Syllabus

Cultural Aspects of Clinical Medicine

Spring, 2012

GOALS

This course is designed to give students who are about to enter the medical field experiences and knowledge about the practice of medicine that they would not otherwise have. The course requires, as a "real-life" laboratory, that each student spend four hours per week at least 11 times during the semester, in an internship in the Emergency Department at Memorial Hospital of South Bend, acting as a Patient Liaison. In that role, students acquire first-hand information about the world of clinical medicine, and are able to compare what they experience with what they read about in the assigned readings. Thus, the academic objective of the course is for students to be able to use various anthropological concepts to describe, analyze, and critique medicine as it is currently practiced in America. The broader objective is to enable students to come to a better understanding of themselves and their career plans.

FORMAT

Most classes will involve discussion--either discussion of the readings assigned for the week, discussion of student experiences in the Emergency Room, or discussion with guest speakers. One or more excursions to external sites will be organized. The Emergency Room experience is organized around 4-hour time blocks; typically these run from 4-8PM and 8PM-midnight. Students must provide their own transportation to the ER. Tuesday and Thursday shifts will run from 12 noon-4PM, and 8PM-midnight.

COURSE REQUIREMENTS

Students are required to serve at least 11 Emergency Room internship shifts by April 28. They must provide their own transportation to the ER. A sign-in system in the ER will serve as an attendance check. It is your responsibility to sign in for every shift you work, since if you do not, I have no way of verifying your attendance. At the end of the semester, I check attendance and if you cannot prove your attendance, I will assume you have not gone. Keep your own attendance record, so that you can monitor your progress toward meeting the requirement. If you absolutely cannot make a particular shift, it is imperative that you inform the nursing staff of your absence. You will be expected to make up missed shifts at another time. If you are not feeling comfortable with the ER internship after the first five weeks of the semester, please speak with me about it! Because the ER internship is so integral to the course, students who do not attend at least 11 four-hour blocks by May 2 (the official “Last class day” of the semester) will have their grade lowered by one full letter for each deficient block. A’s become B’s, B’s become C’s, etc. Keep track of your ER attendances in case there is a discrepancy between what you are registered for and what you think is true.

There will be weekly or near-weekly quizzes throughout the semester. Generally, they will take place on Thursdays. Quizzes are designed so that you can show me you understand the relevant material. “Understand” usually does not mean “memorize,” it means put together, synthesize, get the main point of, or relate one reading to another. Because of this, the validity of an answer sometimes comes down to a matter of judgment; one of the course objectives is that students demonstrate the ability to apply good judgment to course readings. I do not give make-up quizzes. A student may request to take a quiz early by e-mailing me no later than the Tuesday of the affected week. My policy about late work is this: Out of fairness to other students and to my time, assignments (e.g., lab reports, homework, final exam) turned in late will not get full credit.

I expect that students will attend all class activities, keep up with weekly reading assignments, and be prepared to discuss them in class. Active participation in the class discussions improves the quality of the class, because we have a chance to hear different points of view. This, along with the ER requirement above, constitute my policy concerning attendance and its relationship to course grade.

 Journals and Lab Reports

You are required to keep a journal of Emergency Room experiences. The journals are primarily for you, and should be detailed enough to document and support statements you make in the two required laboratory reports. I will want to see a journal entry along with the first lab report. After the first lab report, reorient your journaling to reflect more global assessments of the ER as a setting. (You may want to look at the Lab 2 questions in order to do this efficiently.) I will not ask to see your journal after the first lab report.

The purpose of the first laboratory report is to assess whether you have paid attention during your ER shifts and can describe in detail one specific incident you have witnessed, as well as relate it to some course material. Fifteen points are available for this report. The first laboratory report is due Thursday, March 8. Reports turned in after that date will not get full credit. In addition, turn in your journal with one entry marked for me to read. The marked entry does not necessarily have to describe the incident in your report.

For the first laboratory report, use Format 1 to report on an incident you witnessed in the ER. Your report should replicate each question in the Format exactly as it appears below, followed by your responses. Grading criteria include the detail and thoroughness with which the incident is described. I look for evidence of sensitivity to the nuances/meanings of the encounter as evidenced by how events happen, in addition to descriptions of the events themselves. Also, I pay close attention to the last section, in which you relate the experience to other course material. Grading scale: 1-5 points: Report does not follow required format or several sections lack sufficient detail. 6-9: Report follows format exactly, most sections contain sufficient detail, last section does not thoroughly relate encounter to course concepts. 10-12: Report follows format exactly, all sections are sufficiently detailed, last section is thorough. 13-15: All of 10-12, plus one or more sections that display extraordinary insight. How to succeed without having to re-write: I want the first lab report to be so descriptive that it’s as though I was next to you during the encounter. I want you to act as a reporter with an eye to exquisite details—not only about the “what,” but about the “how.” For instance, if you believe that the patient was angry about something, tell about what the patient did, said, and looked that created that inference. Don’t forget to include yourself in the descriptions. Talk about the demographic characteristics of the actors. Age, gender, and apparent SES form the background of the encounter, and should be explicitly noted. Be organized—keep material pertaining to the same issue together, and don’t repeat it.

