Η εργασία αυτή προτείνει το συνδυασμό δυο θεωριών μάθησης, της μετασχηματίζουσας και της τοποθετημένης μάθησης στην κοινότητα πρακτικής των ιατρών. Οι νεοεισερχόμενοι ιατροί μεταβαίνουν από την περιφερειακή συμμετοχή στη πλήρη ένταξη ανάλογα με τον τρόπο που είναι σχεδιασμένη η εκπαίδευσή τους και το βαθμό στον οποίο συνειδητοποιούν και ελέγχουν τα επιμέρους έργα και τις δραστηριότητες που εκτελούν. Οι ειδικευόμενοι, αλλά και οι πιο έμπειροι ιατροί πρέπει να είναι σε θέση να συνειδητοποιούν το βαθμό και τις διαδικασίες σταδιακής ένταξής τους σε μια κοινότητα πρακτικής και αφετέρου με τον κριτικό στοχασμό να είναι σε θέση να αναλύσουν τις εμπειρίες από τη συμμετοχή τους στην κοινότητα πρακτικής, να είναι δηλαδή σε θέση να υιοθετήσουν πρακτικές με κριτική οπτική και όχι με απλή αφομοίωση. / This work proposes the combination of two theories of learning, transformative and situated learning in the community of practice of doctors. The newcomer doctors transfer from peripheral membership in full membership depending on their education and the degree to which they realise and check the individual work and the activities they execute. The specializer and the most experienced doctors should be able to realise the degree and the procedure of their progressive integration in community of practice. Through critical reflection they should also be able to analyze their experiences from attending the community of practice, that is to say to be able to adopt practices critically, not only through mere assimilation.

Working at the intersection of medical sociology and the psychology of health, language and communication, in this PhD I use thematic analysis (TA) and conversation analysis (CA) to provide an insight into various aspects of doctor-patient communication that may be considered, or are constructed as, challenging and/or delicate for either the patient, doctor or both at a Gender Identity Clinic (GIC) in the UK. This project involves the secondary analysis of two existing data-sets: (i) 21 recorded telephone interviews between my PhD supervisor and transsexual patients who attended the GIC; (ii) 156 transcribed audio-recordings and 38 video-recordings (total = 194) of psychiatrist-patient consultations in the GIC. The first original research paper uses TA to investigate the views and experiences of transsexual patients regarding their communication with psychiatrists at the GIC. An important finding was that patients actually appreciated being challenged in this setting, subsequently the implications of this are considered with regards to the achievability and desirability of patient centred communication. The second research paper uses CA to consider how patients overtly challenge psychiatrists in the GIC in ways that have not been shown in conversation analytic research on medical interactions to date. Analysis of the data corpus revealed that there were three common ways in which patients challenged psychiatrists at the GIC, which are (1) by problematising their questions; (2) by disagreeing with statements that are made regarding their treatment; (3) and by initiating complaints. The findings of this study are considered in relation to the implications that they have for clinicians and for the persistence and desirability of asymmetry in clinical interaction in light of the current debates surrounding the concept of patient-centeredness. The final research paper also uses CA, in this instance to study how the topic of weight, which is often constructed and orientated towards as delicate in talk-in-interaction, is occasioned and discussed by psychiatrists and patients at the GIC. Whereas previous CA research on this topic has focused on how this is constructed by speakers as a moral issue, this paper is concerned with focusing on how psychiatrists (1) establish with patients that their weight is an issue, (2) encourage patients to lose weight by informing them that this is their responsibility and (3) offer advice on the behavior changes associated with weight loss. The results of this paper are discussed with regards to the implications that they have for clinicians who discuss the potentially delicate topic of weight with patients in a number of different settings. This project contributes towards the growing debates regarding the achievability and desirability of patient centred communication and the persistence of asymmetry in clinical interaction. It also contributes to medical conversation analytic literature to date on asymmetry and talk about weight in clinical interactions.

