Monday, 12 March 2012

A Review of Ethnography Literature concerned with Medical Education and Obstetrics

Working on context and history the following review attempts to discuss what's there and what's missing - in order that I may find a place for myself in the vast space of Anthropology of Pregnancy... 
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 ‘Now for the sense of ‘context’. Most generally it is a name for a whole cluster of events that recur together – including the required conditions as well as whatever we may pick out as cause and effect.’ (Richards 1936)

    This review of ethnographic and theoretical literature relating to the learning of obstetrics and medicine begins with a discussion of context, or more specifically a theory of contexts. I refer here to the practice of Articulation (Grossberg 1992) – where the construction of one set of relations comes out of another. Ethnography of pregnancy in Chiapas should be revealed as montage, interrelating contexts that result from social theory and cultural practice rubbing against one another (as proposed by Taussig 1992). Wanting to find out about the actual experience of pregnant women must include a focus on the knowledge, power and practices that inhabit their world. ‘Articulations are never simple and singular; they cannot be extracted out of the interlocking context in which they are possible’ (Grossberg 1992). In this way I wish to take account of obstetrical medicine as cultural practice, as it is reflected onto a specific society via the pregnant body. It will become clear from my review of ethnography centred around medical education that medicine as an all-encompassing cultural practice outside of a UK/US context, is an aspect that has been somewhat neglected.

    Grossberg advocates that to understand a practice one must historically and theoretically (re)-construct it context (1992). In doing so such (re)-constructing should inevitably lead to the processes of learning (Lave and Wenger 1991). For this reason I have also included literature that analyses the historical construction of medicine and anatomy, without which a present day context would not exist.  In the course of unpicking existing ethnography of medical learning (or any kind of learning to be in the world) one is instantly presented with multilayered dispositions. Evans (2006) explains these dispositions as an embodied understanding of a particular way of being amongst others. Relating her analysis of social learning and violence to the work of Lave and Wenger (1991) and their theory of legitimate peripheral participation Evans argues for the recognition of emotion in the learning process. In doing so she highlights the importance of the varying and tacit things that contribute to the practice of learning. Echoing Lave and Wenger’s sentiment that learning is a cultural context that is best analysed outside of an institutional context Evans’ discussion in this paper is useful for beginning to think about learning as socially constructed practices.

   A substantial amount of ethnographic work exists in regards to traditional midwifery practice and apprenticeship in Mexico (see Jordan 1993; Sesia 1996; DavisFloyd 2001; Tinoco-Ojanguren, Glantz et al. 2008; Mills and Davis-Floyd 2009; Smid, Campero et al. 2010). The learning experience and development of the medical profession in Mexico has come under little scrutiny in existing ethnography. An anthropological approach to medical education should focus on the cultural conditions of practices, what is being learnt and then how this translates into practice. The medical student understood as apprentice in a specific community of learning provides an appropriate space for this to happen. The year of social service that a Mexican student must complete at the end of their degree – where they are often sent to rural or heavily oversubscribed urban clinics demonstrates the ultimate passage of apprenticeship and presents the opportunity of an ethnographic understanding of interrelation between medical/traditional practices [1].

Historical Analysis and ethnography of Medical learning

‘...the body is simultaneously a physical and symbolic artefact,..both naturally and culturally produced, and...securely anchored in a particular historical moment...[Yet] we take scientific discourse about human biology to be not simply a narrative but a universal truth...we assume that it applies anywhere at any time and transcends time and place’ (Lock 1993)

   In medical terms the specific historical anchor of the body that Lock is referring to can be found in the development of anatomical dissection and pathology – the emergence of the medical gaze. The anatomical approach was based on the assumption that the more one knew of structure, the better one understood of function (Sinclair 1997:44). By stripping away the layers of the human body its different functions were exposed and translated into fact by prominent physicians of that time. Social and historical analysis of anatomy practices as knowledge creation tends to be based in the Foucauldian assertion that: ‘The gaze plunges into the space that it has given itself the task of traversing...In anatomo-clinical experience, the medical eye must see the illness spread before is the body itself that has become ill’ (2003:166-167).  This anatomo-clinical experience of the medical gaze is a crucial historical juncture that denotes a shift in relationship between physician and patient, ownership of illness and diagnosis becomes that of the physician. From what they are able to see and feel, which must conform to what already exists in text, the physician is now expert of the body that is somehow detached from the subjectivity of the patient.

