one question - DUE IN 3 HRS!!!!!

C O M M E N T A R Y

Ethnography and the Making of Modern Health Professionals

Vincanne Adams • Sharon R. Kaufman

Published online: 4 May 2011

� Springer Science+Business Media, LLC 2011

…it is particularly incumbent on physicians in this time of instability and change to concern themselves with medicine in its largest social sense – with

that part of medicine that cannot be construed in terms of laboratory findings

and standard protocols alone. To be a medical citizen is to concern oneself

both with the realm of politics and social justice and with clinical judgment.

—Charles Rosenberg, Our Present Complaint: American Medicine Then and Now

Charles Rosenberg’s call to arms for the training of health professionals as

optimal medical citizens—concerned with politics, social justice and clinical judgment—recalls a long history of social science engagement with the socio-

economic and political sources and contexts of medical practice (Rosenberg 2007).

Social scientists equipped with ethnographic and analytical insights have offered

critiques from ‘‘the outside’’ for years, noting how biomedicine engages, knowingly

or not, in iatrogenesis (Illich 1982), capitalist exploitation (Navarro 1976),

domination (Freidson 1970)and reductionism (Gordon 1988), that it disregards

the social conditions of knowledge production (Young 1982) and that it turns life

cycle processes and behaviors into objects requiring medical intervention (Conrad

1992; Zola 1972) for example. The examination of medicine as a social and cultural

system that reproduces problems of social inequality or injustice, rather than

eradicating them, never seems to slow. The route by which this reproduction occurs,

V. Adams (&) Medical Anthropology, School of Medicine, University of California, San Francisco, San Francisco,

CA, USA

e-mail: [email protected]

S. R. Kaufman

Medical Anthropology, UCSF Institute for Health and Aging, University of California,

San Francisco, San Francisco, CA, USA

e-mail: [email protected]

123

Cult Med Psychiatry (2011) 35:313-320

DOI 10.1007/s11013-011-9216-0

more often than not, is through the knowledge, practice and development of health

professionals, but seldom has analytic focus been explicitly on the health

professionals themselves. With this in mind, this fine collection marks a significant

moment in social science analyses of biomedical, and especially clinical, knowledge

and practice by taking as its focus the training of—that is, the production of ethical,

practical and practicing—health professionals. This collection investigates how

some of these previously identified problems persist, creating vexing new ethical

challenges for us all. It offers insights that should be read by all health professionals

in training, and we heartily welcome it.

The articles cover a wide range of contexts and problems—from clinical rounds

in elite medical schools to rural services for dentists in training, from US struggles

with cultural competency to global health struggles with cross-cultural poverty.

Together, they expose the profound influence of contemporary forms of rationality

and ethicality on the restructuring of health care, the shaping of health professional

subjectivity and the goals of medicine. The pathways of training and treatment they

interrogate derive from business models of education and ‘service delivery,’ in

which measurability is the key method and outcome. They question the benefit of

efforts to standardize and quantify health care routines. They expose the hidden

costs of new strategies to encourage empathy, cultural sensitivity, and knowledge/

practice of compassionate expertise. The articles show how efforts to transform

patients, health professionals and health care organizations into more effective

practice machines often fail, sometimes miserably, and in almost all cases arouse a

set of ethical questions about how to get things right. Do medical reforms that insist

on recognizable and quantifiable modules in order to maximize efficiency and

generalizability really make for a better kind of medicine, or even one that is

measurably more efficacious? Do efforts to require cultural competency result in

more culturally appropriate care or do they reproduce cultural stereotypes and

ethnocentrism/racism? Do routines of rural care or service in under-resourced

nations or communities make better doctors and dentists, or do these encounters

reproduce structural problems that reinforce social inequality?

The authors in this collection offer new insights on all of these conundrums and

more. They underscore how market-based tools are affecting ethical sensibilities

and work routines. Students and professionals must learn how to recognize and

manage the new objects of value in the biomedical infrastructure—the ‘‘best

practices,’’ ‘‘cultural competence,’’ and routine practice rituals in which medical

competence is enacted. The main actor in this restructuring is the assemblage of new

pedagogical and health care technologies that permeate health professional

activities today, and these articles document the ways in which those technologies

govern practitioners’ understandings of ethical comportment, appropriate care, what

ails the patient and what can and should be done about it. Those technologies

include, for example, the electronic medical record; computer based teaching tools

of all sorts; the standardized patient; the problem oriented patient presentation;

models of ‘cultural competency training; and routinization of class difference as a

diagnostic tool in poor settings.