Rufus of Ephesus's 'Quaestiones Medicinales' is an under-studied work by one of the most respected doctors of Greco-Roman antiquity. This thesis presents a new translation - the first in English of the complete work - and a reassessment of the treatise. I propose that, far from being a simple handbook teaching doctors how to take a patient history, as has hitherto been assumed, QM is an ardent plea for doctors to recognise the limits of their own knowledge and the indispensability of questioning the patient. I argue that QM articulates the idea that the aim of medicine cannot be achieved through medical knowledge alone, and that, in constructing the patient as an essential partner in diagnosis and decisions about treatment, Rufus implies a sharing of authority between doctor and patient that is noticeably different from the emphasis that other authors, particularly the determinedly hierarchical Galen, place on securing patients' obedience, a subject on which Rufus is noticeably silent. I argue that Rufus is unusual in the clarity and candour with which he perceives and acknowledges the limits of medical knowledge, in his conceptualisation of questioning as a discursive rather than a formulaic activity, in his explicit insistence that it must be addressed directly to the patient, in his psychological concept of habits, and in his recommendation of questioning as a strategy for resolving the tension between universal theory and individual experience. I look at modern cross-cultural research into the factors that drive patient compliance, and note that chief among them is patients feeling they are partners in the treatment process. This raises the question whether and to what extent the features that drive compliance are diachronically as well as cross-culturally consistent, and whether Rufus's shared authority model is more likely to have produced successful treatment outcomes than the autocratic paradigm promoted by Galen, and subsequently absorbed into Western medical tradition, that seems to have met with so much resistance.

This thesis contributes original knowledge through an inclusive design approach to lowering language and communication barriers in healthcare and suggests shifting the discussion from culture to context to lower intra-cultural hindrances towards learning English amongst some ethnic minorities. It offers an adaptable, scalable concept for gathering data on ethnic minorities (considering both different generations and religions) and employs a framework based analysis in design. Over the course of three studies grounded on theoretical insights from literature, primary research lead to the development and testing of innovative aids for communication, including educative and motivational elements. This research began by seeking to understand ethnic minority consumers (EMCs) perceptions of any barriers hindering their take-up of products or services in the UK, and their preferences. This is particularly significant as the UK s EMC population is predicted to double by 2051 and to diversify further, presenting challenges for social cohesion and planning future community goals. EMCs also represent a significant market for service and product providers. The research focussed on EMCs from the Indian Subcontinent based on religions and generations. It highlighted that first generation females lacking English and/or literacy (across religions and age groups) faced problems with services and issues around empowerment . The importance of improved access to healthcare was a strong theme. On investigating NHS staffs perceptions, five barriers were identified (Language barriers; Low-literacy; a Lack of understanding; Attitudes, gender and health beliefs; and Information retention) and that a female subgroup was particularly affected. This study sets out staffs perceptions of the aids currently employed and suggestions of what would help. It identified a (currently) low use of visual communication aids in adult-patient care and that pharmacist-patient communication in pharmacies was low. Ideally, staff would like patients to learn English and to use more low-cost visual communication aids. These findings lead to the development of innovative visual communication aids through inclusive and user-centred approaches and participatory design and brainstorming methods. This enabled the development of aids by considering the needs of NHS staff, EMCs lacking English and/or literacy and indigenous elderly people to promote better patient-staff communication including a take-away educational element for learning English at home.

The increase and changes in the demand for emergency care require pro-active responses from the designers and implementers of the emergency care system. The role of Emergency Care Practitioner (ECP) was introduced in England to improve the delivery of emergency care in the community. The role was evaluated using cost-benefit approach and compared with other existing emergency care roles. An analysis of the cognitive elements (situation awareness (SA) and naturalistic decision making (NDM)) of the ECP job was proposed considering the mental efforts involved. While the cost-benefit approach can justify further spending on developing the role, a cognitive approach can provide the evidence in ensuring the role is developed to fulfil its purpose. A series of studies were carried out to describe SA and NDM amongst ECPs in an ambulance service in England. A study examined decision-making process using Critical Decision Method interviews which revealed the main processes in making decision and how information was used to develop SA. Based on the findings, the subsequent studies focus on the non-clinical factors that influence SA and decision making. Data from a scoping study were used to develop a socio-technical systems framework based on existing models and frameworks. The framework was then used to guide further exploration of SA and NDM. Emergency calls that were assigned to ECPs over a period of 8 months were analysed. The analysis revealed system-related influences on the deployment of ECPs. Interviews with the ECPs enabled the identification of influences on their decision-making with respect to patient care. Goal-directed task analysis was used to identify the decision points and information requirements of the ECPs. The findings and the framework were then evaluated via a set of studies based on an ethnographic approach. Participant observations with 13 ECPs were carried out. Field notes provided further insight into the characteristics of jobs assigned to the ECPs. It was possible to map the actual information used by the ECP to their information needs. The sources of the information were classified according to system levels. A questionnaire based on factors influencing decision-making was tested with actual cases. It was found that the items in the questionnaire could reliably measure factors that influence decision-making. Overall, the studies identify factors that have direct and indirect influences on the ECP job. A coherent model for the whole emergency care systems can be developed to build safety into the care delivery process. Further development of the ECP role need to consider the support for cognitive tasks in light of the findings reported in this thesis.