Anatomical theatre, University of Leiden 1596 online source: Wikipedia

   The practice in anatomical theatres (16th and 17th Century), for apprentice physicians was one of observation, of master refereeing from text to body (as opposed to creating text from the body present). The transmission of personally acquired experience to publicly available knowledge is further challenged via the classical artistic style of the period that depicted the dissected body parts and the events themselves (excellent analysis of anatomical art history can be found in: Martin 1989; Sinclair 1997; Massey 2005). Depictions of dissected bodies as artist impressions served to transmit tacit knowledge as concrete medical fact as soon as it appeared in print. This is particularly poignant in regards to the historical construction of the female body, reproductive organs and the pathologizing of pregnancy and birth. During the eighteenth century the publication of two highly regarded obstetric atlases contributed substantially to the epistemological reformulation of childbirth as a medical rather than domestic concern. ‘Stark, brutal and fetishistically naturalistic, these eighteen-century obstetric images medicalized and pathologized childbirth in an unprecedented way (Massey 2005). By pathologizing pregnancy and birth the female body was not only affirmed as a passive recipient of diagnosis, the pregnant body took on s similar representation to ill bodies in need of regulating and treatment. The peculiar aesthetic of the medical gaze– ‘the practitioner’s ability to describe the body persuasively and elegantly, in infinitesimal detail from the inside out’ (Massey 2005) -  culminated in a medical recognition of the foetus as a life product, an entity completely separate from the mother. 
Jan van Rymsdyk's most famous plate from William Hunter's "Anatomy of the Human Gravid Uterus".

     A significant aspect of the anatomical approach is the loss of lay meanings for words used in a medical context (Martin 1989; Sinclair 1997; Martin 1999; Kitzinger 2006), and also how under the medical gaze ‘unambiguous words apply unambiguously to unambiguous things’ (Sinclair 1997). What Sinclair means by this is that things are given a name and then measured as normal or abnormal according to that name. In The Woman in the Body: A Cultural Analysis of Reproduction, Martin (1989) analyses at length the terminology for the female body’s varying life cycle processes such as ‘degenerate’, ‘weakened’, ‘withdrawn’ and ‘lack’. This sentiment in regards to the use of eponyms and body function adjectives is echoed by Kitzinger in her discussion of obstetric language: ‘Gynaecologist’s names are attached to parts of women’s bodies and processes of reproduction as if these men had invented them; Fallopian tubes, Bartholin’s glands...If the baby does not may be because [the woman] has an ‘inadequate’ pelvis. When the cervix is slow to dilate, it is...’incompetent’...’ (2006:22).   This use of language then becomes a way of seeing the world, how students come to categorise bodies in their social world. 

      When presenting their theory of situated learning Lave and Wenger state that participation ‘is always based on situated negotiation and re-negotiation of meaning in the world’ (1991).  The process of transformation that a student will experience involves applying such ‘unambiguous’ terms in everyday life and practices, therefore also demonstrating a shift in how those students will begin to see all aspects of their lives through the medical gaze. The anatomical model forms the basis of medical education and alongside this the pathology model– the body as ill, the machine as broken. The primary stages of medical learning involve ‘scientising the self’ and the world around you (Sinclair 1997), the eponyms used in anatomy and pathology medicine reinforce the notion that this scientific basis itself is a masculine episteme – or as Sinclair so directly states in his ethnography, that: ‘Medicine is a man’s world’ (1997:143).

