described above it was difficult to determine whether or not the knowledge content described by the supervisor was understood in the intended way by the student. In general, the student’s understanding of the content was rarely discussed during supervision.

The topic area of practical skills and illustration of technical equipment was observed when the student was encouraged to carry out practical, everyday tasks or to obtain practical understanding. Typical “how-to-do-tasks” were observed when students were given the possibility to practice something, e.g. perform an abdominal palpation, undertake a neurological examination, insert an intravenous catheter, draw blood from a vein or assist in the operating room. The example below is from a supervision situation in an operating room.

The student stands opposite the supervisor, who is operating. The student is holding retractors and keeping watch for sources of bleeding. So the student is participating very actively. The supervisor is teaching techniques on how the student should handle tissues. Supervisor: Do not wipe with the cloth, dab it up. The student listens and keeps assisting actively. (23) (Field note I, Appendix I).

When performing examinations, e.g. a rectoscopy, the student and the supervisor prepared the equipment and discussed the procedure before meeting the patient. Practical training was initiated either by the student or by the supervisor, and sometimes by the nurse. The medical students were often very eager to get the opportunity to improve their practical skills. They also often pointed out that they would have liked to receive more practical training during supervision (Field note J, Appendix I).

During supervision, students were given the opportunity to become acquainted with technical equipment and to discuss its practical use with their supervisor. During such demonstrations, in which patients were not involved, the supervisor demonstrated the approaches or techniques he or she used to accomplish a practical task. The dialogue below illustrates such supervision, where the supervisor shows how to carry out a practical task (here pleurocentesis) and what to bear in mind.

Supervisor says “It is better to enter with the peang [forceps] and feel with a finger so you get the right spot”. The student asks “How do you feel with the finger that you are inside?”. The supervisor answers “With the finger you know where you are”. The student wonders how he can do it without puncturing the wrong place and the supervisor says that “There is a risk it comes extrapleurally, as we don’t know how high the diaphragm is and that you have to enter it quite deep”. The student asks “How much is quite?” and gets the answer “A couple of decimetres. Just take it easy and then look at the chest x-ray”. (24) (Field note K, Appendix I).

The field note above also illustrates that it may be difficult for a supervisor to verbally transmit practical experience-based knowledge and to make it useful for the student.

The students were expected to act as an attending doctor and to verbally communicate with the patient. Often before meeting the patient, supervisor and student together prepared for the doctor-patient meeting. Then the supervisor would ask the student questions such as: What are you going to tell the patient? What about notification of illness, the next visit, pain management, and the patient’s ability to handle his situation at home? The field note below illustrates how a supervisor focuses on suitable information (what he or she is going to say) in order to prepare the student for the meeting with the patient.

The nurse has pointed out that the spouse is worried that the patient [bedridden due to head trauma] will not take care of himself correctly. The supervisor asks the medical student: “What should one avoid after trauma to the head?”. The student considers the matter and quickly answers: “High pressure on the brain, ... activities?”. The supervisor concurs and adds: “Soft sounds and dimmed light, the brain needs peace and quiet, no TV-games”. Later during the rounds the student uses this knowledge when talking to the patient about how he should behave at home and the patient asks questions. (17)

Students were given opportunities to practice their communication skills. They were also given opportunities to encounter patients and to handle the consequences of their own communication. If the student appeared hesitant or helpless in communication, the supervisor would demonstrate what to say to and what to ask of the patient. Supervisors also pointed out the importance of good communication to obtain valid information from patients and that skills in this domain need to be practiced to develop. Communication was also described as an art that requires innate talent (Field note L, Appendix I).

Supervisors also commented on the manner in which students communicated. This happened, for instance, when a supervisor would underline the importance of the creation of a good relation and of informing the patient in a positive manner

Supervisor: “You started the discussion by talking about which pills are to be discontinued. Does this create a relationship? It is better to start by saying what we can do for the patient (19) (Field note M, Appendix I,).

The topic of handling organisational demands covers situations and behaviours when the supervisors pointed out several ways to handle organisational circumstances, demands and limitations. Organisational demands and how they influence clinical judgments, in the form of restrictions and opportunities, were presented and discussed during supervision. Supervisors explained which patients or health-care conditions should be handled at the surgical clinic and which ones should be referred to other health care organisations or specialists. The field note below illustrates such a situation.

Supervisor: “The anamnesis is long. What can the problem be?”. Student: “A gynaecological inflammation, maybe other similar diagnoses”. Supervisor: “This is no longer a case for the hospital. It is an exploratory case. She should be discharged and further examination made”. (24) (Field note N, Appendix I).

Supervisors described organisational limitations, possibilities and prerequisites, such as available examinations, special routines at the clinic, staff qualifications and resources, or how the work is organized, that influence clinical management. In the field notes below the supervisor speaks of how to handle work in relation to time:

The supervisor ends the discussion, directs the attention to the next patient and notes that they are already 20 minutes late. “This would have been impossible if the students had had their own practice”. (1)

This is extended to include economic constraints.