En-dehors des horaires d’ouverture des cabinets de médecine générale, la permanence des soins ambulatoires (PDSA) est assurée par des médecins effecteurs mobiles (MPDSA), missionnés par le SAMU – Centre 15 et effectuant des visites au domicile des patients. L’ordre de réalisation de ces visites est basé sur un modèle intuitif, défini selon le degré d’urgence établi lors de l’appel au SAMU – Centre 15 et la connaissance du secteur par le MPDSA. Cette méthode intuitive est le plus souvent dictée par la problématique du plus court chemin entre les visites. Le maintien de délais compatibles avec le besoin médical dépend ainsi du flux de visites et du temps d’acheminement des MPDSA. Or, ce temps d’acheminement dépend notamment des effectifs de MPDSA de garde et des conditions de trafic. Les modèles existants d’optimisation des trajets sont inapplicables à la PDSA, en raison de la réactualisation continue de la liste des visites à effectuer, ainsi que de la pondération du délai cible par le degré d’urgence.Nous proposons donc de créer un modèle spécifique d’optimisation des trajets des MPDSA missionnés par le SAMU–Centre 15. Nous développons une méta-heuristique évolutionnaire de type algorithme génétique, dont nous comparons d’abord les performances calculatoires à celles d’une méthode exacte d’optimisation linéaire en nombres entiers (méthode d’optimisation combinatoire non évolutionnaire), sur données théoriques, intégrant les données cliniques (3 degrés de priorité de visite), opérationnelles (taille de la flotte des MPDSA) et les objectifs temporels (3 délais d’effection cible). Les objectifs de ce travail sont de montrer que l’algorithme génétique, comparativement à la méthode linéaire en nombres entiers, conduit à une réduction des délais d’effection des visites MPDSA, donc à un plus grand respect des délais d’effection cibles ainsi qu’à une augmentation du nombre de patients vus par unité de temps (plage horaire de PDSA). Les résultats obtenus suggèrent que l’algorithme génétique est à la fois plus performant que la méthode linéaire en nombres entiers sur tous les critères établis, et que ses performances s’améliorent avec la complexité du problème à résoudre (nombre de patients à visiter, taille de la flotte des MPDSA).L’utilisation de la méthode d’optimisation développée dans ce travail pourrait permettre aux SAMU-Centres 15 d’améliorer le service rendu à la population, en termes d’accès au juste soin et de sécurité du patient. / During out-of-hours times, mobile general practitioners (GPs), appointed by the SAMU - Centre 15 (French public emergency call center), can provide out-of-hours home visits (OOH-HV).The order in which these visits are carried out is based on an intuitive model, i.e. the shortest path problem, and determined according to the degree of urgency established at the time of the call to the SAMU - Centre 15 and the knowledge of the sector by the mobile GP. Maintaining timelines consistent with the medical need thus depends on the flow of visits and the GP’s response times. However, this transit time depends in particular on the number of available GPs and traffic conditions. Existing models for routing optimization are inapplicable to OOH-HV, due to the continuous updating of the list of visits to be carried out, as well as the weighting of the target time by the degree of urgency.We therefore propose to create a specific model for the optimization of the mobile GPs’ sent by the SAMU-Centre 15. We develop an evolutionary meta-heuristic of the genetic algorithm type, whose computational performances we first compare with those of an exact method of integer linear optimization (non evolutionary combinatorial optimization method), on theoretical data, integrating the clinical data (3 degrees of priority of visit), operational constraints data (mobile GPs’ fleet size) and response times objectives (3 target effection times). The objectives of this work are to show that the genetic algorithm, compared to the integer linear method, leads to a reduction in mobile GPs visit completion times, to a greater respect of the deadlines of target outcomes, as well as an increase in the number of patients seen per time unit (GPs time slot).Our results suggest that the genetic algorithm is more efficient than the integer linear method on all established criteria, and that its performances improve with the complexity of the problem to be solved (number of patients to visit, size of mobile GPs’ fleet).The use of the optimization method developed in this work could enable the SAMU-Centres 15 to improve the service provided to the population, in terms of efficiency, safety and quality of access to care.