    Understanding the development of biomedical discourse through the detailed writing of thinkers such as Foucault or Martin is an essential starting point for the study of medicine and medical learning. This is however, one aspect of a study and is in no terms complete if one wishes to make sense of cultural context and local practices. Ethnographic study must go beyond what Good and Good (1993) argue to be the portrayal of a monolithic “biomedicine” that is treated itself as a conceptual category. In their preliminary analysis of the learning experiences of preclinical medicine at Harvard University, they remind us of the dangers of the diametrically opposing views in much medical anthropology between “biomedicine” and “traditional healing”. They point out that this is not helpful in anthropological analysis and culminate in a view of traditional medicine as untouched by biomedicine and vice versa. At its extreme, the use of biomedicine as a conceptual category fails to take into account the agency and interpretations of the people being studied and does not deal with the different types of medical discourses at play in an educational institution.

   In depth ethnographic studies of the medical student as apprentice learner, in the educational setting are limited and have come under criticism for paying minimal attention to the external influences, personal meanings and the phenomenology of ‘specialized medical worlds’ (Good and Good 1993; Sinclair 1997; Atkinson and Pugsley 2005).
   The most prominent examples of medical education ethnographies are: Merton and Kendell (eds) The Student Physician (1957); Becker et alBoys in White (1961); Bloom’s Power and Dissent in the Medical School (1973); and Sinclair’s Making Doctors: an institutional apprenticeship  (1997). Although not an exhaustive list, it is clear from these titles that there is a long tradition of ethnographic research in medical education in a UK and US context. Whilst they vary in focus from institutional mechanisms (Merton and Kendall 1957; Bloom 1973); professional socialisation (Merton and Kendall 1957; Becker 1961; Sinclair 1997) and power and authoritative knowledge (Bloom 1973; Good and Good 1993; Sinclair 1997), none pay particular attention to the interlinking social contexts and the influence of outer society inside the medical school or vice versa. ‘To say that a practice is defined by its effects is to locate the practice in its connections to its exterior, to that which is other to it(Grossberg 1992:53 my emphasis). Instead, ethnographies set in medical education environments have tended to isolate the students and the learning activity from the political, economic and social contexts of the outside world. Sinclair does present the argument that previous ethnographies have failed to deal with the influence of medical specialities that they have ‘been passed over in favour of the assumed homogeneity of the teaching institution’ (1997:14), his work does make a decent attempt to break away from this. Sinclair’s ethnography is still limited in some respects due to its use of the biomedical model as a conceptual category somehow frozen in historical context. Preliminary work by Good and Good is by far the most useful text for considering ‘...the phenomenological dimensions of medical knowledge, on how the medical world, including the objects of the medical gaze...are reconstituted in the process...’ (1993:83) of learning to be a doctor.   

    Anthropological and sociological literature on medicine and reproductive health in Mexico evidences that medical curriculum and clinical authoritative knowledge have their roots in European and North American practices. Ethnography of midwifery models and practices identifies the use and influences of biomedicine (Jordan 1993; DavisFloyd 2001), though the opposite has not occurred in any study of medical or obstetric practice outside of a historical analysis. This instead tends to fall into the trap already discussed of the untroubled monolith “biomedicine” and/or medical “discourse”, untainted by personal meanings or the world of disease and suffering (Good and Good 1993).

    Existing medical education ethnography is useful for the general theoretical arguments it presents towards cultivating a professional identity and exclusive community of practice. However a deeper understanding of the organisational structure of the Latin American medical school; how authoritative knowledge is culturally absorbed and changed; the more complex interlinking contexts of gender, class and ethnicity; and professional/social status of obstetrics is needed in order to understand its role in pregnancy and childbirth in a local context.

“Iatronic Epidemic” and its links to Authorative knowledge in contemporary cultural education systems

   Links between authoritative knowledge, political economy and relations to the State are well documented themes in medical anthropology and also anthropology of pregnancy (Ginsburg and Rapp 1995; Szurek 1997; Ivry 2010) and further connection needs to be made to the role of State (in local and global contexts)and how this informs educational curriculum and the things that medical students learn. This is an argument that Bloom (1989) puts forward in his paper on the sources of resistance to change in medical schools. By analysing the evolution of organisational structure of medical school in varying countries and regions he demonstrates how medical education is inextricably linked to the health service system. Bloom provides a useful model of the Latin American medical school which he generalises as:

‘autonomous professional school connected to the central administration of the university but with no connection to other parts of the university, combined with open admission immediately after secondary school and student activism’ (Bloom 1989).