This collection draws attention to the linkages of governance which are forged

between infrastructural and bureaucratic demands on the one hand, and what it takes

314 Cult Med Psychiatry (2011) 35:313–320

123

to be a ‘good’ clinical-citizen/practitioner on the other. The explorations demonstrate

the ways in which health professionals come to constitute ‘‘themselves as moral

characters’’ (Brada; Shaw and Armin; Stonington) and as ‘‘ethical clinical-citizens’’

(Rivkin-Fish) while also ‘‘being protocoled into oblivion’’ (Pine) or otherwise

(re)-skilled in today’s market-driven health care delivery system. They show that

many of these training protocols, despite being designed to overcome the problems of

social inequality, actually reinforce social injustices, commodified health care, and a

blaming of the victims of poverty and global inequality. At the same time, these

articles point to the fraught nature of this ratcheting back and forth between a hoped

for, new and improved medicine by way of streamlined, quantifiable training, and the

unintended and undesired outcomes that such reforms produce. They reveal how

difficult it is to become a health professional who is engaged in, as Rosenberg notes,

not only good clinical judgment (based on laboratory tests and standard protocols) but

also in actions to redress the social causes of inequality and injustice that underlie

medicine’s persistent shortcomings and blind spots. By emphasizing the centrality of

structures of power and the social relationships and enactments that render the

consequences of those structures invisible in the formation of health professionals,

this collection serves as a stimulus for further social science explorations of medical

epistemology and the organization of training and care. It suggests that despite all

these years of reform, much of which was inspired by previous critical engagements,

we still have a long way to go.

Holmes, Jenks, and Stonington stress in their introduction that these articles stand

on the shoulders of anthropologists and sociologists who began investigating

biomedicine as a sociocultural system decades ago. Attention to the intellectual

roots of this collection reminds us of some of the enduring thematic concerns for

analysts of biomedical knowledge and practice. The more recent regimes of training

and truth-making that this collection explores illustrate newly powerful dimensions

of the biomedical enterprise that demand social science investigation and critique.

Beginning with her 1957 essay, ‘‘Training for Uncertainty,’’ Renee Fox has

documented over nearly a half century the ways in which uncertainty has affected

the organization of training and the everyday work of medicine, and the ways

uncertainty intersects with physician understandings of treatment, prognosis and

suffering (Fox 1957). Her 1980 article, ‘‘The Evolution of Medical Uncertainty,’’

described how uncertainty at the bedside was heightened by scientific and

technological developments in the 1970s which enabled medical progress in

diagnosis, treatment and prevention at the same time as those developments

increased overall risk awareness (of powerful therapeutic side-effects; of research)

and fostered new (and perhaps unrealistic) expectations about health, longevity and

the elimination of disease. The result, she wrote, is that, ‘‘The development of

scientific medicine, then, has both uncovered and created uncertainties and risks that

were not previously known or experienced’’ (Fox 1980).

When Fox revisits the scope of uncertainty in 2000, she describes its enduring

tenacity and most recent forms—the result of the emergence and re-emergence of

infectious disease, the ascendance of genetic knowledge, therapies, and technol-

ogies, the problems of iatrogenesis and medical error and the constraints of

evidence-based medicine on the hallowed doctor–patient relationship. She notes, for

Cult Med Psychiatry (2011) 35:313–320 315

123

example, that increased diagnostic and treatment capabilities produce prognostic

data and that physicians are under greater pressure than ever before to make clinical

predictions, which they are loathe to make and not trained to deliver. Epistemo-

logical uncertainty, too, runs through medical practice and the medical literature.

