Lectures

Doing and Seeing: Cultivating a “Fractured Habitus” through Reflexive Clinician Ethnography

Introduction

The tension between critical theoretical innovation and on-the-ground, practical application has animated intense debate in medical anthropology (Scheper-Hughes 1990). Epistemological and methodological conflicts cropping up at the intersection of medicine and anthropology, though central considerations for all medical anthropologists, represent an inescapable source of tension for MD/PhD clinician-ethnographers. While innovative manuscripts produced by such scholars (Wendland 2019) have illustrated the generative potential of a “fragmented occupational and institutional habitus” (Braslow and Bourgois 2019), little work has attempted to characterize and understand how this fragmented habitus is navigated, embodied, and infused into ethnographic inquiry and clinical practice. 

As physician-anthropologist Claire Wendland (2019) notes, “Medical training acculturates people to intervention: For those who practice medicine, the stance of pure critique often seems morally suspect” (197). Pigg (2013) identifies a similar tension in the field of global health––the “driving imperatives to ‘do something’” (127) about pressing health problems animate what she characterizes as “the problem-solving juggernaut” (133). Other medical anthropologists (Dubal 2018; Englund 2006; Fassin 2012; Prince 2012; Ticktin 2011) have likewise critiqued the impulse to act without self-critical reflection in the context of global medical humanitarianism, on the grounds that it shores up the hegemony of Western biomedicine and obscures harm under the guise of benevolent intervention. The medical humanitarian focus on keeping bodies alive, often termed an “ethics of compassion,” risks displacing a broader politics of rights and justice aimed at redressing economic inequalities and political exclusion. This forward-barreling force comes into conflict with the practice of ethnographic research, which prizes not moving ahead towards a goal, but rather sitting still: pausing to peer laterally at activities and relationships. Our pausing takes the form of a monthly clinical field note sharing group among MD/PhDs in the social sciences. Building on Pigg’s vexed attempts to infuse the ethnographic perspective into the field of global health, we consider the challenges and opportunities arising when ethnographer and health care practitioner are one and the same.

This article describes how our group has cultivated an environment for participants across the spectrum of training to develop intellectual community while negotiating the productive dissonances inherent in clinician-ethnographer subjectivity. Anthropologist Philippe Bourgois has worked at the intersection of biomedicine and critical medical anthropology for decades, training MD/PhD students to witness social suffering and structural violence in order to advocate for a critically engaged social medicine. When he initiated our clinical ethnography group five years ago, he envisioned dually trained scholars, ranging from first-year medical students to seasoned physicians, interrogating the clinical space through disciplined field note taking. Over the years, the group has evolved organically and taken on a range of meanings at different times for different members. For some, it functions as a therapeutic space to process the dehumanizing hierarchy of clinical training and reflexively question the unsettling, but often under-interrogated, aspects of socialization into the medical profession. For others, it allows for a granular unpacking of the interpersonal and structural dynamics unfolding within clinical spaces, leading to advocacy for change through the act of writing. Each month, a different set of pre-circulated field notes are considered for roughly thirty minutes each. The author provides a brief preface prior to opening the floor for group discussion, which commonly draws connections across different notes and draws together recurring themes emerging over time. Our conversations regularly encompass both the medical and anthropological dimensions of the data presented.

In this piece, we show how our group provides a generative space for transgressing disciplinary boundaries and experimenting with methods and practices that meld anthropology and clinical medicine. In describing the process, the participants, and their engagement with one another, this article probes the possibilities of opening space for clinical reflection, socialization, and mutual support for clinician-ethnographers who often find themselves betwixt and between. Abu-Lughod (1990) crystallized a key insight of feminist anthropology when she wrote that “we are always part of what we study and we always stand in definite relations to it” (27). We similarly unsettle the boundaries of anthropology’s identity as a discipline of the Self studying the Other and trouble the applied/theoretical divide by interrogating medicine while practicing it.

Mirroring the group itself, this article is a collective meditation structured around abbreviated vignettes adapted from field notes initially presented in our meetings. Our notes and reflections demonstrate how this collaborative engagement lays the foundation of both an applied medical anthropology and a theoretically engaged clinical practice.

Gatekeepers or Advocates? Seeing Structure

I saw Gerald, a 53-year-old man with schizoaffective disorder, post-traumatic stress disorder, and substance use disorder, in a community mental health clinic in Los Angeles County. Initially, he had trouble being around other people, who he believed were always talking about him and plotting to hurt him. He had been the victim of abuse as a child and assault as an adult. Since adolescence, he had heard voices telling him to kill himself, or to take drugs as he struggled to stay sober. He avoided crowded streets for fear of getting into an altercation and slept outdoors because he couldn’t tolerate crowded shelters.Gerald qualified for wrap-around services from a team including a psychiatrist (Ippolytos), a social worker, and housing and employment specialists. Over time, we found a medication regimen that reduced his symptoms and he got a bed in a transitional sober-living center. His symptoms improved and he became more socially interactive. But he struggled to find work, so he applied for public housing and social security insurance (SSI).

