Navigating specialty training through agency : The Fellowship of the Colleges of Medicines of South Africa

Chauke, Lawrence and Trowler, Paul (2024) Navigating specialty training through agency : The Fellowship of the Colleges of Medicines of South Africa. PhD thesis, Lancaster University.

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Abstract

This thesis examines the experiences of trainee medical specialists in South Africa's national medical specialist certification framework, implemented in 2011. The framework aimed to integrate specialist medical education and establish a unified, quality-assured national certification system. This research project responds to the need for teaching and learning (T&L) research in higher education that considers agency, context, and different research methodologies and philosophies in its conceptualisation of T&L in this field. It is also motivated by my curiosity about how structure and agency interact in specialist medical training, given the health system and educational challenges reported in this area. The thesis seeks to explain how trainee medical specialists use agency to navigate structural constraints during specialist training. The study is grounded in the interpretive-constructivist research philosophy and employed a constructivist grounded theory methodology to investigate the interaction between trainees' agency and structural constraints in the postgraduate (PGME) training environments. Semi-structured interviews were conducted with 30 trainees and recently qualified medical specialists in four specialist disciplines: Medicine, Obstetrics and Gynaecology, Paediatrics, and Surgery in Gauteng Province, South Africa. Participants were selected using purposeful and theoretical sampling techniques. The sample size was determined based on data adequacy. This approached ensured that sufficient data was generated to address the research questions. Interviews were digitally recorded, professionally transcribed, and analysed according to the constructivist grounded theory research methodology. The study provides insights into the structural challenges faced by trainee medical specialists during their training. These challenges seek to hinder them from achieving their personal dreams or aspirations. These challenges include, among others, the organization and structure of the specialist training programs, institutional culture and practices, supervision related challenges, gender and racial discrimination. Some of these constraints (e.g. gender and racial discrimination) reflect the lack of transformation within the PGME training environments and the persistent legacy of apartheid. The study’s findings suggest that, instead of yielding to the constraints, the trainees utilised individual and collective agency to successfully navigate and overcome them in pursuit of their personal dreams/aspirations. Internal dialogues (autonomous and communicative) and social support emerged as important mediators of the trainees’ agency. The above findings are in contrast with the structuralist and individualist perspectives on the relationship between structure and agency which assigns determining power to structure and agency respectively. On the conceptual level, this thesis contributes to the conceptualization of T &L learning in PGME from the perspective of structure and agency, including using different research methodology to conceptualise the structure and agency interaction. It proposes that reflexivity, personal history, and social support are crucial factors that influence personal agency, and as such, should be taken into consideration in all endeavours aimed at comprehending the interplay between structure and agency. From a practical standpoint, this research offers valuable information on the challenges facing medical specialist training in study sites that can be utilised to improve training and to inform PGME policy direction.