Structure and Agency in Medical Case Presentations

TLDR: It is concluded that genres such as case presentations function as mediating tools that allow participants to negotiate agency across generations and across levels of expertise as sets of strategic choices.

Abstract: This study investigated the role that medical case presentations play in the renegotiation or reconstruction of agency that occurs between medical students and physicians. Medical case presentations perform a dual function in teaching hospitals. They constitute formalized ways that physicians convey complex information about patients, and they are educational vehicles which medical students use to demonstrate their medical problem-solving abilities. This study observed and transcribed 16 oral case presentations performed by third-year medical students in a children’s hospital. As part of an interview protocol, two transcripts, one from a less and one from a more expert student, were turned into scripts, dramatized and videotaped. Ten faculty and 11 students were interviewed and asked to identify the differences between a more or less expert student performance. Data were analyzed using modified grounded theory and statistical strategies. Using a combination of dialectical social theories—specifically structuration theories (Giddens and Bourdieu) and activity theory (Vygotsky and Engestrom)-- as well as rhetorical theories of genre (Bazerman, Russell and Schryer), this study concludes that genres such as case presentations function as mediating tools that allow participants to negotiate agency across generations and across levels of expertise as sets of strategic choices. This renegotiation or reconstruction of agency, however, is not unproblematic. Genres have ideological consequences, and, through medical case presentations, medical students are learning to classify in quite specific ways, behaviors that could negatively affect communication with their patients.