Month: April 2015

Instruction, uncertainty, and meta-pragmatic repairing in medical education

At some point in their career, people who are moving towards being acknowledged as Mds enter what is known there as a “clerkship” where they will be, for the first time, authorized to care for a patient, under the gaze of doctors and nurses with various experiences and authority. So what happens during various stages within this clerkship?

When I teach Lave and Wenger’s (1991) altogether brief introduction to “legitimate peripheral participation,” I do not teach it as a theory of learning but as a model for social structuring in Lévi-Strauss’s sense (1962 [1952]).  But Lévi-Strauss was seeking to model a moment in the organization of a people while Lave, in a major development, seeks to model movement through social structurings when everyone and everything involved in the movement constitute this structuring as it will be available for the future.  By an implication that remains to be developed, Lave also opened the way for a modeling of culture change.

In brief, for those who do not know the background to this approach, Lave asks us to move from imagining participation in any position as dependent on earlier learning to imagining this participation itself as producing some personal learning.  Thereby she argues that a personal movement into a position is dependent on mechanisms other than learning (or socialization/enculturation).  These are the mechanisms that make the initial positioning “legitimate” and authorize the acknowledgment of movement.  Wondering about legitimacy and authorization leads to searches for the interactional, political forces that establish legitimate participation, authorize certain forms of leaning, and thus of course, refuse participation, does not acknowledge learning, etc.

Much of this formulation sprung from an interest in apprenticeships and it has been found to be a very useful way of approaching traditional problems generally phrased as matters of socialization into positions—for example the movement that transforms a medical student into a physician.  But there is still a need for more exact accounts of movements that might help us develop further properties of the model.

Given all this, I am thankful to Dr. Yan-Di Chang and her dissertation about a moment in the education of physicians in Taiwan.  At some point in their career, people who are moving towards being acknowledged as Mds enter what is known there as a “clerkship” where they will be, for the first time, authorized to care for a patient, under the gaze of doctors and nurses with various experiences and authority.  So what happens during various stages within this clerkship?

Dr. Chang has a good sense of what makes ethnography worthwhile and also infuriating: there is a long chapter in the dissertation about orientation day when the new clerks are told, among many, many, many things … where the bathrooms are!  Do we really need this level of detail?  Yes, if we are not going to gloss over the difficulties involved in movement across the virtual spaces of social structure.  Yes, if we are going to highlight how much work it is not only to be a “peripheral” participant but also to be the fuller participants who have the responsibility to teach what they can never be quite sure the students do not know.  The people who plan the orientation, and those who actually perform it, are faced with the “instruction manual” problem discussed by Garfinkel (2002: Chapter 6): we, the instructors, know that they, the inductees, will need instruction, we can imagine what they will need, but we cannot be sure.  So the actual moment of interaction is difficult for all, and open for much deliberation, including self-reflective deliberation by the instructors about how to do it the next time.

Dr. Chang then proceeds through several other moments when all these matters become salient.  There is the encounter with one’s first patient and how to balance his care with one’s personal life while knowing that one might make mistakes, while knowing that one should ask for advice but not necessarily from whom, while being told that one has made a mistake one had not noticed, and all the while knowing that a person well-being, if not life, is at stake.  Moving into the position of “physician” re-arranges a small crowd!

Dr. Chang then takes us into a more detailed, almost conversational analytic, look at another salient moment in the life of the whole polity: the senior doctor’s rounds when a few students (including both beginners and some more advanced) have to present a case to the doctor, in the presence of fellow students, as well as other more seasoned personnel.  Everyone is participating legitimately.  The hierarchies are multiply indexed discursively and practically, particularly by the balance between questioning, proposing answers, redirecting and sometimes actual instructing.  But the detail of the conversation reveal again and again that noone is following a script.  Everyone has to handle multiple uncertainties that cannot be resolved simply by following rules or applying knowledge.

Everyone is indeed in movement, re-constituting hierarchies which, as Dr. Chang illustrates in a later chapter are themselves subject to meta-pragmatic deliberation among the most legitimate and fullest of participants.  There the questions keep arising: how do we best prepare future doctors? Could we produce “happy doctors”?  These are the conversations that must have guided medical education as it shifted though various models in the history of Taiwan.  And they are the conversations that will participate in transforming it.

The detail in Dr. Chang’s dissertation made me think in a somewhat inchoate fashion about the interactional consequences of the instruction manual problem.  At any moment in an asymmetrical interaction (and perhaps all interactions are) one must wonder what it is that the other person does (not) know.  But, of course, this wonder cannot be settled in any definite fashion.  In any event there would be no time.  Conversational analysis has clearly demonstrated the extent of “repairs” in face to face interaction.  It is as if all conversation occurred in what, to play on Vigotsky, one might call a zone of “proximal ignorance” where all participants have to play with first, what they can make each other pass as knowing (that is they authorize each other’s participation), and, second, what some must instruct others who have exhibited allowable ignorance at this moment and about this (that is, at other moments, a display of ignorance about this might lead to status degradation).

What Dr. Chang, building on other work, illustrates again is that this is not simply a moment to moment matter that must proceed under meta-pragmatic discursive awareness (as classical theories of cultural learning have assumed).  It is also a process taking place in longer sequences where meta-pragmatic discursive awareness is very much involved.  In the day to day matter of moving students into the position of physicians experiential difficulties abound: a future doctor must find out where the bathroom are, must face her first patient along with experienced nurses, must explain her actions to other doctors.  At every moment further deliberations must occur to develop, repair, redirect what has happened before.  And these deliberations may, or may not, make moving medical students into physicians a smoother process for all involved.

