Snapshots and snippets: General practitioners ...

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Health & Place 13 (2007) 532–544 www.elsevier.com/locate/healthplace

Snapshots and snippets: General practitioners’ reflections on professional space Frances Rapporta,, Marcus A Doelb, Glyn Elwync a

Swansea University, School of Medicine, Grove Building, Singleton Park, Swansea SA2 8PP, UK Swansea University, School of the Environment and Society, Singleton Park, Swansea SA2 8PP, UK c Cardiff University, Centre for Health Sciences Research, University Hospital of Wales, Heath Park, Cardiff, UK b

Received 20 March 2006; received in revised form 18 July 2006; accepted 19 July 2006

Abstract The paper presents the results of a mixed methods study of British general practitioners’ (GPs) reflections on professional space in terms of practice and self-identity. Inter-textual content analysis of 12 biographic and photographic datasets revealed four themes: workspace, re-appropriated space, life space and sacred space. GPs are ambivalent about their working environments, spending time and energy creating ‘best fit’ spaces, until lack of function becomes an habituated part of daily routine. Whilst some appear helpless in the face of change, others are making their presence felt through embodied, personalized or authorial spaces. r 2006 Elsevier Ltd. All rights reserved. Keywords: Inhabited space; Workspace; General practice; Mixing methods; Self-identity

People leave presence in a place even when they are no longer there. Andy Goldsworthy

Introduction This paper describes a novel, mixed-methods approach to examining general practitioners’ (GPs) reflections on their workspace in order to clarify how workspace influences medical practice and the sense of self. This is a topic that has not been addressed within primary care, although some work exploring the relationship between hospital Corresponding author. Tel.: +44 01792 513497; fax: +44 01792 513430. E-mail address: [email protected] (F. Rapport).

1353-8292/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2006.07.005

spaces, healthcare provision, and health status has been conducted within secondary care (Kearns, 1991; Kearns et al., 2003). Examining the impact of workspace on medical practice complements the notion that the way we live and the spaces we create—‘life’s landscapes’— are integrally linked. Life’s landscapes are active parts of our lives. They are the media in and through which social relations are produced, reproduced, contested, and transformed (Debord, 1977; de Certeau, 1984; Lefebvre, 1991). Kearns and Barnett (1997) highlight the ability of space to be: ‘‘an interpretable text which contributes to meaning in the broader canvas’’ (Kearns and Barnett, 1997, p. 173), suggesting that space is more than simply the environment in which we produce our social relations. It is socially constructed, and therefore saturated with social interest.

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The literature on the social construction of the workplace concentrates on the relationship between working practice and workspace, highlighting people’s responses to work, workplace, colleagues and performance (McDowell, 1997; Boyer, 2004). Warren (2002), for example, examines organizational aesthetics—people’s aesthetic experiences and how they might be communicated in the workplace—and Kearns et al. (2003) consider the effect of the built environment on healthcare practice and policy. Kearns (1991) describes the healthcare environment as encouraging a culture of advanced consumption that offers great expectations for health practice. Research concentrating on the ability of hospitals to impact on good health has explored the appearance, design and organizational features of space (Harris, 1997; Johnson et al., 2003; Mathieson, 2003). Radley and Taylor (2003, 2003a), for example, use photo-elicitation techniques in conjunction with patient interviews to clarify how patients are rehabilitated following surgery and the effects of the hospital ward on recovery. Within primary care, however, little research has been undertaken on the effects of workspace on care provision, though Gothill and Armstrong (1999) discuss the early development of the GP workplace in relation to the construction of the GP role. Armstrong’s paper on space and time in general practice describes developmental aspects of surgeries, surgery types and forms, presenting surgeries as more than just physical backdrops to doctor– patient interaction. The surgery is ‘‘a space with internal and external social boundaries which in their turn are intimately linked to the events which occur within them’’ (Armstrong, 1985, p. 654). In view of the scant research in this area, this paper sets out to clarify whether GPs consider workspace in relation to professional practice and self-identity. It also gives significant consideration to the methodological approach taken in this study in order to highlight and ascertain the potential of an underused methodology. We illustrate not only how GPs conceptualize and engage with their workspaces, but also how the strengths and limitations of the methodology have impacted on the research. The next section presents the empirical and methodological background to the study. Background to the study The healthcare setting in which British GPs consult has recently undergone dramatic change,

