Clinical experience : an ethnography of medical education

This thesis reports an ethnographic study of undergraduate nodical students at Edinburgh University, in their first year of clinical studies. It explores various aspects of their 'clinical experience' in the course of that year. The thesis is organized in four parts. Part I provides the context for the research. The conduct of the study is reported, and the methods used (participant observation, interviews and self-administered questionnaire) are discussed. The medical school, the undergraduate curriculum and the work of the fourth (first clinical) year are also outlined. Part II examines two major concepts - 'student culture' and 'professional segmentation'. The variety of medical and educational experiences that students encounter, and the students' understandings of segmentation within the medical school are examined. This part of the thesis also explores how students use their understanding of such diversity in organizing their own careers in the medical school. The argument is also illustrated with case studies of individual clinical attachments. Part III is focused on the social Interaction of clinical teaching - between doctors, students and patients. The management of clinical information in such encounters is discussed. The argument proceeds with a consideration of theconditions for the successful accomplishment of bedside teaching, and of contingencies which can undermine such accomplishment. Part IV develops the analysis begun in Parts II and III. The management of medical knowledge is analysed further: the 'classic case', 'clinical experience' and clinicians' appeals to indeterminate knowledge are documented. These topics are linked with the theme of Part II, as it is argued that divergencies in personal knowledge are grounded in processes of segmentation in the medical profession and the medical school. Thus the themes of 'professional segmentation' and 'clinical experience' are reunited in the concluding section of the thesis

Ethnographic writing, the Avant-Garde and a failure of nerve

The paper reminds us that there has been a long history of mutual influence between ethnography and aesthetics. There is nothing new or recent in textual or graphic experimentation inspired by anthropological or sociological fieldwork. We have not had to wait for the so-called crisis of representation to acknowledge this. Anthropology was among the direct sources and inspirations for modernist aesthetics and textual practice. I go on to suggest that too many contemporary forms of textual experimentation are in fact lacking in truly experimental, avant-garde, force. We need collectively to revisit the values and practices of modernism. I suggest that too many contemporary texts display sentimental realism, a preoccupation with feelings and personal experiences, grounded in realist forms of biographical or autobiographical writing. This represents, I shall suggest, a collective failure of nerve. I call for more disciplined forms of experimentation that are more relevant to a modernist sensibility as well as more faithfully ethnographic

Consciousness in scientific and folk psychology

The intentional properties and subjective qualities of conscious states pose special problems for physicalism. Yet 'consciousness' is a term of the vernacular that picks out such a heterogeneous group of phenomena that it will not be a good explanandum for science. This thesis adopted the position that we are licensed to theorize about the phenomena of consciousness, provided we are careful to dump all excess folk-psychological baggage surrounding the term. It was argued that the purposes and goals of folk psychology differ considerably from those of scientific psychology, for folk psychology is first and foremost a craft. Cognitive psychology is bound to the analytical strategy by way of functionalism. Various forms of functionalism were investigated, and two non­ mutually exclusive versions were favoured: homuncular functionalism and microfunctionalism. This led to the view that nature is multi-levelled, and therefore that functionalism may be better known as structural-functional theory. S-F theory should seek to explain the processes and structures of the mind­ brain, rather than attempt to find the states posited by folk psychology within the cognitive system. Traditional cognitive models view the mind as a highly structured system of semi-autonomous processors under the monitoring and guidance of a central executive. But this thesis argued that to postulate a 'consciousness module', while a natural extension of functionalist 'boxology', is merely to pander to our folk-psychological intuitions of the will or 'inner self'. Some of the 'new wave' of cognitive models -those that do not posit an executive -were reviewed. Phenomenal consciousness is the one major stumbling block for physicalist theories. Although this thesis agreed that qualia do not exist, it was evident that no theory has yet provided a bridge across the explanatory gap between third-person science and first-person phenomenology over which sceptics feel safe to cross. Nevertheless, it was argued that Dennett's (1991a) latest theory, with its intelligent use of metaphors and analogies, is one of the most promising steps in the right direction. Finally, it was argued throughout that an interdisciplinary approach is crucial if science is to uncover the mysteries of consciousness