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What some anthropologists who reply did, on a Thursday in February 2015

In the first few minutes of the conference, Ray McDermott put it this way: “when someone says stupid or mean things about kids, I want them to know I will be at their door the next day.” This, he said, is “reply anthropology.” Replace “kid” with “mothers,” “haitian farmers,” or whomever is talked about in stupid ways, and variations on this presentation of self were made.

In my last post, I argued that “Applied Anthropology” is, to all of us anthropologists, a total social fact, a “thing”—both in Mauss’s and Latour’s senses.

But that does not tell us much about the actual practices of anthropologists who find themselves caught by this thing facted in a long history. So, today, I wonder about what was done, one Thursday in February 2015, in New York City, in a classroom of a Columbia building. Then and there, a bunch of anthropologists told each other what they do. What did they say?

In the first few minutes of the conference, Ray McDermott put it this way: “when someone says stupid or mean things about kids, I want them to know I will be at their door the next day.” This, he said, is “reply anthropology.” Replace “kid” with “mothers,” “haitian farmers,” or whomever is talked about in stupid ways, and variations on this presentation of self were made. Some argued that McDermott was simply saying, colorfully, what may have been the presentation of anthropology by Boas in the United States, Mauss in France, Malinowski in England, and many others: when someone says stupid, or at least mis-informed things, about human beings, anthropologists will notice, shudder, bring out obscure, and often actively obscured, practices through painstaking observation. They argue among themselves on how to interpret the observation and what observations to conduct next. Then anthropologists reply. And now, they examine the replies to their replies as others continue to mis-represent their work and, more significantly, the work of the people about whom the conversations are held.

On that Thursday, the replies, and the replies to the replies, took many forms. Those who replied did it from the variety of positions in which they find themselves given the vicissitudes of their careers. Paige West talked to us about the work she has been conducting, somewhat under the academic radar, with colleagues in Papua New Guinea culminating with her “co-founding … the PNG Institute of Biological Research, a small NGO dedicated to building academic opportunities for research in PNG for Papua New Guineans.” Terrence D’Altroy and Brian Boyd talked about the extra-archaeological work needed to allow for the doing of archaeology in complex contemporary conditions. Scott Freeman told us about Haitian farmers have been doing. And he showed how this work keeps being obscured by the constraints under which local NGOs must operate. I’d say that West, D’Altroy, Boyd, Freeman, Oliveira, Baines, Hudson, that is “we,” anthropologists, were replying to what others had been saying. We asked our others, mostly from outside anthropology, to look further at the people whom they want to help, and particularly to consider the exuberance of the people’s activity around professional or state-sponsored activity. That is, to the extent that there we were saying something useful to our professional audiences, we were saying it because of what we have learned about the social conditions of all human activity, including professional activity. And, by analyzing the conditions of our work reflexively, we were also developing anthropological theory.

Jean Lave generalized all this by telling of her experience building an institution within another institution: a Ph.D. program in Social and Culture Studies in Education within a School of Education within a university priding itself on its international status as a research university. Her experience as an anthropologist willing to build new institutions within old ones is one the participants in the conference recognized: as conversations with colleagues proceed, we are told either that we are not anthropological enough (next statements by anthropologists in research positions) or that we are too anthropological (next statements by colleagues in the professional school).

I hope that the conference will help us turn the tables: 1) replying to those whose work obscures human activity is what anthropology does, and 2) replying effectively requires more anthropology.

First, as anthropologists, we go where people work and learn about it through that work. These days, many people work in and around (N)GOs particularly when these involve dangerous matters in their lives. How they work, and how this work is organized, is a core issue in anthropology. As Lave reminded us, quoting Gramsci, we must assume that, among the people there are “organic intellectuals,” and thus complex organizational processes producing their position, its local authority and discursive forms. Giving new accounts of all these complex processes, including the relationship among all intellectuals (organic or not), is a profoundly theoretical task.

Second. Facing the ethno-methodology of everyday work in professional settings requires more rather than less anthropology. Professional activity of the non-organic kind, that is the activity of professors and other professionals, whether working with/in or with/out (N)GOs, is also everyday activity that requires the kind of practical intelligence which allows all involved to recognize that this (that we are doing or see being done) is just what “we do.” But all work on such activity, in any setting, including the work of “scientists” (Kaplan on “logic-in-use” 1964; Latour on science 1987) and other licensed professionals (Wieder 1974), has demonstrated that the formal problematics of the activity (as it may be stated in mission statements, flow charts, program descriptions, etc.) is but an aspect of the activity itself that can easily obscure other aspects of the practice, whether the practioners are “aware” or not of the gap between what we are known as doing and what we just did. Bringing out the possibly contradictory constraints of that gap is what anthropology offers. Workers in schools, hospitals, development agencies, government offices, etc. should require that more anthropology, at its most disciplined.

References
Kaplan, Abraham
1964 The conduct of inquiry: Methodology for behavioral science. Scranton, PA: Chandler Publishing Co.
Latour, Bruno
1987 Science in action. Cambridge, MA: Harvard University Press.

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