We proudly documented his improvement and progress toward his stated goals. We considered him a success story. But Gerald stopped showing up for appointments. After his case manager persuaded him to return to the clinic, he explained that his SSI application had been rejected because my clinical notes indicated he was getting better. Frustrated that we had not successfully facilitated what he considered the most important component of his care, he stopped attending the clinic. He told me: “I want you to know, I’m not getting better, and I never will get better! Don’t ever write that I’m getting better again!” He asked for an increase in his medications and emphasized how poorly he was doing. His care team met to discuss whether Gerald’s SSI application had been denied because of his documented improvement, whether he was malingering by asking his team to exaggerate his symptoms for the sake of SSI benefits, and how we could help him most effectively.

The specter of the “malingering” patient haunts settings in which poor people seek medical care. This is the patient who seems to be “gaming the system,” intentionally trying to come across as ill in order to obtain certain benefits, such as hospitalization, in order to escape sleeping on the streets, or to secure benefits such as SSI. These interactions generate suspicion, resentment and conflict, and interfere with therapeutic rapport. Clinicians often feel as if these patients are trying to fool them and wasting the scarce time and resources of an overburdened health care system. Once a patient’s story is scrutinized for inconsistencies, implausibilities, and deviation from familiar patterns, the task often becomes figuring out a way to speedily discharge or dispatch these patients who are seen as obstacles preventing the care of more deserving and authentic patients.

The clinical ethnography group promotes critical reflexivity that helps identify and articulate unspoken assumptions and dynamics that are part of everyday clinical work, prompting me to do the work of contextualizing clinic interactions in the world beyond the space of diagnosis and treatment. Structural changes over the last 40 years have rendered medical disability one of the most robust sources of public benefits for the indigent and the medicalization of suffering as one of the few remaining ways to secure public support in neoliberal America (Hansen, Bourgois, and Drucker 2014; Kalofonos 2019; Whittle et al. 2017). These perspectives illuminate the stakes of the interactions described above. The motivations of both clinicians as well as patients are shaped by structural factors that position physicians as gatekeepers of social welfare benefits. While American valorization of autonomy and denigration of dependence position the patient who seeks benefits as suspect (Fraser and Gordon 1994), these incidents can be reframed as opportunities to advocate for and collaborate with patients who are navigating systems often set up to frustrate and turn people away. An ethnographic lens can point the way towards clinical and policy alternatives that disrupt these dynamics, displacing the frustration and resentment from being directed towards the patient and instead channeling it towards changing an inequitable health and social welfare system.

Space for Reckoning: Complicity with Clinical Harm

As a fourth-year medical student in the surgical intensive care unit (SICU) at a Los Angeles County Hospital, only one patient was there almost as long as I was—Alice we called her. She came in bleeding from her tracheostomy, and we searched unsuccessfully for weeks to find the source. Despite her precarious health, she did not hesitate to express her disappointment in us during rounds and often waved to get our attention while we discussed her case. But her tracheostomy rendered her unable to speak, and the attending surgeons generally continued talking without pause, ignoring her attempts at communication. Her mental capacity was hard to understand or establish—her son signed all her consent forms because of her history of dementia and she would often stop interacting or communicating without warning. Eventually we consulted geriatrics to help manage her myriad chronic problems. The following day we read the geriatrics note with shock: they had discovered an explicit advance directive where she made clear she did not want further intubation or operations and would rather pass away peacefully at home than in a hospital despite her family’s push for further interventions. She hated hospitals. At this point she had been intubated and extubated many times to prevent her from suffocating on her own blood, making frequent trips to the operating room in the process. The geriatrics note also specifically asserted that the SICU did nothing wrong and was not negligent in its care for her because we were going by the consent of her son, who was aware of this advance directive. There was no discussion of policies or protocol implementation that could have prevented this.

For practicing clinicians, the imperative to “do something” is not only a moral one, but also a professional and ethical responsibility. We are obliged to act, to provide care for our patients, and simultaneously constrained by the institutional priorities and structural boundaries of the hospital. This moral imperative is conjoined to and acts in service of an imagined future where the patient is healthier, better resourced, and out of the hospital, and must be produced through ever shrinking time and resource shortages that clinicians face daily. These temporal logics—of efficiency and futurity—often foreclose an ethnographic present. They likewise create a very narrow framework for understanding and evaluating the effects of what we do in the moment. In the surgical ICU, this manifests in a drive towards life above all else. It is a metric by which we both judge our successes and dismiss the costs to our patients. When the alternative is death—as often follows critical illness or injury––the push towards survival often eclipses the tolls of getting there. Alice’s literal lack of voice in this vignette speaks to the lived powerlessness that all patients, but particularly those in the ICU, must live through during their hospital stay.

