Special Journal Issue: Culture, Medicine, and Psychiatry — Anthropologies of Clinical Training in the 21st Century

The June 2011 issue of Culture, Medicine, and Psychiatry is a special issue entitled, “Anthropologies of Clinical Training in the 21st Century.” Seth M. Holmes, Angela C. Jenks, and Scott Stonington, in their opening words, introduce the central question with which the issue’s articles grapple:

Throughout the 1970s and 1980s, medical anthropologists increasingly turned their attention to the examination of biomedicine as a sociocultural system. A significant portion of this study focused on medical education, exploring the ways in which biomedical practitioners—primarily physicians but also nurses and other members of biomedical health care teams—learn both the “art and science” of medicine.
These early studies recognized the central role that clinicians can play not just in care and healing, but also in social control and the mystification and reproduction of social inequality. Given the important role of clinicians in navigating interrelationships among uncertainty, suffering, the body, and society, it is essential to understand their roles, actions, motivations, and ethics. One key way to understand clinicians is to study the process by which they become biomedical professionals.The articles in this special issue apply anthropological theory and methods to the analysis of contemporary biomedical training, engaging with a number of recent changes in the field of biomedicine and employing recent insights from the field of anthropology. Medical education today must be examined within the context of new emphases on multiculturalism, global health, and health disparities; an increasing concern with standardization and evidence-based medicine; the development of for-profit and managed health care; demographic shifts among health practitioners, most notably the increasing percentage of female medical students; increased recognition within academic medicine of the so-called “hidden curriculum”; and the introduction of various forms of the culture concept itself into medical education.

Given the emerging and novel nature of many of these developments in biomedicine and biomedical training, the articles in this volume draw upon recent study in philosophy, science studies, and anthropology that addresses the role of experts and expert knowledge in contemporary society. While most previous studies on clinical training have focused on socialization, this volume instead shifts the focus onto the production of clinical subjectivities. What kinds of people are formed through contemporary processes of clinical training, and how do these evolving subjects transform health, power, and other aspects of social life?

The collection of eight articles in this issue, along with abstracts, are as follows:

Facing Death, Gazing Inward: End-of-Life and the Transformation of Clinical Subjectivity in Thailand
Scott Stonington

In this article, I describe a new form of clinical subjectivity in Thailand, emerging out of public debate over medical care at the end of life. Following the controversial high-tech death of the famous Buddhist monk Buddhadasa, many began to denounce modern death as falling prey to social ills in Thai society, such as consumerism, technology-worship, and the desire to escape the realities of existence. As a result, governmental and non-governmental organizations have begun to focus on the end-of-life as a locus for transforming Thai society. Moving beyond the classic outward focus of the medical gaze, they have begun teaching clinicians and patients to gaze inward instead, to use the suffering inherent in medicine and illness to face the nature of existence and attain inner wisdom. In this article, I describe the emergence of this new gaze and its major conceptual components, including a novel idea of what it means to be ‘human,’ as well as a series of technologies used to craft this humanity: confession, “facing suffering,” and untying “knots” in the heart. I also describe how this new subjectivity has begun to change the long-stable Buddhist concept of death as taking place at a moment in time, giving way for a new concept of “end-of-life,” an elongated interval to be experienced, studied, and used for inner wisdom.

The Moral Aesthetics of Simulated Suffering in Standardized Patient Performances
Janelle S. Taylor