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reflecting both contractual and societal shifts (Elwyn, 2005). Until the 1920s and 1930s, family doctors worked from home (Armstrong, 1985). Doctors now work predominantly in buildings specially designed as ‘fit for purpose’ spaces. These are National Health Service (NHS) managed spaces, part of a cost-rent scheme where GPs are scrutinized for their fund management, whilst space is re-arranged to accommodate greater use of information technology and new patient record-keeping systems (Elwyn et al., 1999). This is further affected by movements away from generalist to specialist positions influencing the place of the GP within the organizations in which they work (Elwyn and Hailey, 2004). Methodological framework The study employed mixed methods, namely the combination of two datasets—digital photographs and object-orientated biographies. In the last 10 years, still photography and biography have emerged as two important social scientific research methods that fit within a plethora of new techniques for exploring, describing and interpreting how we view the world (Rapport, 2004). New approaches to social action and its interpretation provide researchers with opportunities to move away from formulaic notions of how to conduct research (Crang, 2002), encouraging an interest in research that extends beyond belief in the ‘status of numbers’ (Doel, 2001). By broadening the scope of qualitative inquiry, methodologies have become more than ploys to elicit data in different ways. They have become alternative epistemic positions from which to view the world (Rapport et al., 2004, 2005). In healthcare research a movement away from the conventional has also come to be defined by regular forays into mixing methods. Most commonly, this refers to the mixing of quantitative and qualitative methods, much lauded in mainstream medical and health services research. But mixing methods can also refer to ‘within-method’ triangulation, with different qualitative datasets grouped or ‘triangulated’ to provide depth to understanding (Maggs-Rapport, 2000; Rapport et al., 2006). Within-method triangulation has, however, met with mixed reviews, following claims that it promotes method undercutting and the blurring of inquiry (Silverman, 1994). Holloway and Todres (2004) remark that to avoid mixed methods introducing inconsistency into a chosen approach, explicit descriptions should be included in any study

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F. Rapport et al. / Health & Place 13 (2007) 532–544

of data collection procedures to indicate: ‘‘The intentions and philosophical underpinnings’’ of different methods (p. 100). In this study, within-method triangulation of photographic and biographic data was employed to clarify how GP workspace was reflected upon by GPs. Within-method triangulation not only enabled the team to compare one dataset with another (Stake, 2003), it also introduced the possibility that one dataset could extend understanding of the other. We recognize that there is an over familiarity with textual stimuli and as a consequence, that researchers are guilty of ‘reading’ the possibilities that words render more readily than their visual counterparts. We hope the paper will challenge an over-dependence on understanding through words, by indicating that there are other ways of approaching data presentation that are just as valid. Photography Within healthcare research, the role of the photograph has focused on data generation. In photo-interviews, for instance, photographs are said to give birth to stories and can, therefore, be employed as aids to data collection, rather than as ends in themselves (van Leeuwen and Jewitt, 2002). Photographs shown to research participants help identify people or places, and participants can offer their own commentary on the readings of the researchers. If we take as an example the work of Radley and Taylor (2003a, b), where patients photographed aspects of the hospital ward that related to their experience of illness and recovery, these data could be discussed at a later stage through interviews to clarify people’s reflections on healthcare and recovery. Photographs revealed, in this case, how the process of remembering is one of transference between different representations. Radley and Taylor concluded that by responding to photographs, patients were indicating that the physical setting was integrally linked to recovery through a ‘coexistence’ of body and ward. Images have been employed within Anthropology to serve as records of reality; ‘‘Documentary evidence of the people, places, things, actions and events they depict’’ (van Leeuwen and Jewitt, 2002, p. 5); and, less commonly, as aesthetic products or evocative images (Barthes, 1977). In A Fortunate Man (1967), Berger and Mohr (1967) use photographs to evoke different rural environments, illustrating how different settings provide the

context within which lives and lifestyles can be seen to take place. Their work led to a consideration of the deceptive nature of landscapes and the way they can provide ‘a curtain’ behind which the theatre of life takes place. ‘‘For those who, with the inhabitants, are behind the curtain, landmarks are no longer only geographic but also biographical and personal’’ (p. 13). In the study reported in this paper, photographs were employed to enable GPs to present their workspaces in a variety of ways and to challenge the researchers to move beyond the more conventional reliance on single sources of data for interpreting workspace presentation. This was in recognition of the notion that textual expression can offer only a partial insight into human experience. By employing photographs as vehicles to knowledge we were able to explore how they revealed GPs feelings, thoughts and memories, and consider whether these were echoed in the biographies. Biography Like photography, biography also offers a departure from traditional data collection methods. Biography gives insight into language-in-use and how we ‘word the world’ (Rose, 2000). Biography may also lead to personal revelation and offers research participants a forum to tell of lived experiences through the recreation of the lived world without the direct influence of the researcher. Traditionally, biographies have been used to help formulate hypotheses in research, based on the notion that biography, in and of itself, lacks reliability (Becker, 1970). However, according to Hatch and Wisniewski (1995), biography provides us with a range of alternative notions of reliability, including: ‘‘Adequacy, aesthetic finality, accessibility, authenticity, credibility, explanatory power, persuasiveness, coherence, plausibility, trustworthiness, epistemological validity and versimilitude’’ (p. 128–129). Biography, within a health research context, can clarify how individuals give meaning to health and illness, instilling social ‘realism’ into data collection (Roberts, 2002). It also enables research participants to situate events within a meaningful and socially significant frame of reference. Extending beyond the human, researchers may also undertake biographies of objects in order to reveal the ‘social lives of things,’ from their myriad uses and ‘careers’ to their manifold powers and affects