The practice of ethnography allows us to question these boundaries and to imagine alternative forms of care. By taking field notes, we begin to invite an ethnographic present into clinical practice, both doing and sitting with what we have done. The ritual of group ethnographic discussion provides both accountability and fosters community support. This practice forces a confrontation between a “fractured habitus” wherein our duty to clinical best practice meets an open analysis of what could be done. Or, even more simply, but of no lesser value, is the experience of acknowledging the ways we as clinicians harm our patients and participate in institutional violence. This is neither a practice of therapeutic absolution nor of true accountability, which would require our patients’ participation. Instead, it falls somewhere in the middle––a reckoning among peers who understand analytically and experientially what it means to work towards the health and well-being of our patients and at times, despite our best intentions, cause harms ranging from mundane medication side effects to more egregious medical errors. This situated knowledge—from both thinking and doing—is a unique offering that clinician anthropologists bring to the field of medical anthropology. It is often easy to view institutional frameworks of legitimacy and the individuals who propel them as abstractions or as flatly subservient agents of structural violence. Our embroiled, and complicit, positionality as acting clinicians enlivens our understanding of how people in positions of power come to reproduce institutional violence—or subvert it.

Butt of the Joke­­: Unpacking the (Un)Professional

Scrub-clad first-year medical students squeeze into a computer lab. Moments ago, we were studiously stooped over what our instructors referred to as “our bodies”­––one of the fourteen cadavers propped prostrate on stainless steel tables, frozen as if feigning an exaggerated response to the feeling of cold metal beneath them. Implicitly, we know their most valuable trait is that they no longer feel.

Now, in the computer lab, during a quick breakout session, we take turns practicing an abdominal ultrasound exam on each other. In the quick transition from working on the lifeless to the living, there can be no doubt that feeling fits in somewhere. The sticky blue gel squirted onto the stomach, the slow and methodical gliding of the probe, the nervous darting glances and awkward giggles of titillated nerds. The scene is uncanny in its starkly unsexy eroticism. “Gross Anatomy Lab” acquires another valence.


The exercise wraps with five minutes to spare. “What else can I tell you guys?” asks the ER attending physician teaching the session, scanning the room eagerly for interest. A hand creeps up in the back. “What kind of cases do you usually see?” “Oh, you name it, we see it,” he says with a proud smirk. “Let’s see, what can I show you?” He unholsters his phone and begins to scroll. Swipe. Long swipe. Pause. “Eh.” Long swipe. Suddenly, a pointed finger punctuates the search. “Check this out!”

Whipping the screen around, we see an anterior-posterior X-ray of a pelvis. We’re not meant to identify a fracture, but rather a radiolucent foreign object glowing in the middle of the frame.

“It’s a Maglite!” His exclamation is met with a swell of laughter as the implication sinks in. “He said he slipped and fell… They always do.”

Who are “they,” why are “we” laughing, and what does that teach “us”?

Similar to the way in which the previous vignette unpacks the “micro-physics of power” (Foucault 1990) operating in the surgical ICU setting, this reflection documents just one among many miniature rites of socialization through which our collective identity as physicians is forged during training. In his bawdy bid to impress eager students, the instructor in this vignette humiliated a person who became a patient who became the butt of a joke. His actions conveyed, more than simply an attempt at tasteless entertainment, a meaningful lesson to us future doctors. We are frequently admonished to honor as sacred the fact that our patients entrust us with their stories, bodies, and lives. What was learned in this moment, however, is that this precept is not upheld equally for all patients. What’s more, the ridicule of certain patients––particularly those who are already stigmatized––can function to craft community among (future) clinicians.

While William interpreted this scene as fundamentally homophobic, he experienced it as relatively banal. No one questioned the instructor, and class promptly adjourned. In the following days, he discussed his discomfort with a few friends, but put it behind him in service of chugging along through the curriculum; dwelling would do little to diminish the overflowing flashcard deck. Much like clinical practice, the demands of medical education propagate the ideology that sitting and thinking merely “drag confident, useful action down into a mire of doubt and criticism” (Pigg 127-28). Without the dedicated space of the group, and the associated impetus to write and reflect, he likely would have discarded his feelings, seeing them as orthogonal to his progression through school. By sharing his experience as a field note in the clinician-ethnographer group, however, he was able to more fully probe his unease. Not only did that processing provide a kind of healing, but it also exposed a dimension of medicine’s hidden curriculum (Hafferty 1998) and the norms and values inculcated in providers that shape clinical interactions and outcomes.