Format 1:

Who was there?

What was the purpose of the encounter from the perspectives of the different participants?

What happened? Who said and did what?

What were the outcomes of the encounter for the participants? (Outcomes include medical, social, feelings and thoughts.)

How did you fit into the encounter? How did you feel about it?

Did the encounter lead you to any new understandings about the ER or about yourself?

What concepts or ideas from the course lectures, readings or discussions were demonstrated in the encounter? How did the encounter illustrate the concept? In what ways did the encounter depart from the "textbook" definition of the concept? If it departed from the “textbook” definition, why did that happen, in your estimation?

_____________________________________________________________________________________________

The second laboratory report is due Tuesday, May 1. Reports turned in after that date will not get full credit. The purpose of this assignment to assess how well you have grasped the features of ER culture, and how well you can describe them to me in a coherent, detailed, and thoughtful way. Grading criteria include whether the report addresses every point listed in Format 2, and does so in more than a cursory, superficial way. That is, I look for richness of detail and evidence of having paid attention to the nuances and subtleties of the setting, as well as its obvious features, in the report. A “nuanced” account includes how general rules vary—by person, role, or situation. Essentially, I want to know how much you learned about the ER over the whole semester. I'm NOT interested in distinct incidents but rather more global assessments. I pay particular attention to the part of each section which inquires about what the particular aspect of the ER (space, touch, etc.) indicates about ER culture. I am looking for reports that go beyond the obvious and superficial aspects of the “cultural surface” and reveal layers of values and premises. Fifteen points are available for this report. You need not turn in your journal. Grading scale: 1-5 points: Report does not follow required format or several sections lack sufficient depth. 6-9: Report follows format exactly, most sections contain sufficient depth, one or more discussions of what a particular aspect of the ER indicates about the setting displays lack of insight. 10-12: Report follows format exactly, all sections are sufficiently detailed, all discussions of what a particular aspect of the ER indicates about the setting are insightful. 13-15: All of 10-12, plus one or more sections that display extraordinary insight. How to succeed: For this lab, I’m most interested in how well you can “peel the onion” of the culture of the ER back to the values underlying the practices you note, and the premises that create the values. Remember the discussion of the stethoscope, how it illustrated the value placed on objective indicators of illness (rather than the patient’s own subjective account) and how that, in turn, reflected the premises of Enlightenment natural science—that there is an objective reality “out there” that can be known and understood. For each of the sections of the report that call for what the practice indicates about ER culture, “peel the onion” of the practices you report back to their underlying values (what’s good and what’s bad) and premises (beliefs about the nature of the world).

For the second laboratory report, use Format 2 to describe the setting of the ER as you have experienced it over the entire semester. Your report should replicate each question in the Format exactly as it appears below, followed by your responses.

Format 2:

Discuss the use of space.

How is physical space arranged and subdivided?

What types of space exist and who uses what space?

How is space allocated among different actors?

How do you know to whom it belongs?

What does the use of space indicate about this the culture of the ER?

Discuss the use of touch.

Who touches whom?

When?

How?

What does the use of touch indicate about the culture of the ER?

Discuss customs related to speaking.

Who speaks?

Who speaks first in a conversation?

Who interrupts?

Are there patterns related to the loudness of speech?

What do your observations about speaking indicate about the culture of the ER?

Discuss practices concerning naming and titles.

What indicators of identity (badges, nametags, modes of dress, etc.) are present?

What titles are used, and when?

What does the manner of identity indicator and name usage tell about the culture of the ER?

Discuss the dynamics of eye contact.

Where do participants look?

Who looks at whom?

When?

How intently?

What does the pattern of eye contact indicate about the culture of the ER?

Discuss concepts of time.

How is time structured by various participants?

What "kinds" of time (e.g., good or bad, fast-moving or dragging) are noted by participants?

Discuss yourself in your role.

What are you doing in the setting?

How do you fit in?

How does the setting make you feel?

COURSE GRADING

The course grade is based on 105 possible points, distributed as follows:

Quizzes 40 points

Final Exam 10 points

Lab reports (2) 30 points–15 on each

Homework 15 points

Discussion contribution 10 points (3 points individual, 7 points group)

A semester total of 91 points guarantees you at least an A-. A semester total of less than 50 points is considered failing.

I strongly encourage you to keep your papers and maintain a record of your point totals, in case there is a discrepancy between what I have for you and what you think you should have.

Class meets Tuesdays and Thursdays 5:00 – 6:15 in Room 241, DeBartolo Hall.