(Appadurai, 1996; Barthes, 1972; Kopytoff, 1986). Object-orientated biography is an especially powerful technique for disclosing how the form, function, and significance of objects are fashioned in context and mutable over space and time (Doel and Segrott, 2003, 2004; Hebdige, 1979, 1988; Schivelbusch, 1992; Segrott and Doel, 2004). For example, a brick in the hand of a builder has neither the same capacity for action nor the same meaning and social significance as when it is taken up by a conceptual artist or a rioter. Object-orientated biographies allow the researcher to trace the heterogeneous and distributed ‘actor-networks’ that they sustain (Callon et al., 2002), the social work that they accomplish (Latour, 1992), and the social interests that they serve (Winner, 1980). The fact that human agency is always accomplished in consort with nonhuman agencies is widely recognized by healthcare researchers. The potential of object-orientated biography should therefore be self-evident. In its range of forms; including oral testimony, written text, auto-biography and the examination of personal artefacts, such as diaries, letters and memoirs; subject-centred and object-orientated biographies can be analysed both as ‘stand alone’ products and as grouped data—‘inter-textually.’ Inter-textual examination explores how texts respond to, refer to, transform and are transformed by other texts, and how the range of representations of the social world relate to one another. ‘‘We understand the social world through the lens of prior representation, because whenever something is invoked which happened somewhere else, or in some other time, or to someone else, then representation is being utilized’’ (Stanley and Morgan, 1993, p. 3). Consequently, inter-textual examination makes links between datasets based on the manner in which one set triggers, invokes and eventually clarifies understanding of the range of possible representations within GPs’ social worlds. In our consideration of how object-orientated biographies and photographs impacted one on the other, it is the inter-textual nature of these datasets that is investigated in this paper. Method Following ethical approval from the Local Research Ethics Committee, three GPs were recruited for a pilot study. Participants were chosen from a convenience sample of GPs known to the

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researchers. Given that the pilot mimicked the study in terms of methods of data collection and analysis, the pilot data were incorporated into the study. To enlist a further nine GPs into the study, it was decided to approach the total population of GPs in the greater Swansea area (n ¼ 148). To ensure that GPs were recruited at different stages in their careers, the cohort was stratified into three groups. Group A were senior partners, group B were GPs who had been in a post for 3 years or more (but not the senior partner), and group C were GPs within 3 years of appointment. The names of GPs within each group were ordered randomly and GPs were approached in turn until three GPs from each group had consented to take part. Thirty-six approaches were made to Group A, out of a total possible 36 GPs; 55 to Group B, out of a total possible 88 GPs; and four to Group C, out of a total possible 21 GPs. From the 12 GPs recruited, two were female (out of a total of 49 female doctors) and 10 were male (out of a total of 97 male doctors). This indicates that the senior partners were the most difficult group to recruit, with a very low response rate, whilst the GPs within 3 years of being appointed were the easiest group to recruit. GPs were all sent an information sheet and letter that asked them to write a biography of their room and to take digital photographs of it. Given that our concern is with how workspace influences medical practice and self-identity, we asked GPs to write an object-orientated biography, rather than a subjectcentred biography. Accordingly, the information sheet requested the GP to: ‘‘Describe your room and your place in it in relation to your working practice.’’ It was emphasized that no patient identifiable data should be included, but, other than this, the brief was left purposefully broad to enable GPs to render their space in their own way, with as little researcher influence as possible (Rose, 2000). In writing a biography of their rooms, the only stipulation was that it should be at least two sides of A4 paper. This was to ensure sufficient data for analysis. No other guidance was given. This was to minimize the extent to which the researchers would over-determine the form, style, and content of the biographies. In photographing the room, three stipulations were given. There should be at least five photographs, one of which should be taken from directly in front of the desk in order to record the paraphernalia on the desk; and one from the door, in order to capture as much of the room as possible. These requirements were made in order



