No Doctor is an Island

“We can see physician–physician power dynamics play out in several ways.”

In this issue of Medical Education, Armson et al. report on an ethnographic study of how small groups of family physicians work together in communities of practice to apply new evidence-based information into practice.¹ From these data, the authors developed a ‘change talk’ framework to illustrate the conversational elements which propel the adoption and adaptation of medical and practice knowledge.¹ They conclude that iterative questioning and sharing of practice experiences in small learning groups helps physicians develop feasible and rigorous strategies for incorporating new knowledge and practice changes.¹

The ‘change talk’ framework was identified within the context of mono-professional communities of education practice (CoPs), in this case groups of family physicians centred on continuing medical education. CoPs, often understood as a group of professionals sharing a set of problems and learning and innovating together, are valuable in medicine, particularly for professional development.² CoPs are frequently mono-professional (e.g., family physicians or specialist physicians), as they are in the Armson study, rather than intraprofessional (e.g., a mix of family physicians and specialist physicians). Mono-professional knowledge generation shapes the questions asked, comparators considered and therefore the knowledge generated. As a result, the knowledge may not be seamlessly transferable to other professional groups. We can see this in clinical practice guidelines produced by groups of specialist physicians, often without fulsome involvement from family physicians. These guidelines have the hallmark of focusing on the diagnosis and management of a single illness or organ system, without consideration of how therapeutic options may interact in patients with multiple co-morbidities.^{1, 3} The paper by Armson et al. has provided a testament to the value of mono-professional continuing education CoPs and can be used to consider how additional benefit may be realised within intraprofessional education CoPs and which challenges may be encountered.

It is often assumed that professional learning and working could be enhanced by taking another’s perspective in account. Research has, however, shown that understanding another profession is not made possible by simply taking perspective but by getting perspective.⁴ This means that direct conversations between specialists and family physicians are essential⁴ to the practice of high quality comprehensive care. In order to realise the promise of true intraprofessional collaboration and education, physicians must acknowledge and overcome engrained professional and social hierarchies that manifest in power dynamics.^{5, 6} We can see physician–physician power dynamics play out in several ways; previous research has shown that physicians easily overlook how hierarchy can lead to different perceptions of risks and patterns of silencing.⁵ These intraprofessional power dynamics are also present within medical education settings, where there is a tradition of physicians and trainees hiding their uncertainty to maintain credibility.^{7, 8} This may be exacerbated in specialist–family physician interaction because the intraprofessional hierarchy often places specialists at a higher status than family physicians, such as in educational arrangements which find family physicians being trained by specialists, but seldom reverses that dynamic.⁹

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