Ethnography and craft knowledge

The paper has twin themes: the creative work of ethnographic interpretation, and the ethnographic interpretation of creative work. Illustrated with reference to recent and current fieldwork on craft, dance, and opera, it suggests some ways in which the ethnographer might creatively engage with her or his chosen fields. It criticizes the current view of “grounded theory,” which is found to be far too procedurally driven, in favor of more creative explorations of data

The surveillance of cellular scientists' practice

We discuss a set of practices surrounding the creation of Good Manufacturing Practice (GMP) performed within a cell laboratory. This process exemplifies a wider imperative to render visible the work of laboratory science. The creation of visibly accountable practices in turn reflects and reinforces the wider trend towards standardisation of cell practice. Standards themselves have thus become some of the artefacts created in laboratories, biobanks and other sites of biomedical work. Such processes of visibility and accountability translate the local, craft practices of laboratory work – often tacitly performed and transmitted – into explicit forms of knowledge production and regulation. Where once, however, laboratory work depended to a large degree on trust, newer modes of regulation impose new layers of mutual surveillance. Visibility is enhanced through technologies of inspection and surveillance, by increased volumes of self-documentation and by the imposition of regulatory protocols. Together these transform what was once implicit in the working practices of trusted professionals into explicitly accountable practices. Therefore the achievement of GMP accreditation is one example of the current imperative towards reflexive-accountability where new trans(national) monitoring technologies create new regimes of surveillance in biomedical science

Kinscapes, timescapes and genescapes: families living with genetic risk

This article synthesises recent research examining how families live with genetic risk and the processes of genetic decision-making and disclosure among family members who have been or are at risk of transmitting a familial genetic condition. Its aim is to generate substantive theory that can inform our understanding of the interactional processes at work in the distribution of mutual knowledge and awareness of genetic risk in families. The article is structured around three interrelated concepts. Kinscape refers to the constellation of relations and relatedness that are recognised practically; timescape to the multiple temporal frames of social relations and their transformation and genescape to the constellation of knowledge, belief and practice surrounding genetic inheritance. All three concepts are simultaneously natural and cultural. Their intersections create the conditions of kinship and genetics

The moral and sentimental work of the clinic: the case of genetic syndromes

This paper reports on the genetics clinic and examines the wider functions it provides for parents who have a child with learning disabilities that may be associated with an underlying genetic cause. It derives from an ethnographic study of one clinical genetics team within a UK clinical genetics service and their clinical caseload, specifically their cases of genetic syndromes associated with dysmorphology, a speciality within clinical genetics. Dysmorphology is the medical study of abnormal forms in the human and is concerned with the identification and classification of a variety of congenital malformations. Our analysis of the clinical consultations and subsequent interviews with parents indicate that obtaining a genetic diagnosis and classification of their child’s problems was not the sole function of these consultations. In addition, the clinic provides parents with moral absolution from having ‘caused’ their child’s problems and is an important site for the sentimental and celebratory focus on the child. Thus, the role of the clinical genetics service is not merely to assemble a diagnosis from the available information and to provide a source of expert opinion on the causes of the condition, but to provide reassurance to parents who might otherwise blame themselves (or be blamed by others) for their child’s condition. An important aspect of these consultations was the sentimental work of repairing the child, providing a sphere in which the development and behaviour of the child is discussed in favourable terms, and given assurances of ‘normal’ parenting and family life, often in marked contrast to their experience in the wider public world. Thus, the work of establishing diagnostic categories also allows important moral and sentimental work to be accomplished within the clinic

Closing the regulatory regress: GMP accreditation in stem cell laboratories

Contemporary biomedical research is conducted amidst regimes of national and transnational regulation. Regulation, like rules generally, cannot specify all the practicalities of their application. Regulations for biomedical research impose considerable constraints on laboratories and others. In principle, there is a never-ending regress whereby scientists have to provide increasingly more guarantees that protocols have been followed, standards reached and maintained, and rules adhered to. In practice, regulatory regress is not the actual outcome, as actors find ways of establishing closure for all practical purposes. Based on ethnographic case studies of two sites of biomedical work – the UK Stem Cell Bank and an anonymous laboratory working with primary human foetal material – this article documents the possibility of regulatory regress and strategies aimed at its closure