I can be reached at:

Mailbox in Anthropology Office–611 Flanner Hall

Email: rwolosin@nd.edu

Website: http://www.nd.edu/~rwolosin

Overview

The course is structured around a set of issues that very broadly have to do with the clinical encounter, its antecedents and consequences. In general, we consider the two major parties to the clinical encounter--the patient and the provider--in parallel ways. After a few preliminaries (Weeks 1 and 2: introduction and an orientation to the ER), we consider the world of malady: health and disease, illness and sickness. These form the background of the clinical encounter for patients and providers alike. In Week 5, we take up, on the patient side, the social and cultural causation of malady. In Weeks 6 through 9 we switch tracks and explore the world of various health care providers. Week 6 gives an overview, while Week 7 deals with a sector of the labor force that is outside the ranks of "official" medicine. Weeks 8 and 10 consider physicians, first their training, then their practice. Special attention is paid to the internal transformations that are supposed to occur in the process of medical education. Also, we address several alternative ways of viewing physicians and their social roles. Finally, in Week 11, we focus narrowly on the encounter itself; in Week 12, we note that some of the outcomes of medical encounters are not what the participants desire. In Weeks 13-15, we broaden out the focus again, and read, first, about the internal culture of medicine, namely medical language and its use (Week 13), then how medicine relates to its external culture (the everyday culture we live in). Lastly, we address the issue of cultural change, that is, how social forces are changing medical culture.

Within this larger structure, each week has a bunch of readings that speak to some of the major issues pertaining to the topic at hand. Some weeks have a "meat and potatoes" article--a key article that does the dirty work--bears the brunt of the teaching message for the topic. Some weeks don't, and present a more kaleidoscopic picture of a topic, with the various facets parceled out among the various articles. Some articles are, frankly, there for fun or for flavor, or to pose questions or provoke thought. Some illustrate points made by me or by another author. For most (but not all) of the topics we consider, there is no set of grand, underlying principles, so that one of your tasks as a learner is synthesis--putting material together in a way which allows you to think about it in a meaningful and parsimonious way. In my "Reader's Guides," (available on my website) I give you some starting places for how you might think about the material, realizing that for many of you, this stuff is really pretty wacky. But there are some threads or themes that pervade the course, and we turn and return to them in various contexts.

Week of: Topic

Jan 17	Introduction to the course. A direct attack on preconceived notions about medical practice. The way clinical medicine is practiced today in America is one of many alternative ways; its specific history and context determine its character. What our system is--biomedicine.
Jan 24	Orientation to the hospital and ER internship. There is a clash of cultures between patient (a representative of lay culture) and staff (representatives of biomedicine). Why and how. Also, some tools to help you get a handle on ER experience, considering it from the standpoint of the staff, the patient, and some thoughtful observers.
Jan 31	Health and disease. Culture shapes ideas of malady, health, disease. Contrast between specialized, biomedical vs lay conceptions. Health as cultural construct. Disease as constructed by biomedicine, and medicine as a social institution.
Feb 7	Illness and sickness. The subjective side of malady--that is, the experience of patienthood. To ignore it is to fail as a doctor. Various ways of dealing with disease.
Feb 14	Cultural and social influences on health and disease. How malady responds to social and cultural forces, in addition to biological ones.
Feb 21	Players in the Healthcare game. An appreciation of the multitude of interests and outlooks that pervade medicine, through the various types of workers in it.
Feb 28	Healers and healing. Recognize that there is more to health care than the traditional magic bullet approach of biomedicine.
Mar 6	Curers and curing I: Training. Medical education as a profoundly self-altering experience; how does it happen? What is the process?
Mar 20	Curers and curing II: Practice. What we expect from physicians, and what we get. The moral dilemma that underlies the medical profession—self-interest and altruism.
Mar 27	The doctor-patient encounter. The central event in clinical medicine is the flesh and blood meeting of doctor and patient. Theme and variations. Why is the practice of medicine so variable? Doesn’t this imply bad doctoring, or at least, wasted resources?
Apr 3	Problems of patients. Patienthood is more than a set of roles; it brings with it various problems. What sort of harms are involved, and how does medicine respond to them?
Apr 10	Cultural aspects of clinical medicine. Some practices in medicine give it a particular flavor. The perspective goes beyond individual medical encounters to examine cultural features that pervade the enterprise, from linguistic practices to fads and trends in medicine. A key question: What is the proper relationship between the "art" of medicine and the "science" of medicine?
Apr 17	Medicine and the wider culture. Medicine is not a closed system--a world unto itself, devoid of interaction with the larger society. Indeed, it is in a dialectical relationship with society as a whole, such that it influences and is influenced by its portrayals.
Apr 24	Cultural change within medicine. Medicine as culture is constantly changing. Forces from inside and outside are promoting change. We may be leaving an era -- the modern era -- and entering a quite different one.
May 1	Last class; Review, Lab 2 collected; final exams handed out.