Standardized patient (SP) performances are staged clinical encounters between health-professional students and people who specialize in role-playing the part of patients. Such performances have in recent years become increasingly central to the teaching and assessment of clinical skills in U.S. medical schools. SP performances are valued for being both “real” (in that they involve interaction with a real person, unlike written examinations) and “not real” (in that the SP does not actually suffer from the condition portrayed, unlike an actual patient). This article considers how people involved in creating SP performances reconcile a moral commitment to avoid suffering (to keep it “not real”), with an aesthetic commitment to realistically portray it (to keep it “real”). The term “moral aesthetic” is proposed, to indicate a sensibility that combines ideas about what is morally right with ideas about what is aesthetically compelling. Drawing on ethnographic research among SPs and SP program staff and medical faculty who work closely with them, this article argues that their work of creating “realism” in simulated clinical encounters encompasses multiple different (and sometimes conflicting) understandings and practices of realism, informed by three different moral aesthetics: (1) a moral aesthetic of induction, in which an accurate portrayal with a well-documented provenance serves to introduce experientially distant forms of suffering; (2) a moral aesthetic of inoculation, in which the authenticity and emotional impact of a performance are meant to inoculate students against the impact of future encounters with suffering; (3) a moral aesthetic of presence, generating forms of voice and care that are born out of the embodied presence of suffering individuals in a clinical space. All are premised on the assumption that risk and suffering can be banished from SP performances. This article suggests, however, that SP performances necessarily raise the same difficult, important, fundamentally ethical questions that are always involved in learning from and on human beings who are capable of suffering, and who need and deserve recognition and respect as well as care.

En-case-ing the Patient: Disciplining Uncertainty in Medical Student Patient Presentations
Seth M. Holmes and Maya Ponte

The problem-oriented medical record is the widespread, standardized format for presenting and recording information about patients, which is taught to future physicians early in their medical training. Based on our participant observation of medical training, we analyze the ways in which the patient presentation operates in medical training as a disciplinary technology that manages uncertainty in the clinical decision-making process. We uncover various mechanisms at work including the construction of a coherent narrative structure in which chaotic experiences are re-organized and re-interpreted to fit neatly in a linear plot with a predictable ending, the atomization of the patient as a whole into separable “problems,” the attempt to solve these “problems” as though they are independent of one another, and the mystification of translations in scale, which give rise to much of the uncertainty in medicine. Operating at the boundary of the chaotic and often ungraspable world of the suffering experience of the patient and the highly structured realm of the medical record, a patient presentation is one medium through which both a disciplined record of experience and disciplined medical practitioners are produced. This process functions to transform the human subject patient into a recognizable, generic clinical case, and the medical student into an identifiable, professional future physician.

Learning the Moral Economy of Commodified Health Care: “Community Education,” Failed Consumers, and the Shaping of Ethical Clinician-Citizens
Michele Rivkin-Fish

Leaders of health professional schools often support community-based education as a means of promoting emerging practitioners’ awareness of health disparities and commitment to serving the poor. Yet, most programs do not teach about the causes of health disparities, raising questions regarding what social and political lessons students learn from these experiences. This article examines the ways in which community-based clinical education programs help shape the subjectivities of new dentists as ethical clinician-citizens within the US commodified health care system. Drawing on ethnographic research during volunteer and required community-based programs and interviews with participants, I demonstrate three implicit logics that students learned: (1) dialectical ideologies of volunteer entitlement and recipient debt; (2) forms of justification for the often inferior care provided to “failed” consumers (patients with Medicaid or uninsured); and (3) specific forms of obligations characterizing the ethical clinician-citizen. I explore the ways these messages reflected the structured relations of both student encounters and the overarching health care system, and examine the strategies faculty supervisors undertook to challenge these messages and relations. Finally, I argue that promoting commitments to social justice in health care should not rely on cultivating altruism, but should instead be pursued through educating new practitioners about the lives of poor people, the causal relationships between poverty and poor health, and attention to the structure of health care and provider–patient interactions. This approach involves shining a critical light on America’s commodified health care system as an arena based in relations of power and inequality.

From “Lists of Traits” to “Open-Mindedness”: Emerging Issues in Cultural Competence Education
Angela C. Jenks

The incorporation of “culture” into U.S. biomedicine has been increasing at a rapid pace over the last several decades. Advocates for “cultural competence” point to changing patient demographics and growing health disparities as they call for improved educational efforts that train health providers to care for patients from a variety of backgrounds. Medical anthropologists have long been critical of the approach to “culture” that emerges in cultural competence efforts, identifying an essentialized, static notion of culture that is conflated with racial and ethnic categories and seen to exist primarily among exotic “Others.” With this approach, culture can become a “list of traits” associated with various racial and ethnic groups that must be mastered by health providers and applied to patients as necessary. This article uses an ethnographic examination of cultural competence training to highlight recent efforts to develop more nuanced approaches to teaching culture. I argue that much of contemporary cultural competence education has rejected the “list of traits” approach and instead aims to produce a new kind of health provider who is “open-minded,” willing to learn about difference, and treats each patient as an individual. This shift, however, can ultimately reinforce behavioral understandings of culture and draw attention away from the social conditions and power differentials that underlie health inequalities.

