This chapter derives from in-depth, longitudinal, collaborative and what is termed auto/biographical research among 25 general practitioners (GPs), or family physicians, working in demanding inner-city contexts, including inner London (West, 2001). The research focuses on the learning, role and wellbeing of such GPs during a time of changing roles and expectations, including within the management of healthcare in Britain, and a period of growing criticism over performance and levels of accountability. The serial killer Dr Harold Shipman has replaced, at least in part, the heroic Dr Kildare in the popular mind, and stories of doctors’ mistakes far outweigh the triumphs (Smith, 2001). The inner city presents distinct challenges to doctors in a mounting crisis of social exclusion, escalating problems of mental health and growing alienation, as well as increasing inequalities in health and healthcare (Bardsley et al, 1998).

The research chronicles and theorises, using case study material and an interdisciplinary ‘cultural psychology’ (drawing on sociology, feminism and feminist psychoanalysis as well as the adult learning literature), the impact and meaning of social and cultural change among a diverse group of GPs. It focuses, too, on the role and nature of ‘lifelong learning’ in the management of change and professional development. It documents some of the doctors’ doubts and anxieties about training as well as the biomedical model itself, in the face of problems that often seem more social and psychological than physical in nature. It explores the psychological distress and feelings of helplessness that can haunt a doctor, and the difficulties of dealing with this in a medical culture in which doctors are taught that they should know and cope. The stories at the heart of the chapter are of two doctors who, because of multiple identities and experiences of oppression, have felt on the margins of the profession. Such GPs – ‘outsider-insiders’ – raise radical questions about the health of medicine, its training and some epistemological assumptions about what doctors need to learn.

Self-directed learning

The starting point for the research was an evaluation of self-directed learning (SDL) groups for GPs in inner London. The groups were established in the early 1990s following concern over standards of care and the morale of many doctors. They were designed to give space to GPs to consider ‘critical incidents’ with selected patients that might be causing particular anxiety.