Though not entirely unproblematic in its generalisation (particularly between the public/private institutions), this is a useful definition when thinking about the position of the medical school as straddling the general university space, elite professional status space and with the university hospitals, a direct connection to the public health service in action. Medical learning does not happen in a vacuum away from cultural practice and society and one could assume that the curriculum must reflect the direct practices of the hospital or clinic – which in turn are driven by health and welfare initiatives of that given time. The nature of apprentice learning will also mean that students are learning from physicians who continue to practice, moving between an idealised text book static medicine and a multi-layered, everyday practice of medicine defined by cultural, political and economic contexts. 

   The iatronic epidemic is a term used by Castro (2003; 2004; 2004; N.d. ) who has examined violations of reproductive rights in Mexican hospitals including practices of unnecessary caesarean sections, transcaesarean contraception insertion and sterilization without direct consent. By comparing ethnographic data with existing statistical data from the mid 1990s through to 2001, Castro et al (N.d. ) describe how obstetricians can be the driving force behind the rapid rise in caesarean sections, to a point where Mexico is now amongst the highest incidences in the world (Althabe and Belizán ; WHO 2009; Castro, Heimburger et al. N.d. ). An iatrogenic epidemic refers to a practise in relation to its effects, a problem caused by doctors by their own actions. In this case that of gyno-obstetricians in Mexican hospitals (public and private) and interventions in pregnancy and birth. Grossberg establishes that: ‘...a practise is not where it is...but at all of those sites where its existence makes a difference to the world’ (1992:53). Here there is a direct connection to Castro’s work and the theoretical basis’ of learning discussed in the introduction to this literature review. By providing further links to teaching hospitals and cultures of surgical intervention in the learning of obstetrics, Grossberg’s practice of articulation provides a tool for analysing the interlocking cause and effect from educational institution to wider societal context, from community practices to individual lives.

    The work of Castro in Mexico City public hospitals is the closet one becomes in trying to relate obstetrical education knowledge and practice in a Mexican context, and also in relation to political economic realms of health policy. There is a need to re-address some of the major issues brought out by Castro’s detailed ethnographic work, in respect that the context of pregnancy in Chiapas can never a stable subject of study. Since Castro’s data was collected Mexico has changed its President and majority party twice; there has been a global financial crisis; Millennium Development Goals have entered into their final phase; and baseline welfare provision has further developed (Seguro Popular and Oportunidades cash transfer programme) leading to clinical provision in more rural areas and with that further meshing of urban and rural medical practice. How medical and obstetric education has evolved alongside these political and economic stages and the links to economic crisis, structural violence and reproduction have yet to come under any ethnographic analysis.

    In essence there is a good existing base of ethnographic literature from which to build upon. Ethnography of reproductive health and pregnancy in Mexico also tends to reflect that of the wider literature – much analysis begins with the practice of qualified and experienced gyno-obstetricians. Where students and educational structure appear they tend to do so as a background concern. This may be because they are often in an observing, apprentice role and so are described for participation around the main character – the seasoned obstetrician or consultant. In doing so ethnographic understanding of learning medicine and obstetrics is so far absent from the focus on institutional practices – in so much that it could be accused of being taken as a given, as if the training of medical students is a dormant part of the wider context. This is in direct comparison to celebrated ethnographic studies of Mexican midwifery in terms of apprentice learning and meanings of professional that use learning practices as their very focus. I refer here again to Grossberg’s proposition that a practice located in its connections to its exterior and the interrelated effects it has on that exterior, is what opens up the practice and makes it visible to social analysis. In this respect ethnographic analysis of pregnancy and birth in Chiapas must take into account the learning of obstetrics and institutional identity as part of the wider context.


London, Routledge.
London, Oxford University Press.


[1] There have been some pilot programmes of incorporating local midwifery in clinical spaces for example see: Smid, M., L. Campero, et al. (2010). "Bringing Two Worlds Together: Exploring the Integration of Traditional Midwives as Doulas in Mexican Public Hospitals." Health Care for Women International 31(6): 475-498.

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