Previous research has examined patients’ level of satisfaction with the care, in an attempt to develop health care services that match patients’ expectations and needs. Nevertheless, there is still considerable debate among researchers over conceptual and methodological issues. This research programme investigated factors that contribute to patient satisfaction with health care in two fairly different European health care systems (the UK’s NHS and Greece’s ESY). A further aim was to develop a scale to assess patient satisfaction and health care evaluations within these two cultural contexts. In order to achieve those aims, a sequential exploratory strategy incorporating, qualitative and quantitative designs was used to explore patient health care evaluations, patient satisfaction, expectations, health care experiences, interpersonal qualities of the doctor-patient relationship and health care contextual factors at both micro and macro level. Three studies were conducted: Studies 1a and 1b examined levels of patient satisfaction with health care delivery in Greece and the UK respectively. More similarities than differences were found between the two samples, but aspects of health system evaluation differed. The data obtained from this study informed the development of the Patient Expectation and Satisfaction Scale (PESS). The psychometric properties of the preliminary version of the scale were subsequently tested in non clinical populations in Greece and the UK (Studies 2a and 2b). The pilot testing of the PESS was based on a proposed theoretical framework suggesting that patients’ expectations depend on the nature of past experiences and current expectations. The variable that influences some of the differences between the two countries is health culture in terms of contextual health care differences. Although findings revealed similarities between the two cultures, differences were found relating to dissatisfaction, health care evaluations, expectations and the quality of the doctor-patient relationship. A revised version of the PESS, based on these findings, was administered to hospital outpatient populations in both countries (Study 3). The Patient Satisfaction and Expectation Model that emerged from this analysis incorporated three levels of patient satisfaction: at the micro level, the macro level and the interpersonal level. The importance of patients’ understanding of professional competence and its salience as a predictor of the effectiveness of the doctor-patient relationship was highlighted. The quality of the doctor-patient relationship emerged as an important determinant of patient satisfaction and adherence. The overall findings of this research programme suggest that patient satisfaction is multidimensional; despite contextual differences between the two health care systems, a universal concept exists that includes health care expectations, health care experiences, interpersonal qualities and aspects relating to operational and organisational structures at both micro and macro level.

This exploratory study examined the perceptions and realities of work life balance among medical doctors in Nigerian Public Hospitals. The study aimed to investigate the coping strategies adopted by medical doctors to manage work life balance and finally to examine the gender differences in the lived experiences of male and female medical doctors in Nigeria. The literature revealed that conceptualising work life balance models or employee flexibility in an African work setting is problematic when juxtaposed with primordial African cultural values where work and life are an indissoluble existential unit. The transition from an agrarian economy to new capitalist workplaces in many African countries is still relatively new. This study fills the gap by unveiling the implications this narrative has for understanding contemporary WLB. Forty-one semi-structured in-depth interviews were conducted for this study. It involved male and female doctors from public hospitals across three geopolitical zones of Nigeria. The sample of doctors interviewed were specifically resident doctors with a wide range of specialties. Thematic method of data analysis was adopted to provide major themes which were used to discuss the findings of the research investigations. The findings reveal that work in the Nigerian medical sector is notoriously intense as it underscores challenges of long working hours, intense work demand and staff shortage. The findings further suggest women must tread a ‘delicate balance’ between subordination to male authority, domestic responsibilities and ambition/achievement in a professional career. This study makes two key contributions to knowledge. Firstly, the study contributes to existing literature on work-life balance in the Nigerian context, elaborating the situation with work-life balance initiatives and how medical doctors in Nigeria manage to cope with the shortcomings of the organisations. Secondly, the findings fostered a useful extension of the work-family border theory. The border theory explains how individuals navigate between life domains and boundary management. However, the theory has provided little information on the factors that affect how employees manage and negotiate between the domains. This led to the development of the work spiritual life balance model.