Conclusion

Pigg’s appeal to sit and think stems from the conviction that “ethnographic practice allows itself to pause in the eddies created by the forward momentum of global health activity” (132). Our MD/PhD field note sharing group fashions an eddy in the forward momentum of our clinical training and professional duties. Pausing to look carefully around, thereby taking a “step to the side of the problem-solving juggernaut,” enables us to recognize our embeddedness in systems that perpetuate harms we aim to ameliorate through our clinical practice and research. While our group lends a sorely needed space for analysis in the oftentimes corrosive and dehumanizing structures of medical practice, we recognize the limitations of our model––namely, that it does not fundamentally dismantle the forces that exert violence on our patients (133). Because our analyses remain close to our clinical observations, however, our group avoids abstracted intellectualization. Our aim in threading this needle is not to reify the moral authority of physicians by appending social theoretical justifications to our jurisdiction. On the contrary, one of the most salient themes to emerge from our group––borne out in the vignettes we shared and many we did not––is the relative powerlessness of individual clinicians in relationship to broader forces. To state this is not to abdicate responsibility; rather, we aim to leverage authority to spotlight systemic issues shaping our profession. While the individual clinician struggles against a rigid health system, a coalition of clinicians can work collectively to mobilize change. Indeed, that is one of the goals of our reflections and writings. We aim to lay the groundwork for a theoretically engaged clinical practice and an applied medical anthropology. Our hope with this piece is to offer a replicable pedagogical model that could be employed both in other MD/PhD social science training programs––which are rare but becoming less so––as well as with other clinicians who would benefit from the ritual of having a dedicated space for sitting, thinking, and advocating for more humane medical practice.


William Schlesinger is an MD/PhD candidate in the David Geffen School of Medicine and UCLA Department of Anthropology. He received his BA in Women’s, Gender, and Sexuality Studies from Yale University in 2013. Will’s dissertation research centers on pre-exposure prophylaxis to HIV (PrEP), a promising yet controversial new technology in the biomedical HIV prevention toolkit. At the intersection of critical medical anthropology and sexuality studies, Will’s research questions what the failure of PrEP to bring about a meaningful overall reduction in rates of HIV in the United States reveals about the biomedical production and sociopolitical governance of risky sexual subjectivities. His work has been funded by the David Geffen Medical Scholarship and the Fulbright Program (Germany). 

Emily Jones is an MD/PhD student in the David Geffen School of Medicine and UCLA Department of Anthropology. She received her BA in Biology from the University of Pennsylvania in 2012. Through ethnographic research in a Southern California public hospital system, Emily’s dissertation research investigates hospital-based violence intervention programs and their responses to gender violence. Drawing on feminist anthropology of violence and critical medical anthropology, her research examines the entanglements of care and criminalization in the medical encounter. Her work has been funded by the David Geffen Medical Scholarship and the Fulbright Program (Nepal).

Liza Buchbinder is an anthropologist and internist within the field of social medicine, conducting research and providing care to under-resourced populations. After college, Liza joined the Peace Corps in Togo, West Africa, where she lived in a rural village and forged a lifelong commitment to the community. After two years of service, Liza entered medical school at UC Berkeley-UCSF Joint Medical Program. During medical training, she completed her PhD in medical anthropology and returned to the Togolese village, traveling across West Africa to track the community’s diaspora of adolescent labor migrants. Her work is now the basis for a book manuscript on the limits of naming violence against adolescent domestic servants through the rights discourse on child trafficking. Dr. Buchbinder’s research focuses on critical human rights & development and the relationship between habitat destruction and emerging infectious diseases. An embroiled clinician and anthropologist working in a diverse array of settings, she is also working on an ethnography that explores physician-patient subjectivity and burnout.

Ippolytos Kalofonos is a practicing psychiatrist and a medical anthropologist. He is an Assistant Professor in the UCLA Center for Social Medicine and the Humanities the UCLA International Institute as well as the Department of Psychiatry at the West Los Angeles Veterans Administration Medical Center (WLA VAMC). He is currently conducting clinical and ethnographic research with Veterans experiencing homelessness and psychosis. His book entitled “All I Eat is Medicine:” Going Hungry in Mozambique’s AIDS Economy, an ethnographic study of the early days of the AIDS treatment scale-up, is due out in June 2021 the University of California Press Series in Public Anthropology.


Acknowledgements

Research towards this publication was supported by NIH NIGMS Training Grant GM008042.

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