to ensure sufficient data for analysis, to facilitate a content analysis of GP workspace, and to signal our expectation that the desk would be the principal object around which general practice is currently arrayed and performed (although as we shall see below, the longstanding centrality of the desk is arguably being challenged by the new-found significance of the computer). The biographic and photographic datasets were analysed by a multi-disciplinary research team drawn from Geography, Primary Care, Health Sciences and Health Services Research. Individual researchers first viewed the photographs and read the biographies separately, and then compared and contrasted them. Three group analysis sessions followed. This process encouraged a thoughtful response to the datasets and enabled the researchers to move away from over-generalization in order to concentrate on the particularities of the observations. It also facilitated group discussion of complex, multi-perspectival relations within the datasets and the juxtaposition of parts and wholes of images and texts. Each dataset was treated both as a discrete unit and in relation to the other dataset, so that inter-textual interpretation and within-method triangulation took place. This was accomplished in terms of: the process of data collection, their ability to address study aims and objectives, the study content and context, and the rich display of imagery and written work relating to the way in which reality was rendered. Group analysis of the photographs explored the visual context within which objects were presented, their clustering, and their frequency of presentation. Connections between photographs, working practices and expressions of seniority were recorded, the way in which objects were taken into GPs’ workspaces (Garlick, 2002), ‘practitioner situatedness’, spatial awareness, and ‘positioning’ (Crang, 1997). Finally, researchers explored how objects were organized into a workspace and how this workspace functioned as a space of action and affect. Group analysis of biographies revealed emergent patterns in content, context, writing style, format and presentation (van Manen, 1990). There are many approaches for analysing biographies described in the literature (e.g. Denzin, 1989; Cresswell, 1998). This study took an interpretive biographic stance (van Manen, 1990; Robson, 2002), where interpretation of both form and content took place: first individually and then in a group. As with visual data analysis, group analysis

sessions concentrated on: what had been written, how it was written, and whether it related workspaces to practice, seniority, action and affect. When presenting the results below, it should be noted that although biographic and photographic datasets were treated in their entirety during data analysis, we are unable to present complete biographies and photographic datasets within the paper due to limitations of space. We have chosen, therefore, to present those data that most clearly support the four dominant themes that emerged. Furthermore, although the two datasets have been triangulated, each nevertheless has a consistency and integrity all of its own. Consequently, even when the two datasets converge, one cannot be discounted as merely serving to illustrate the other. Here as elsewhere, the visual and the textual form two distinct series, and the relationship between them is always differential and never identical (Deleuze, 1988; Doel, 2001). This is why it is necessary to present both the words and the pictures in order to express a particular power or affect. For even where the content of each appears to be the same, neither the text nor the image is redundant. They stand in a relation of ‘supplementarity’ and express a ‘difference producing repetition’ (Deleuze, 1994). The visual and textual are juxtaposed in the ‘Results’ section below to urge the reader to consider how space can be rendered differently with different media. They highlight different styles of data presentation and how these different styles lend themselves to an enriched understanding of the special contexts in which we were working. Results Within-method triangulation of the datasets revealed four dominant themes: workspace, reappropriated space, life space and sacred space. Each will be presented in turn, before discussing the impact of the methodology on the results. Workspace This theme concentrates on the nature of work and labour, and paradoxically presents space as both embodied and disembodied. Embodied space, particularly noticeable in the photographs, refers to the way space is offered as an extension of the human body. Despite the absence of people in all of the photographs, the accumulated traces of work


are clearly visible. The stethoscope draped across a GP’s chair, the open sphygmomanometer box, the open drawer and the detritus of the previous surgery scattered across the room are tangible signs of the fact that work has taken place. In stark contrast to this regard for human labour, other images conveyed a disembodied, instrumental attitude to work with an almost complete effacement of humanity and the specificity of the GP. These spaces could be described as efficient, functional, abstract and alienable, with little to testify to the irreducible fact of human labour. The struggle between embodied and disembodied spaces is perhaps most keenly felt in relation to computer technology. Photographs of desktops—the most intimate of office-bound workspaces—are dominated by keyboards and monitors, and they reveal the prominent position of computer and printer within nearly all of the GPs’ rooms. Biographies echo this dominance, with computer technology referred to on a number of occasions in bewildering and often negative terms: The new General Medical Services (GMS) contract has made the computer central to the consultation at the expense sometimes of the patient. The consultation skills I learned talked about the doctor centred consultation. The majority of consultations are now computer centred (C1). This highlights the increasing centrality of technology in the GPs’ office, and the way that GPs are struggling to accommodate change, and the direct, visceral impact of information technology on working practice. Computer technology, however, is also recognized for its many positive uses, particularly its ability to enable GPs to move outside the confines of the room through networking. This comes across most clearly within the biographies, some of which allude to the ambivalent sense of dependency and freedom that has emerged in the wake of new technology:

realized that direct patient contact was severely impeded: Since [the keyboard] is set at 901 to the main desk, it means that we have to almost turn our backs on the patient to key things into the computer (C2). Furthermore, in just under half the biographies, GPs expressed anxiety about the unsuitability, inconvenience and inappropriateness of their workspace for achieving best practice. They recognized that the arrangement of objects in the room was often unsupportive to patients and far from helpful for practitioners, and that space could be: ‘‘Significantly improved on’’ (B2). This came across in both biographic and photographic datasets, suggesting GPs are unable to control their workspaces but are nevertheless resigned to working within restricted environments: As a female partner with an interest in gynaecology, sport and musculoskeletal medicine, the examination area, with its electrically controlled hydraulic couch is an important area of the consulting room. The only challenge is that the couch is not quite long enough for really tall patients, and it is difficult to get them onto the couch without sticking their legs under the trolley at the end (C2) (Fig. 1). GPs live and work according to the ambivalent ‘rhythm’ and ‘calculus’ of objects (Baudrillard, 1996). Workspace comprises a constellation of objects, including: desks, clocks, chairs, couches,

Email communication—instantly networking with some colleagues scattered far and wide— transporting me in professional terms into many different worlds (P2). GPs also considered the suitability of the room for patient care, and often emphasized a lack of fit between space and patient need. With the central positioning of the computer, for example, one GP

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Fig 1. Illustration 1 (C2).


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instruments, documentation, computer hardware and computer software. Re-appropriated space The second theme, re-appropriated space, focuses on how GPs re-appropriate space in order to reflect seniority of practice or social status, to imbue a unique object or event with a sense of aura or else to encourage workspace to resemble domestic spaces full of home comforts, intimacy and safety. Reappropriated space highlights GPs’ reactions to the alienating nature of work and the photographs are particularly adept in showing how re-appropriation takes place through the acquisition of ornaments; some of which are symbolically charged, such as the crucifix, keepsakes, family portraits and landscape paintings that populate the shelves, walls and desktops of consultation rooms. Photographs also allude to the performance of power, manifested most strikingly in the hierarchical relationship between GP and patient chairs. The GP invariably sits in a larger and more comfortable chair than the patient, and the GP’s chair is frequently placed in a key position within the room for maximum affect (see Fig. 2). Power relations are also played out between partners within the same practice, with objects being appropriated or subverted to distinguish between senior and more junior partners, or partners sharing space based on hierarchical divisions. Amongst the group of GPs within 3 years of being appointed, space was often shared with others. In these circumstances biographical descriptions emphasized their lack of satisfaction with how the room was being kept and the smells and objects

Fig. 2. Illustration 2 (C2).

left in the room after other people’s surgeries. Those sharing rooms frequently expressed frustration about their lack of ownership of the room and an inability to control its possessions: I have been a partner in the practice for just over 1 year and due to lack of consulting room space I have been sharing the senior partner’s roomy I do not feel any ownership of this roomy I find the room very cluttered and badly organized with poor use of space (C1). Furthermore, GPs were very aware of these power struggles and the relationship between space and seniority of practice. Consequently, once they became a fully fledged partner, GPs were loath to return to locations that they had frequented as trainees. GPs expressed relief at being able to ‘buy in’ to the hierarchical system, and indeed worked hard to preserve the very hierarchies that once put them in their place: I decided against the room partly ‘cos it’s where I had been when I was training and I didn’t want to be in the same place when I held a substantive post (P3). Whilst personal motivation to individualize rooms gives an added dimension of mystique, power is also imbued through the gloss of consumerism, which is evident in the lounge style furniture and furnishings that sets one GP apart from another and which allows the GP to move beyond the stark functionalism of ‘fit for purpose’ spaces for the performance of medicine. It is interesting to note that within this domestic scene, space is often narrated as an historic story. This is clearly evident in the biography of the desk depicted in illustrations 3 which presents space in terms of an object’s historical trajectory. Indeed, eight of the 12 GPs rendered their workspace as an historic story, expressing both temporal longevity and authorial presence, and thereby depicting, within their biographies, both the passing of time and lived duration. However, the historic story also affords the sense of imminent change. The past must be left behind and with it the particular gravitas that an object or ornament has conjured up. These, we are told, must be surpassed in order to conform to modern, ‘fit for purpose’ spaces and the structures of practice that such spaces support and enable: What a tale this desk could tell, if only it could talk. Constructed in Massachusetts USA it was


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medical arena awakens the practitioner to the possibilities of accommodating patient need more effectively: The next day I was armed with my box of offcuts and cuttings, and scattered them about my room. The effect was pleasing on the eye and the patients seemed to respond to the life enhancing qualities of living foliage (P1).

