Why don't we take a look at the patient? : an anthropological analysis of how doctors become doctors

The present thesis is a study of how doctors learn to make clinical decisions; decisions about diagnosis and therapy of the individual patient in the context of the clinic. It is based on ethnographic fieldwork and anthropological analysis carried out in 2006-2009. The key informants are nine doctors who go through internship and the empirical field is the wards and clinics of regional hospitals, university hospitals and general practice. The thesis is in three parts. The first part is the design of the study. This includes reviews of clinical reasoning (Chapter 1) and medical education (Chapter 2); the conceptualization of clinical decision-making (Chapters 3-4) and the development of a theoretical framework of learning (Chapter 5); a presentation of ethnographic fieldwork as methodological approach with special considerations of auto-ethnography (Chapters 6-7); and a description of the process of analysis (Chapter 8). The second part is the findings of the study. This is made up by four chapters, which each describe one of four processes of construction in decision-making and how the interns learn to participate in these constructions. Each of these chapters is followed by a chapter, which discuss conditions of clinical work that facilitate this learning. Chapter 9 describes the construction of relations, and Chapter 10 discusses the dynamics of clinical space as the context for these relations. Chapter 11 describes the construction of decisions, and Chapter 12 discusses the relation between these decisions and the norms and ideals for clinical reasoning, including evidence-based medicine. Chapter 13 describes the construction of information, and Chapter 14 discusses the clinical language which interns must learn to use in communication. Chapter 15 describes the construction of action, and Chapter 16 discusses the moral aspects of clinical practice and how the local moral economy guide clinical practice. The interns are found to learn the practice of participating in complex interactional processes of decision making. Through this process they develop an identity as professional. They learn to adapt to local conditions for clinical work. They learn to search for problems which are simple and acute, to solve these through technical rapid action, and to express their reasoning through a specialized clinical language in line with local spectrums of normality. This is described as the per astra pathway. In this extensive learning process, they come to embody the norms and traditions of the various clinical settings. This makes them effective in clinical practice, but also generates a special blindness in the clinical gaze. When uncertainty or wonder arise in clinical encounters, they have little experience in deliberate reflection and creative interaction, and they learn instead to revert to the general decision pathway above. Parallel to this empirical track of the project is a search for, and development of, a theoretical perspective able to describe clinical decision-making in practice. This is presented in the third part of the thesis and discussed in relation to the empirical findings. Chapter 17 presents the synthesis of the theoretical track of the project in the Prometheus perspective and the Clinic Action CycIe. Chapter 18 explores how same of the interns’ actions may be reinterpreted as a potential for learning in the light of the new perspective. Chapter 19 suggests how it may serve as a framework for discussion and development of decision-making in the context of medical education and clinical practice. The new perspective differs from established conceptualizations of clinical reasoning, and epistemological groundwork and continued research of clinical practice is needed to unfold the potential of this new perspective. Chapter 20 presents an integrated summary of the empirical and the theoretical track of the project

Where does a diagnosis come from: Questions about the local context in diagnostic reasoning

Medical anthropologists have studied a great variety of phenomena in medicine and health care across the globe. However, the field of acute medical conditions have received less attention from social sciences. In medicine, this is the field that provides the key inspiration for studies on clinical decision-making. It is the acute and dangerous diseases that receive the greatest attention and it is the medical specialities dealing with these conditions that receive the highest acclaim within the profession. In the article two cases from departments of internal medicine and surgery are presented that demonstrate that the diagnostic process is not free from influence from the clinical setting and social context more generally, but is rather dependent on it. Doctors are seen to use in their diagnostic work a combination of what is here called a local spectrum of normality, a search for available fast-track action pathways and a locally negotiated hierarchy of different sources of information. The implication of the findings is discussed against prevailing notions of diagnostic reasoning in medicine. The article is a preliminary exploration of issues that warrant more attention in future studies

Den praktiserende læge - eksistentiel søgen efter professionel identitet

I gamle dage kunne enhver læge blive praktiserende læge. I løbet af de sidste 50 år har de prakti-serende læger skabt et speciale  – almen medicin – på linie med andre lægelige specialer. Men  i den samme periode er det blevet tiltagende vanskeligt at definere, hvad faget er – og hvad der  udgør den praktiserende læges roller  og identitet. I denne artikel undersøges, hvordan et kur‑ sus i kommunikation og eksistentialisme danner rammen om konstruktionen af en søgen efter  professionel identitet. Ved hjælp af narrativ teori indkredses flere mulige fortællinger, der både  relaterer sig til den enkelte læges personlige situation og fagets samfundsmæssige kontekst: et  personligt eksistentielt narrativ, et relationelt narrativ og et somatisk narrativ