The shifting nature of medical knowledge is made more troublesome by the

demands of evidence-based medicine which constantly replaces old truths with new

knowledge and which leads to questions about which evidence is good enough (Fox

2000). Her studies on these topics moved beyond socialization theory to illustrate

how health professional ethical knowledge and practice are organized by the

contours of science and the move towards managed care. Along with others, she

emphasized that bioethics, in its focus on logico-rational principles of analytic

philosophy, ignores the topics of health disparities, unequal power relations and

poverty as ethical problems that are foundational to disease and illness and integral

to medicine (Fox 1990, 2000). Her work drew connections among medical training,

practice and the formation of ‘‘medical citizenship’’ that Rosenberg, in the epigraph

above, later describes and that this collection further explores.

Physician sensibility, scientific and institutional developments and the links

between them are emplaced firmly in the broader realm of the social in the essays

assembled by editors Margaret Lock and Deborah Gordon, in Biomedicine Examined (1988). That collection was among the earliest to strongly demonstrate ‘‘the social and cultural character of all medical knowledge’’ (p. 7) and the ways in which medical and scientific practice are inherently social enterprises, interdepen-

dent with society. The volume sought to dismantle the idea that biomedicine, and

the sciences on which it rests, represent an objective and value-free form of

knowledge ‘‘which claim neutrality and universality’’ (p. 19). The essays reveal how

structures of medical practice are socially constructed, how values strongly shape

what physicians do and that disease categories and definitions are not given but

rather are created, represented and understood in institutional, cultural, and

historical contexts. Above all, the volume illustrates that biomedicine is not a

monolithic entity, but rather that it is comprised of specific practices, rituals and

ideologies, all well within the realm of social analysis.

From the 1990s, analyses of the many forms and features of the biomedical

enterprise have stressed its location in political and economic webs of power

relations in which health disparities flourish and social justice languishes. The role

of the ‘technological imperative’ in medicine, central to US medicine from the mid-

twentieth century, has become even more dominant as evidence-based medicine

supports an expansive clinical trials industry and the creation of more therapeutics

for more conditions—but only for those who can gain access to them. The

‘biotechnical embrace’ (Good 2001) is now a world-wide phenomenon, contributing

to new forms of ‘‘ethical self-formation’’ among practitioners (Stonington) and the

development of a dual discernment of appropriate, ethical care depending on

whether one is practicing medicine ‘here’ or ‘there’ (Brada; Rivkin-Fish). Greater

fragmentation in health care delivery, greater emphasis by health care organizations

on models of efficiency for training and practice, the normalization of differential

treatments in affluent and poor settings, and computer-guided diagnosis, treatment,

charting and goal setting all have changed clinical medicine and the ways in which

316 Cult Med Psychiatry (2011) 35:313–320

123

trainees and professionals learn to ‘do’ medicine, to ‘be’ clinicians and to function

within medicine’s highly varied organizational environments (Holmes and Ponte;

Pine; Taylor; Shaw and Armin). These most recent developments are the crux of the

matter in this collection. What these articles show us has unsettling implications for

the future of medicine as a practice in which healing and social justice can thrive.

Recognition is the large, unifying theme that runs through these articles—that is, what students and professionals are taught to recognize as the skills that constitute

clinical-ethical citizenship in the market-driven, standardized, and high-tech health

care arena today. Each article explores how what many would call ‘‘new and

improved’’ techniques that clinicians and clinicians-in-training learn actually govern

their understandings of patients, treatments, and their own clinical-ethical expec-

tations of caregiving in particular settings. Each portrays specific tools now

considered essential or optimal for clinical development and practice. Thus, we have

the following, for example: standardized cultural competency training modules in

which ‘competence’ about diversity can be measured to track practitioner

‘improvement’ in understanding cultural difference, and the slippage between

categorical vs. reflexive thinking these modules produce (Shaw and Armin; Jenks);

the rise of computer based Health Information Technology systems designed to

reduce clinical error but which actually conceal labor shortages in the nursing

profession that may be the true cause of higher rates of medical error (Pine); the

problem-oriented patient presentation that creates both a ‘‘categorizable, recogniz-

able and generic’’ patient/case and a professional physician but dehumanizes the

patient and the doctor–patient relationship (Holmes and Ponte); the use of students-

in-training to serve the globally and locally underserved and uninsured and the

mystification, rather than exposure, of local and global social inequalities (and