Adequate access to and appropriate use of medical evidence by clinicians have been posited as influencing the quality of clinical decisions and outcomes of patient care. The broad aim of this case study of a tertiary hospital was to provide understanding of how the information experiences and practices of paediatric physicians in Nigeria influenced their information practices and the potential implications for patient care. To achieve the research aim and objectives, a qualitative exploratory study was conducted using multiple sources of data: interviews, diaries, observation and social network chats. Overall, twenty semi-structured interviews were conducted, and seven clinicians provided a week-long information activity self-reports through diaries. Supplementary data were gained via the researcher's personal observation and social media chats with some participants. Paediatricians in the cadre of: Consultants, Senior Registrars, Registrars and Residents provided the data which was analysed using the interpretative method. The results indicate that the paediatricians' information needs were on: managing challenging cases, supporting diagnostic decisions, managing evolving diseases, managing illnesses in the tropical context, drugs and dosage, refreshing the memory, keeping updated, and passing professional examinations. In general: i)there was haphazard approach to information literacy tuition for the clinicians during professional education resulting in varied information capabilities, and inadequacy of knowledge and skills for good information practice; ii) obtaining medical information from colleagues was the predominant feature of paediatricians' information practices; iii) printed textbooks were the paediatricians preferred source for obtaining medical evidence, however, there was a growing popularity in the use of electronic medical information sources, including at the point of care; iv) a perception of inadequacy of the hospital library services resulted in the paediatricians developing rejection behaviour towards the services, labelled in this study as information service rejection behaviour (ISRB); v) there was general perception by the paediatricians that access to, and use of medical information supports patient care and achievement of better treatment outcomes. This perception instilled a sense of value for information use, demonstrated through the clinicians' dedication to the self-provision of information resources; vi) a dearth of medical resources germane to the contextual management of illnesses led to inadequate clinician knowledge in a good number of cases. A new model of information behaviour entitled 'the knowledge production model of the paediatricians' information behaviour has been developed from the findings of this study, thereby extending existing scholarly perspectives on people's information behaviour. The Kpro model enunciates the concept of 'knowledge-based information behaviour' (KIB) which was exhibited by the paediatricians. The study recommends that i) the information literacy skills training (ILST) model developed from the findings, be used as a practical tool for inculcating information literacy to the paediatricians at the level of residency training; ii) the hospital management/librarians prioritise the improvement of information resources, services and infrastructure e.g. reliable internet service, e-library at wards and consulting rooms, and clinical librarian services, to enhance good information practices among the clinicians; iii) retraining of the hospital librarians for increased service delivery effectiveness; iv) increased local research through the establishment of Journal Clubs by the paediatricians to enhance local publishing of medical literature.

This thesis contributes to the historiography of women in medicine by exploring, in-depth, one small specialty, public health, which, from 1974, offered women doctors working within it equality of opportunity with men for career development. At that time, most women doctors working in the English health service were relegated to junior or support roles, their particular needs for family-friendly working environments being largely ignored. This research examines the reasons behind the development of these equal opportunities and the subsequent rapid trajectory of women doctors in public health, comparing it with the much slower progress made by female colleagues in hospital medicine and general practice. In considering the factors helping or hindering women’s advance in medicine from 1974, it proposes that these changes occurred in public health because the specialty was not tied to the pyramidal model of medicine, developed in the 1930s by senior male doctors for male doctors, which dominated other specialties and which stifled progress. An innovative feature of this research, following women’s entry to consultant and training posts in proportions equal to men in public health, is to highlight their subsequent move into major strategic roles within the health service management structure from the late 1980s. Interviews with senior public health men and women doctors help shed light on how this move was achieved and how women in strategic positions were able to combine high profile careers with domestic responsibilities. Also includes five transcipts of interviews : The five interviewees, whose career stories are presented here - Professor Sian Griffiths, Professor Sheila Adam, Professor Mala Rao, Dr Sue Atkinson and Professor Fiona Sim - were selected, with the help of the Faculty of Public Health, for their considerable achievement in strategic leadership roles in public health practice, whether in leading complex organisation, chairing national policy committees, leading international work, promoting education and development.