In the field

Forming the sample of general practitioners was initially convenience based. A GP who had a particular interest in clinical communication was asked and agreed to participate, and he contacted three colleagues who also agreed to take part in the study. The doctors were first told about the study verbally and then received an information letter about it along with the informed consent form. The doctors were told that I was working on a PhD-project in medical ethics and that I was interested in what issues doctors deal with in their clinical work, with a particular focus on the value-laden aspects of medicine. I normally went to the office in question a day before the study was to commence to notify the office secretaries about it and give them the patient consent forms. On the day of the study itself, there would be a placard on the wall in the waiting room with information about the research and which doctor was involved. Meanwhile, the secretaries would give the informed consent forms to the patients who had appointments with the doctor I was observing and then collect them when they had been completed. If a patient did not want me to be present in the consultation, the secretary would report this to the doctor and I would wait in a nearby room. Very few patients declined to participate.

In accordance with Grounded Theory, I tried to approach the field with an open mind, although being a doctor I did indeed know the clinical work and circumstances that might arise. However, I attempted to put my medical interest in the background and concentrate on the human interactions. At first, this proved to be quite difficult to achieve. I found myself wondering what illness a patient was suffering from and trying to work out what examinations the doctor would undertake next. However, I frequently forced myself to focus on other aspects of the scenario: how did the

doctors pose or move their bodies? How did the patients sit? What were the surroundings like? How did the patients phrase their concerns? How did the doctors react? When did the doctors interrupt the patients, and when did they follow up on a patient’s worries? When did the doctors record in the patient journal? These were the kinds of questions that I tried to concentrate on when observing the doctors, along with the general questions that were always at the back of my mind: what is happening here? What are the doctors’ main concerns?

We did not tape record the encounters because we did not want to disturb the consultations any more than I already had done with my presence. In addition, my attention was primarily on observing the encounter overall, not just the spoken dialogue, and so tape recordings would place too much focus on the audible dimension of the situation. Another option was to conduct video recordings, but we considered this to be too great an intrusion into the consultation. Moreover, since I intended to follow the doctors over the course of their entire working day, in both patient and non-patient settings, I would have been required to walk around with a video camera on my shoulder, which was not realistic. Instead, I tried to be a more anonymous part of the setting. I normally sat in a corner of the office, sometimes dressed in a white coat and sometimes in my normal clothes, depending on the doctor under observation. I took notes throughout the day, but not while a patient was present. The doctors and patients only rarely spoke to me during the consultations, but after the latter had left the former would often address me as a fellow colleague or student, inviting me to comment. I also took notes on these events, as well as on the work the doctors did in between patients. Finally, I was able to observe other non-patient situations which were part of the doctors’ working day, like joint lunches, internal staff meetings, telephone consultations and dealing with paperwork.

In order to exemplify this part of the process, I give a brief illustration of my notes.

The first one is taken during a patient consultation; the second one is from an internal morning session:

Young, female patient; seems new to the doctor. Immediately pulls out her mobile phone; says she has several issues and that she has brought a list. The doctor sits back in his chair, appears calm;

does not speak, but awaits the patient. The patient wonders if he could check up on her blood

count, because it has previously been low. “...and I have celiac disease, just so that you know”.

“Yes”, the doctor replies “certainly”. He turns to the computer and prints out a form, the patient continues to speak.

All of the doctors are gathered around a table, the senior consultants on one end, younger doctors, house officers and students on the other end. There are not enough seats; some younger colleagues sit on chairs and sofas nearby. The house officer (who has been on duty the previous night) presents the new patients without interruptions, sometimes supplied by a senior colleague. The other doctors look down at their patient lists; hardly any comments or emotional expressions.

Grounded Theory recommends that the researcher does not record observations and interviews, but instead takes notes during the fieldwork. It is argued that recording situations produces too much data, which often overwhelms researchers. Researchers should instead trust in their own abilities to discover what is of interest in the scenario being observed. Since the method is aimed at producing a theory that illuminate what happens in the observed field rather than accurate descriptions, meticulous recordings of the precise dialogue used or body language exhibited are beyond the scope of the research. Grounded Theory stresses that researchers should be realistic about what they can do and should also take care to utilise their time and efforts where they are needed most. Consequently, researchers must use their skills actively in the fieldwork, focusing closely on what is actually happening.

After the doctor had finished his or her final consultation, we built in time for an interview, which normally lasted between 30 and 60 minutes. I began these sessions by asking the participants about how they thought the day had gone and how they had felt about being observed. Most stated that they believed that things had gone well, and while they had initially been very aware of my presence, they had soon forgotten about the observation and carried on as normal. I went on to ask about the day’s work and whether the doctor regarded this to have been a normal working day. I asked if there had been patients or situations that they had found particularly difficult to handle and if there had been circumstances in which they had felt positive about their efforts and thought that they had been good doctors. Normally, this would lead to follow-up questions which attempted to probe what the doctors had experienced as difficult or satisfactory and what they were striving to achieve. I would also ask

questions about particular patients or situations that I had taken note of as being especially interesting, surprising or difficult to comprehend.

This is a small example of such a questioning from an interview:

Interviewer: Were there any patients today who you found particularly difficult or demanding?

Doctor: (stops to think) Perhaps the elderly lady, I always think that she is a lot older than she really is, I have problems in understanding what it is she really wants. I wish she could be a bit clearer and say: ”I am here for a blood pressure check-up”. Instead, I have to ask her: “Are you here for a blood pressure check-up?” I get so insecure...

Interviewer: She brought up a lot of complaints: aches, ringing in the ears, anxieties...

Doctor: Yes, she speaks of it every time!

Interviewer: Is that why you did not follow up on any of that?

Doctor: (laughs a little embarrassed) Yes. We have gone through these issues earlier and she presented them in exactly the same manner that time. So I did not feel like there was anything new.

After the interview, the doctors would often ask me for my opinions and feedback on what I had witnessed, but this turned out to be surprisingly difficult to respond to. My notes mainly consisted of pieces of events and analysis and associations, and I was thus rarely able to provide any clear summary or make suggestions about what all of this information might mean. After I had left the doctor’s office, I then sat down to complete my notes, going over the events again and again in my mind and writing down fragments of what might be of interest. This process actually took a lot of time, even taking me up to a week after the initial observation before I was then ready to observe the next doctor.