cultural stereotyping) that these reproduce (Brada, Rivkin-Fish); the standardized

simulated patient performance, considered the best method (because it is

standardized) for representing illness and suffering and thus for measuring ‘‘clinical

skills’’ but that also becomes a site for ethical induction and innoculation (Taylor);

and the jarring ethnographic possibility of breakthrough moments when reflexivity

enables the health professional to reflect critically on biomedicine and embrace the

possibility of ‘‘not knowing for sure’’ what to do (Stonington). The authors in this

volume agree that clinicians come to embody the logics of a new clinical gaze

through those tools. That is, clinicians learn what to recognize about patients and about themselves through those tools of medical reform. ‘‘Re-skilling’’ technologies and educational strategies mandate new ways of knowing patients, systems of

service delivery and above all, the new kinds of ethical opportunities that clinicians

need to embrace.

The entrenched moral economies of health care settings shape clinician

sensibilities as well, as many of the articles in this collection show. Here, the

analysis of misrecognition is as important as that of recognition. ‘‘Skilling’’ health professionals for work in ‘resource-poor’ and ‘community’ settings, for example,

ends up reinforcing stereotypes of the poor as responsible for their ill health and

treating cultural difference as a problem of medical incompetence. Such efforts sit

awkwardly next to the growth of required programs in cultural competency across

US medical schools. Deliberation over how to appropriately represent ‘‘cultural

Cult Med Psychiatry (2011) 35:313–320 317

123

difference’’ as a problem of self vs. other may or may not be hitting the mark if

larger problems of abject poverty and the commodification of health (literally—one

has to be able to afford health to have it) are overlooked. These problems of

commodified health care infrastructures are deeply vexing to professionals,

including those in training, when they are asked to engage in efforts to both save

money and organize their treatments and caregiving in ways that are not ideal and,

in fact, at odds with their reasons for such a career choice. Here too are problems of

misrecognition.

When read as a group, the essays raise important questions about how to enable

and empower health professionals who want to engage in activism, social justice,

and socio-political reform without transmuting these efforts into personal strategies

for ethical choice. How can the ethical struggles of health professionals in training

today be made to bear fruit in the real world? Health professionals arrive to their

training with pre-formed ideas about the sources and causes of the health problems

they will confront. What is the responsibility, then, of the institutions that teach

them, and what sort of ethics become embodied in the choices these schools make

about how and what kinds of training will be required? Where misrecognitions are

seen with the institutionalization of things like ‘‘cultural competency,’’ ‘‘rural

service work,’’ ‘‘simulated trauma’’ or even ‘‘SOAP’’ notes, we might also pose the

question of how to better prepare students in the health professions for a life of

clinical work—in which patient problems extend far beyond what they ‘‘present’’ in

the clinic; treatment options have less to do with standard of care and more to do

with the uneven distribution of resources; and health professional understandings of

patient problems and treatment options reach deep into the kinds of cultural

knowledge(s) that are shaped and reproduced by the structural inequalities of the

larger (global) health care delivery landscape. Efforts toward social justice and

health advocacy start, as these articles illustrate, with individual ethical reflection on

the nature of one’s work, one’s place in the world, and one’s personal sense of

effectiveness as a health professional, but such personal commitments can have

effects far beyond one’s expectations. The articles are an outstanding start for

re-invigorating discussion about medical pedagogy and practice in today’s market-

based context for health care delivery.

Finally, this collection offers an important new methodological insight. The

articles, without explicitly stating so, reveal how ethnography can serve as both a

social scientific method and a unique approach to medical practice. These articles

take medical anthropology beyond a critique from the outside, beyond analyses of

biomedicine as a cultural system. They show that ethnography can be useful for

remaking the ‘‘medical citizens’’ Rosenberg hopes for so that they can practice with

a greater knowledge of the socio-cultural-economic sources of inequity and thus

with some conceptual tools for their amelioration.

