‘Place’ and clinical reasoning development in context: an ethnographic case study

Introduction: Place-Based Medical Education (PBME) aims for more physicians who are better prepared to serve medically underserved communities. However, discussions about the role of ‘place’ in PBME remain largely conceptual, with limited empirical evidence. In a previous scoping review, we identified a lack of research examining how distinct features of place influence the development of Clinical Reasoning (CR) and proposed the ‘HARD’ framework to guide future studies. The current study builds on this work to explain how place impacts the development of clinical reasoning in medical students. Methods: This was an ethnographic case study situated in General Practice (GP) settings. Four primary cases, five supplementary student cases, six supplementary GP supervisor cases, nine campus-based teaching sessions, and two group interviews generated a rich data set, consisting of field notes and audio recordings derived from 120 h of participant observations, transcripts derived from 57 interviews, and digital copies of ten curriculum documents and workplace-based teaching, learning and assessment artefacts. The study’s immersive ethnographic design shaped the thematic analysis of the data. Results: The analysis identified five domains of CR development and revealed that each student followed a unique pathway, shaped by placement-specific affordances. Guided by the HARD model and informed by ‘sense-of-place’ as an interpretive lens, further analysis generated novel empirical evidence on how CR development in context shapes a distinct sense of place-dependence and place-identity. Discussion: Aligning with the HARD conceptualisation, findings highlight CR development as simultaneously cognitive, relational, and socio-material. This expansive, hence transtheoretical, perspective supports students, educators, and researchers in understanding place distinctiveness by enhancing attention to context as content in the design and delivery of physician training in and for Places of PBME and beyond.