Fig. 3. Illustration 3 (A1).

purchased by the Great Western Railway Company for the station-master’s officey The desk was purchased for me, as a presenty Purchase cost £10. My manager wishes me to move to a more modern desk. What will become of my old roll-top? Well fortunately my sonyhas agreed to take custody of it after my retirement. So the desk will continue to be a silent witness to life experiences for some years to come (A1) (Fig. 3). Re-appropriated space suggests that, unlike the embodied or disembodied spaces described in theme one, space is not simply about work. Indeed, if we move beyond its functional aspect we are presented with an aspect of space that is much more than simply a work environment. It is something bigger than medical practice. It is a truly social space. It is to this aspect that we now turn. Life space The re-appropriation of space and the excess that personalization, aura and empowerment offers, presents us with our third theme—‘life space’. Life space indicates the ‘lived-in’ nature of space, the supportive and individual character that offers an excess of personal symbolism. Life space is space writ large—space that pretends to be more than mass-medical intervention but nevertheless cannot escape its social and institutional contexts. For what is striking about all bar one of the GPs’ presentations, clearly evident within photographs and biographies alike, is the extent to which rooms are something other than medical spaces. Biographies reveal the relationship between life space and patient interaction: how space that extends the

Photographs complement biographies in revealing how medical imperatives can be domesticated and dissimulated. In a certain sense, the domestication of space is a continuation of the re-appropriation of space through techniques such as personalization. Indeed, the domestic scene has a longstanding (if fraught) association with comfort, intimacy and trust—qualities that are also associated with medical, therapeutic and professional practice. However, the domestic scene is haunted by the reality of delivering healthcare en masse. So whilst personalization is an individual response to context-specific alienation, dissimulation may be seen as a systemic response to collective alienation, a yearning for familial values, which might lend themselves to the provision of healthcare, that is more in line with professional expectation and more suited to patient need. The impersonal form, which is overcome by the outward embellishment of the life space, is especially evident in the repetition of mass-produced, pine-effect furniture and chromeplated chairs from one surgery to the next—a structural trend that is aided and abetted by the ubiquitous office-furniture catalogue and the imperatives of fund management. Domestication is particularly evident in one GP’s photographic dataset, where walls and shelves are filled with dozens of analogue clocks, most of which appear to have been acquired from pharmaceutical companies and their sales representatives. The biography presents these clocks as diversionary objects: The kids come in and they count the clocks and they try and spot the new ones. That gives me time to talk to their parents (B1) (Fig. 4). Yet this proliferation could be read in a number of ways: as an expression of the GP’s self-conscious idiosyncrasy; as an ironic commentary on a thoroughly commodified healthcare market; or as an excessive display of medical rationality that borders on the absurd—a means without ends. Either way, the effect is neither personalization nor domestication, but disorientation. One might


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suggest that in such circumstances truly humane relationships between GPs and patients once again become possible.

tion, diagnosis and prognosis. Consequently, whilst in other spaces, such as waiting rooms and corridors, walls and notice-boards will be replete with a righteous discourse of health-related propaganda; such as information, advice, support groups and campaigns; this is not evident in relation to the couch area. Between the sacred and the profane, there would appear to be little space for overt moralising and what we are left with are family photographs, landscape pictures, and vertical blinds. Having examined the four dominant themes within the data we return to the second aspect of this study: a consideration of the strengths and weaknesses of mixing methods within healthcare research. This is discussed in terms of the difference between conceptualizations of space in written and visual formats, and the way in which the textual data extends the visual data.

Sacred space

Methodological considerations

The fourth and final theme engages with the ethics rather than the aesthetics of space. On the one hand, most of the spaces within the consulting room are essentially profane. Profane space holds no taboos or prohibitions and as a consequence it is acceptable to display furry animals adorning computers or a medley of accoutrements surrounding the desk such as glass bottles, personalized mugs, holiday souvenirs and trinkets. Profane spaces can accommodate the humorous and lend themselves to deviant thought:

GPs rendered space very differently depending on whether they were photographing or writing about their rooms. For a number of GPs, photographs emphasized a lack of individual character. Many of the GPs took very similar photographs of the same generic features, especially in relation to the desk. As a result, photographed rooms conveyed a sense of predictability. There were, however, exceptions to this form of visualization. Three GPs photographed a large number of personal touches to their rooms in the form of ornaments, trinkets, photographs, clocks and paintings (see Figs. 3 and 4 for example). Biographies were thoughtful, provocative, highly individualized, and sometimes surprising, witty and unnervingly blunt. In all cases it was clear that GPs had spent considerable time and effort writing about their rooms and their practice, and they had sought to make their mark through very personal writing styles. As a consequence, it was possible to identify GPs as much through their writing styles as through their narratives. For example, one GP wrote informally and humorously:

Fig. 4. Illustration 4 (B1).