The volume Lock and Gordon assembled in 1988 illustrated that biomedicine is

not objective, neutral and universal. Their goal was to show how social science

exploration of the inner logics, local practices and social production of the many

forms of biomedicine might improve knowledge about the rationales for actual

practices. The articles in this collection highlight some of the still recalcitrant

rationales for practice (cultural stereotyping; reducing the patient to assessment,

318 Cult Med Psychiatry (2011) 35:313–320

123

plan, etc.), and they describe the more recently adopted justifications for

streamlining, quantifying and generalizing training techniques. But going farther,

this CMP collection recognizes that many of the problems that have plagued

medicine are not going away and that some are being introduced or re-introduced

through new technologies and fiscal mandates. Efforts to standardize training by

using real people as simulated patients still create ‘‘cases’’ that can be fragmented

into objectivized parts, even when the real life problems of simulators bleed into the

‘‘fake’’ performance of disease. Political economic critiques that lead to reforms in

health care training and make it possible for students to serve poor patients may

only reproduce the social inequalities they seek to redress. The routinization of

medical practices aimed at generating better standards of care may distance patients

from their caregivers in new and frightening ways.

These articles suggest that new types of medical and caregiving engagements

may be possible through careful ethnography. No longer are health professionals

fully caught in the webs of objectification and reductionism that come along with

enculturation in the medical profession; caregivers in training are themselves not

uniform nor uniformly positioned in their ethical embrace of market-based

mandates. They struggle with how to be and with how to see their efforts in

ways that will serve their patients and resonate with the kind of medical citizen they

wish to become. The authors show how ethnographic methods can be part of the

arsenal of doing ‘‘medicine in its largest social sense’’ (to refer back to Rosenberg).

Efforts to overcome the boundaries of disciplinary divides between anthropology,

medical anthropology, and medicine are, perhaps the strongest contribution of this

collection. We applaud the editors and contributors for using ethnography as a

potential intervention in clinical practice and training.

References

Conrad, P.

1992 Medicalization and Social Control. Annual Review of Sociology 18: 209–232.

Fox, R.C.

1957 Training for Uncertainty: Introductory Studies in the Sociology of Medical Education. In The Student Physician. R.K. Merton, G. Reader, and P.L. Kendall, eds., pp. 207–241. Cambridge:

Harvard University Press.

1980 The Evolution of Medical Uncertainty. The Milbank Memorial Fund Quarterly. Health and

Society 58(1): 1–49.

1990 The Evolution of American Bioethics. In Social Science Perspectives on Medical Ethics. G. Weisz, ed., pp. 201–220. Dordrecht, Boston: Kluwer Academic Publishers.

2000 Medical Uncertainty Revisited. In Handbook of Social Studies in Health and Medicine. G.L. Albrecht, R. Fitzpatrick, and S. Scrimshaw, eds., pp. 409–425. London; Thousand Oaks, CA:

Sage Publications.

Freidson, E.

1970 Professional Dominance: The Social Structure of Medical Care. New York: Atherton Press.

Good, M.J.D.V.

2001 The Biotechnical Embrace. Culture Medicine and Psychiatry 25(4): 395–410.

Gordon, D.

1988 Tenacious Assumptions in Western Medicine. In Biomedicine Examined: Culture, Illness, and Healing. M.M. Lock and D. Gordon, eds., pp. 19–56. Boston: Kluwer Academic Publishers.

Cult Med Psychiatry (2011) 35:313–320 319

123

Illich, I.

1982 Medical Nemesis: The Expropriation of Health. New York: Pantheon Books.

Lock, M.M., and D. Gordon

1988 Biomedicine Examined. Boston: Kluwer Academic Publishers.

Navarro, V.

1976 Medicine under Capitalism. New York: Prodist.

Rosenberg, C.E.

2007 Our Present Complaint: American Medicine, Then and Now. Baltimore: Johns Hopkins

University Press.

Young, A.

1982 The Anthropologies of Illness and Sickness. Annual Review of Anthropology 11: 257–285.

Zola, I.

1972 Medicine as an Institution of Social Control. The Sociological Review 20(4): 487–504.

320 Cult Med Psychiatry (2011) 35:313–320

123

Copyright of Culture, Medicine & Psychiatry is the property of Springer Science & Business Media B.V. and its

content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's

express written permission. However, users may print, download, or email articles for individual use.