The supervisor states that we cannot work miracles with the patients; we have to draw limits somewhere since this is an emergency ward and the hospital does not have limitless resources. (6)

Students were instructed on how to handle and enter medical records, make referrals and write prescriptions. Supervisors gave examples of what to focus on, and of what were obligatory and important to document and/or on how to draft a proper epicrisis (Field note O, Appendix I).

The supervisor describes the basic principles of chronic pain conditions and points out that one should start with a theoretical image of the so-called “pain ladder”. Perhaps the number of medications should be reduced, but this is a difficult task. It can take time and must be done in collaboration with the patient. (2)

D) Supervisor to student: “If you read through the text calmly, you will probably clarify the situation”. The student reads the text again and says: “Ah, now I understand what it means”. “Good”, the supervisor says, “please tell me what we should do with the patient”. The student looks up and asks whether the patient is to go home today with the drainage. The student looks to the supervisor for an answer.

Supervisor: “Before making your mind up you better examine the patient to assess the condition”. (6)

E) During the rounds the supervisor examines a patient with a fluid-filled abdomen. Supervisor: “Look [he then shakes the abdomen with his hand], do you see the wave-like movement in the abdomen? When you see this, there is a lot of fluid in the abdomen”. (17)

F) During the sit-down rounds the supervisor asks: “How long should the patient be made to fast?”

Student: “When did she arrive? Any pain?”

Supervisor: “There are intermediate possibilities. She may drink a little as we have no plans to operate. In this case it is more about how the patient feels, as we don’t know what’s wrong with her. She could have an ileus. We could let her drink and if she vomits she may have an ileus? Try it!” (21)

G) A patient has had a hernia operation and the student asks about the patient’s ability for physical exercise. Supervisor: “There is evidence that it heals better if he moves about, although not so that it hurts. He should avoid pain in all cases”. (19)

H) During a sit-down round the student, supervisor and nurse discuss the treatment of a patient with acute abdominal pains. The student asks the nurse “why is the patient kept on a fasting diet”. The nurse provides an overview why the patient must not eat or drink. She says it is good for the patient to starve since this reduces the pain and nausea, which may improve the patient’s condition. The supervisor joins the discussion and asks the student: “How long should the patient be kept on fast?” The student does not answer the question but reflects: “The patient is not in pain...”/ The supervisor once again raises the matter of fasting during the round, when another patient’s prescriptions and continued treatment are being discussed. (21)

I) In the operating ward when the student comes from the clinical education ward to participate in an operation. The student has met and spoken with the patient and has scrubbed his hands. The student stands opposite the supervisor, who is operating. The student is holding retractors and keeping watch for sources of bleeding. So the student is participating very actively. The supervisor is teaching techniques on how the student should handle tissues.

Supervisor: Do not wipe with the cloth, dab it up. The student listens and keeps assisting actively. After about 15 minutes of assisting, the student says: “It is amazing how quickly you get used to such a very strange situation”. (23)

J) The supervisor asks the students if there is anything they would have liked to have more of during the period of practical clinical supervision. The students would have liked more practical, hands-on activities, e.g. placing a fixed catheter (urine catheter), a ventricular probe or a venflon - more nursing tasks. They have mostly ended up writing epicrises. (12)

K) During the practical training the supervisor explains how one performs a pleura punction. The supervisor shows how one can aspire and drain contents by using a three-way tap. Then the supervisor explains that the procedure requires two people to handle the tubes and one to take care of the patient. The supervisor shows with his fingers in the air how he manages emergency cases and says that “It is better to enter with the peang and feel with a finger to get the right spot”. The student asks “How do you feel with the finger that you’re inside?”. The supervisor answers “With the finger you know where you are”. The student wonders how he can do it without puncturing the wrong place and the supervisor says that “There is a risk it comes extrapleurally, as we don’t know how high the diaphragm is and that you have to enter it quite deep”. The student asks “How much is quite?” and gets the answer “A couple of decimetres. Just take it easy and then look at the chest x-ray”. (24)

L) The supervisor pointed out that not everyone has the gift of being able to get the essential information from the patient in an exact and efficient manner. (1)

M) Supervisor: “You [turning towards the student] started the discussion by talking about which pills are to be discontinued. Does this create a relationship? It is better to start by saying what we can do for the patient: ’We are going to give you nourishment and energy so you feel stronger’. Start with the positive items, start with offers instead of with restrictions”. (19)

N) During a sit-down round a patient with gynaecological problems is being discussed. Supervisor: “The anamnesis is long. What can the problem be?”. Student: “A gynaecological inflammation, maybe other similar diagnoses”. Supervisor: “This is no longer a case for the hospital. It is an exploratory case. She should be discharged and further examination made. This patient should not be in the hospital”. (24)

O) Discussion between the supervisor and student during the sit-down round on how to fill out the medications list. The supervisor demonstrates the process and what to write in the different columns. (7)