I was allowed to choose the colour scheme, and obviously opted for shocking pink and navy blue (P1). However, there was one place within the room that was spared from profanity, the examination area, with its couches, white walls, discrete screens, and near absence of ornamentation, personalization and domestication. The space around the couch is also referred to in the biographies with the due respect that a sacred space demands: The examination couch and the ritual sphygmomanometer add the credentials and weight of ‘science’ to the process of addressing this man’s concerns (P3). Sacred spaces are reserved for the fundamental work of medicine and healing the sick—examina-

At home I’d fallen in lovey [S]uddenly inspiration hit, paintings in my consulting roomy My consulting style changed. The room made me feel more relaxed, more myself, and this seemed to resonate with the patientsy My professional mask slipped and connection became easier (P1).


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Another GP wrote with a considered prose that highlighted a mixture of reflection and introspection:

the way in which it affected the GP’s consultation style:

The quality and intimacy of this space is the essential crucible without which the surrounding infrastructure both in physical and human terms would be largely redundant (P3).

My favourite feature is my painted chest which contains all my patient information leafletsy [M]oving it in made me feel instantly at home here, too. So many of my patients comment on how attractive it is, and it has become a real talking point in the consulting room and helps to break the ice in difficult consultations (C2).

Yet another GP wrote in a clipped manner, with terse, bullet-pointed sentences, reminiscent of a short memo. The bluntness of this presentation had the effect of giving an added urgency to the words, suggesting that each was carefully considered for maximum impact: My room is untidy. I keep it that way to stop other people using it. It ticks, it drives patients mad. They say how do you cope with that and I say I don’t hear it. I like to think that is because I concentrate on them. I keep my room like it is for three reasons: 1. The kids come in and they count the clocks and they try and spot the new ones. That gives me time to talk to their parents. 2. I have always liked fish, so do the kids, something to talk about, helps gain their confidence. 3. I keep one toy in the room, the difficulty I usually find is stopping them playing with it, again it gives me time. What I really need for my room is a regular cleaner and duster. Nobody wants to touch anything because it is so untidy; the lesser of two evils. It would be nice if I could open the window (B1). The above examples illustrate very different writing styles and we would suggest that one of the major strengths of using mixed methods is the variety and range of visual and narrative forms that can be considered together, and by so doing, can help extend understanding. In addition, it was noticeable that the workspace biographies often enhanced our appreciation of the workspace photographs by situating the world of objects within a broader social, historical, and institutional context. In particular, the biographies highlighted how objects were used and their impact on everyday working practice. For example, one object was described not only for its physical characteristics, but also for

Finally, in terms of the strengths of using mixed methods analysed inter-textually, we would argue that triangulated datasets offer additional insights. Biographies shed light on facets of images that were understated, unclear to look at or ambivalent in their placement within the room, and the writing often clarified why a photograph had been taken in a particular way. Photographs, on the other hand, enriched the biographies, visualizing thoughts and emotions through the very presence of the objects within the room. Embellishing the findings in this way, we would argue, provides a deeper understanding and a clearer insight into the subject matter than a single dataset can provide on its own. In terms of the potential weaknesses of mixing methods in healthcare research, we recognize the need to guard against undercutting one dataset with another, the need to clarify the value of both datasets from the outset, and the need to consider how datasets are going to be analysed, first independently and then in relation to one another. Failure to do so can easily lead to methodological mazes and presentational flaws. When developing the study design we decided that we would not be returning to the doctors directly with their data, as we wished to undertake the study from an independent researcher perspective, without the influence of the doctors involved. In addition, for the purposes of data analysis, we wanted to examine whether the inter-textual, triangular approach would add to our understanding by bridging gaps in our knowledge base. However, having undertaken this exercise independently, we now intend to return to participants through photo-elicitation interviews to explore their views on the photographs they took and the biographies they wrote. This will not only help clarify differences between researcher and GP interpretations, it will also enhance the datasets already collected.