The Ethical Self-Fashioning of Physicians and Health Care Systems in Culturally Appropriate Health Care
Susan J. Shaw and Julie Armin

Diverse advocacy groups have pushed for the recognition of cultural differences in health care as a means to redress inequalities in the U.S., elaborating a form of biocitizenship that draws on evidence of racial and ethnic health disparities to make claims on both the state and health care providers. These efforts led to federal regulations developed by the U.S. Office of Minority Health requiring health care organizations to provide Culturally and Linguistically Appropriate Services. Based on ethnographic research at workshops and conferences, in-depth interviews with cultural competence trainers, and an analysis of postings to a moderated listserv with 2,000 members, we explore cultural competence trainings as a new type of social technology in which health care providers and institutions are urged to engage in ethical self-fashioning to eliminate prejudice and embody the values of cultural relativism. Health care providers are called on to re-orient their practice (such as habits of gaze, touch, and decision-making) and to act on their own subjectivities to develop an orientation toward Others that is “culturally competent.” We explore the diverse methods that cultural competence trainings use to foster a health care provider’s ability to be self-reflexive, including face-to-face workshops and classes and self-guided on-line modules. We argue that the hybrid formation of culturally appropriate health care is becoming detached from its social justice origins as it becomes rationalized by and more firmly embedded in the operations of the health care marketplace.

From Healing to Witchcraft: On Ritual Speech and Roboticization in the Hospital
Adrienne Pine

Healthcare Information Technology (HIT), touted as a panacea by U.S. political actors ranging from Newt Gingrich to Barack Obama, is central to emerging forms of healthcare governance which Holmes et al.—in their critique of the institutionalization of magical thinking brought about by Orwellian techno-Newspeak—have provocatively labeled fascistic. Drawing from data collected over 3 years of working with and teaching continuing education (CE) courses for thousands of registered nurses as lead political educator for the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC), I argue that HIT is an integral component of a broader technological restructuring of healthcare and thus society, both of which are part of a social discourse that is tied to a transformative system of ritual speech, with profound implications for healthcare work, patient health, and democracy.

“Not Here”: Making the Spaces and Subjects of “Global Health” in Botswana
Betsey Brada

This essay argues that what makes “global health” “global” has more to do with configurations of space and time, and the claims to expertise and moral stances these configurations make possible, than with the geographical distribution of medical experts or the universal, if also uneven, distribution of threats to health. Drawing on a study of public–private partnerships supporting Botswana’s HIV/AIDS treatment program, this essay demonstrates ethnographically the processes by which “global health” and its quintessential spaces, namely “resource-limited” or “resource-poor settings,” are constituted, reinforced, and contested in the context of medical education and medical practice in Botswana’s largest hospital. Using Silverstein’s work on orders of indexicality, I argue that the terms of “global health” are best understood as chronotopic, and demonstrate how actors orient themselves and others spatio-temporally, morally, and professionally by using or refuting those terms. I conclude by arguing that taking “global health” on its own terms obscures the powerful forces by which it becomes intelligible. At stake are the frames within which medical anthropologists understand their objects of study, as well as the potential for the spaces of “global health” intervention to expand ever outward as American medical personnel attempt to calibrate their experiences to their expectations.

In addition, commentary on the articles is provided by Vincanne Adams and Sharon R. Kaufman in an afterword entitled, “Ethnography and the Making of Modern Health Professionals,” and Mary-Jo DelVecchio Good in “The Inner Life of Medicine: A Commentary on Anthropologies of Clinical Training in the Twenty-First Century.”