Sygdommens rum

Antropologien har menneskers praksis i fysiske og sociale rum som en integreret del af sit forskningsprojekt (Bourdieu, 2000; Ingold, 2000b). Et etnografisk feltar- bejde er en omfattende affære, hvor en principielt endeløs række af forskellige aspekter af menneskelivets mange aspekter analyseres og fortolkes – boformer og livsformer, kommunikation og handel, de fysiske objekter og sprogets kategorier, slægtskaber og fællesskaber, udveksling og konflikt, status og økonomi etc.Men medicinske antropologer har beskrevet – og kritiseret - at antropologien traditionelt har sat grænsen for udforskningen af mennesket ved kroppens over- flade og overladt menneskets biologi og patologi til andre fag; mens medicinen nok har set ydre faktorer som betydningsfulde for sygdom, men fortsat som ad- skilte fra ”den egentlige” sygdom (Baer, Singer & Susser, 2003). Disse skel er nu ikke blot til diskussion, de bliver direkte udfordret og gjort til genstand for un- dersøgelse. Det er denne udfordring, som vi ønsker at give en platform med dette temanummer af Sygdom & Samfund

Tidsskrift for Forskning i Sygdom og Samfund – 10 år i et krydsfelt

Tidsskrift for Forskning i Sygdom og Samfund udkom første gang i begyndelsen af 2005, men var klar til trykning nogle måneder før, så derfor stod der “2004” på forsiden. Med det nummer du nu har i hånden fejrer tidsskriftet derfor sin 10 års fødselsdag, og som ved alle runde fødselsdage kalder det på festtaler, refleksioner og status over tiden som er gået og måske en morsom anekdote eller to om fødselaren.Men inden dette bliver ren festtale og løssluppen morskab, har vi i redaktionen også lyst til at bruge dette som en mulighed for lidt analytisk eftertanke. På den ene side ønsker vi at diskutere om tidsskriftet bevæger sig i den retning, som vi oprindelig ønskede, og om vi har opnået noget at det, som vi ville opnå. På den anden side er tidsskriftet del af større bevægelser i sundheds- og samfundsvidenskab, og det kan være nyttigt at overveje i hvilket omfang, tidsskriftet bliver et billede på disse bevægelser. Det er altså både tidsskriftet som handlende subjekt og som objekt for påvirkning udefra, som vi har lyst til at bruge lidt tid på

Storytelling in Focus Group Discussions: A Narrative Approach to Phenomena With Temporal Dimensions in Medical Education Research

People can express experiences, opinions, and perspectives in stories. In a story, the experiences can be relived and discovered independently of time and place. In medical education, it is a fundamental premise that time progresses, and it is within this temporal space that students learn, acquire competencies, and form identity. It is also within this space that much qualitative research is conducted. However, qualitative examinations at one point in time will result in only a snapshot of a dynamic phenomenon that evolves over time. Existing approaches to qualitative research are often inadequate to accommodate this dynamic development without applying a time- and cost-consuming design such as longitudinal investigations. The purpose of this paper is to present storytelling as a useful research approach to include temporal dimensions in cross-sectional qualitative data collection. We describe the background for the approach, argue for its use, and provide a practical example of storytelling with the use of a fictional character in online focus group discussions to explore a dynamic phenomenon in medical education research. Overall, storytelling offers a narrative approach to qualitative research that allows the researcher to explore phenomena across time and space. The approach has the advantage that it can be used in different formats both oral and written, digital or physical.</p

Sygdommens etik – en introduktion

Vi lever i en brydningstid, hvor de etiske aspekter af sundhedsarbejdet bliver til- tagende synlige i det daglige kliniske arbejde. De store bevægelser i verdenssam- fundets udvikling med pandemier, krige og flygtningsstrømme – og de markante demografiske ændringer med aldrende befolkninger og centraliseringer, der ska- ber supersygehuse såvel som hospitalstomme udkantsområder – både viser og konsoliderer grundlæggende etiske spørgsmål om, hvad mennesker opfatter som godt, sandt, rigtigt og forkert i forhold til lidelse. Tidens mange og store problemer anskues typisk som determinanter for fremtidens sygdom og lidelse (Baer, Singer &amp; Susser, 2003), og vi har naturligt nok en trang til at finde løsninger på denne li- delse på det strukturelle og samfundsmæssige plan. Alligevel er det i patienternes levede liv og i deres konkrete møder med sundhedsvæsenets aktører, at lidelsen bliver synlig, fortalt, fortolket, håndteret og løst. Samfundets værdier, vurderin- ger og prioriteringer træder for alvor frem her og bliver til små etiske praksisser i hverdagen og i klinikken. Det er disse praksisser – der forholder sig til det store i det små – som vi ønsker at sætte fokus på med dette temanummer

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

Background - How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made. Method - The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors. Results - Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing. Conclusion - Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing

Sykdommens Etikk – en fortsettelse

Velkommen til dette temanummeret om Sykdommens Etikk; det andre numme- ret med denne tittelen og en direkte fortsettelse av første nummeret som kom ut våren 2022. På de følgende sider fortsetter vi undersøkelsen av det feltet og den problemstillingen som ble satt opp i det første temanummeret. Denne teksten blir derved en fortsettelse i tillegg til å være en introduksjon. Det gjelder også i høy grad for artiklene – av Lau &amp; Møllebæk, Thoresen &amp; Rugseth, og Andersen &amp; Of- fersen – som kan sees som en fordypelse i en del av det større landskapet som ble skissert i det forrige nummeret