Discussion The main messages to come out of this study are that up to half the GPs were neither wholly satisfied nor wholly dissatisfied with their workspaces, constructing environments of ‘best fit.’ Furthermore, just over half work within the parameters of inadequate spaces, where lack of function becomes a part of their daily routine. Within this situation, GPs are experiencing, but unable to contend fully with, advances in technology and modernization, accommodating the inadequacies of space by making do with what is available. It is worth emphasising two diametrically opposed responses to this. Firstly, there are the group of GPs who, in the face of tensions within the system, are loath or seemingly helpless to effect change. In spite of the fact that GPs are aware that space is not wholly suited to their own needs, or the needs of their patients, they are reluctant to question the quality of the spaces in which they work and are content to re-align working practice to accommodate mediocrity and mismanagement. Descriptions of the disembodied nature of space emphasize this, highlighting the fact that GPs are no longer the epicentre of working practice. In the face of objects, such as the computer, that continue to hold a central position in their surgery and their lives, GPs feel justified in abrogating responsibility for effecting change. Secondly, we see a very different response to space when space is manipulated and embodied. Embodied space very clearly signifies that the GP is present and emphasizes: seniority of practice, home life and home comforts or, through the apportioning of a sense of aura to the surgery, the elevation of certain objects or events within the room to positions of great significance. Life space, manipulated and embodied, reflects life events, portrays the GP’s persona and encourages the GP to make his or her mark on the environment, placing the consulting room within its own social contexts. Life space is to be valued for the manner in which it extends the medical agenda. There is also an ethical element to these findings that cannot be overlooked as it is evident that certain areas of the consulting room will not countenance change, personal or otherwise. This is particularly the case in the couch area, where the ‘profanity of life space agenda’ is overruled by the sacred. It is here that the serious business of medicine takes place—where

manipulation, frippery and chance are simply unacceptable. Embodied or not, this study reveals that inhabited GP space is clearly unsatisfactory. Orgetta and Gassett (1961) observed that the landscapes in which we live say much about who we are and Winston Churchill remarked that we shape our buildings and thereafter our buildings shape us. If our environments shape our identity we must conclude that, at least to some extent, the GPs in this study are displaying low morale and low selfesteem, where practice is characterized as ‘doing one’s best’ in poorly functioning spaces within a setting of ever tightening resources. As described in the aims, we were interested not only in GPs reflections, but whether, given the opportunity, GPs considered space in terms of professional practice and self-identity. Although some GPs conducted a deeply reflective response to this brief in those terms, space was generally presented, both verbally and textually, ‘as is,’ with little consideration of one’s identity as a professional working with longitudinal relationships across social, psychological, family or community contexts of health and illness. This was a small sample of GPs who agreed to participate from a large potential cohort and there was little researcher input, leaving participants to address the brief as they wished, perhaps bringing different issues and approaches to bear. However, those study limitations could also be considered strengths. A small sample group from a potentially large cohort offers the assurance that the participants were highly motivated to take part, writing detailed descriptions and taking thought-provoking photographs. In addition, the mixed methods approach lent itself to little researcher input, suggesting that the datasets are entirely representative of the views and opinions of the research participants. Methodologically we have ascertained the value of mixing methods within the primary care research arena—each dataset extending the other without undercutting taking place (Silverman, 1994)—and as a result, this has left the researchers better informed and clearer in their understanding of GPs’ reflections. In addition, each dataset was able to clarify puzzles or incongruities within the other and, as a consequence, to offer a more rounded picture of the complexities of the topic area. This study highlights immense tensions within the system and at the same time illustrates that GPs are


failing to impact significantly on the structural forms that institutions have imposed upon them. Nevertheless, it is perhaps commendable that GPs are managing to work within less than perfect spaces, adapting to an NHS environment that is slow to change (Armstrong, 1985), where resources are often scarce, and where GPs are still able to embody, re-appropriate, and inhabit what at first blush appears to be an increasingly uniform and disenchanted working environment (cf. de Certeau, 1984). Further work is required to explore these issues in more depth. If, as we suggest, GPs work in workspaces ranging from the embodied to the disembodied, the sacred to the profane, the technological, clinical and modern to the homely life space, further work could consider why some GPs function satisfactorily whilst others are demoralized, demotivated and alienated. It would also be important to consider the patient angle: how do patients reflect on these workspaces and what do they think about the relationship between care provision, patient need and aesthetically enhanced care environments? The literature indicates that people value not only clinical know-how but also aesthetically appealing settings for patient–professional encounters (Harris, 1997; Johnson et al., 2003; Mathieson, 2003; Gesler et al., 2004). Finally, it would be important to ask how we can make systemic changes to the structures surrounding professional practice to affect the current regime of state controlled contractual environments so that resources are more effectively matched to personal need. It is perhaps surprising that, given the relevance of these questions to GP practice, there is so little published work in this area. Indeed, we surmise that until this topic is given the full attention it is due, GP surgeries will continue to be unsatisfactory and GPs will continue to make-do: ‘‘I have realized that many of my every day actions and the layout of my every day workspace, are the result of a gradual evolution without specific planning’’ (A3).

Acknowledgements We would like to acknowledge the advice that Professor Paul Wainwright, Kingston University and St. George’s University of London, provided as this project developed.

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