The relevance of clinical ethnography: reflections on 10 years of a cultural consultation service.

BACKGROUND: Training health professionals in culturally sensitive medical interviewing has been widely promoted as a strategy for improving intercultural communication and for helping clinicians to consider patients' social and cultural contexts and improve patient outcomes. Clinical ethnography encourages clinicians to explore the patient's explanatory model of illness, recourse to traditional and alternative healing practices, healthcare expectations and social context, and to use this information to negotiate a mutually acceptable treatment plan. However, while clinical ethnographic interviewing skills can be successfully taught and learned, the "real-world" context of medical practice may impose barriers to such patient-centered interviewing. Creating opportunities for role modeling and critical reflection may help overcome some of these barriers, and contribute to improved intercultural communication in healthcare. We report and reflect on a retrospective analysis of 10 years experience with a "cultural consultation service" (CCS) whose aim is to provide direct support to clinicians who encounter intercultural difficulties and to model the usefulness of clinical ethnographic interviewing for patient care. METHODS: We analyzed 236 cultural consultation requests in order to identify key patient, provider and consultation characteristics, as well as the cross cultural communication challenges that motivate health care professionals to request a cultural consultation. In addition, we interviewed 51 clinicians about their experience and satisfaction with the CCS. RESULTS: Requests for cultural consultations tended to involve patient care situations with complex social, cultural and medical issues. All patients had a migration background, two-thirds spoke French less than fluently. In over half the cases, patients had a high degree of social vulnerability, compromising illness management. Effective communication was hindered by language barriers and undetected or underestimated patient/provider differences in health-related knowledge and beliefs. Clinicians were highly satisfied with the CCS, and appreciated both the opportunity to observe how clinical ethnographic interviewing is done and the increased knowledge they gained of their patients' context and perspective. CONCLUSIONS: A cultural consultation service such as ours can contribute to institutional cultural competence by drawing attention to the challenges of caring for diverse patient populations, identifying the training needs of clinicians and gaps in resource provision, and providing hands-on experience with clinical ethnographic interviewing.

[Ethnography and fieldwork: the crisis of representation and beyond]. / Ethnografie und Forschen im Feld: diesseits und jenseits der Krise der Repräsentation.

Writing as a nursing researcher about the subjects that comprise the nursing profession means writing about oneself. Conducting ethnographic research on subjects within one's own professional culture and interacting with these subjects in the field poses a challenge. Ethnographic research analyses and opens out the horizon of one's own professional culture for the benefit of the potential reader. However, at the same time, the researcher's self within an ethnographic framework is called into question. In anthropology the researcher-subject relationship is deemed a special relationship, and in this article both authors reveal the precarious status of their research object. In this article an attempt is made to let the nursing subjects speak for themselves, while at the same time the authors write about their subjects' social practices an communication processes. To date there has hardly been any German research work within nursing dealing with this critical area of interest. The authors seek to provide an introduction to the constitutive parts of ethnography and the crisis of representation and beyond. In addition, they present two reflexive accounts.

From "lists of traits" to "open-mindedness": emerging issues in cultural competence education.

The incorporation of "culture" into U.S. biomedicine has been increasing at a rapid pace over the last several decades. Advocates for "cultural competence" point to changing patient demographics and growing health disparities as they call for improved educational efforts that train health providers to care for patients from a variety of backgrounds. Medical anthropologists have long been critical of the approach to "culture" that emerges in cultural competence efforts, identifying an essentialized, static notion of culture that is conflated with racial and ethnic categories and seen to exist primarily among exotic "Others." With this approach, culture can become a "list of traits" associated with various racial and ethnic groups that must be mastered by health providers and applied to patients as necessary. This article uses an ethnographic examination of cultural competence training to highlight recent efforts to develop more nuanced approaches to teaching culture. I argue that much of contemporary cultural competence education has rejected the "list of traits" approach and instead aims to produce a new kind of health provider who is "open-minded," willing to learn about difference, and treats each patient as an individual. This shift, however, can ultimately reinforce behavioral understandings of culture and draw attention away from the social conditions and power differentials that underlie health inequalities.

En-case-ing the patient: disciplining uncertainty in medical student patient presentations.

The problem-oriented medical record is the widespread, standardized format for presenting and recording information about patients, which is taught to future physicians early in their medical training. Based on our participant observation of medical training, we analyze the ways in which the patient presentation operates in medical training as a disciplinary technology that manages uncertainty in the clinical decision-making process. We uncover various mechanisms at work including the construction of a coherent narrative structure in which chaotic experiences are re-organized and re-interpreted to fit neatly in a linear plot with a predictable ending, the atomization of the patient as a whole into separable "problems," the attempt to solve these "problems" as though they are independent of one another, and the mystification of translations in scale, which give rise to much of the uncertainty in medicine. Operating at the boundary of the chaotic and often ungraspable world of the suffering experience of the patient and the highly structured realm of the medical record, a patient presentation is one medium through which both a disciplined record of experience and disciplined medical practitioners are produced. This process functions to transform the human subject patient into a recognizable, generic clinical case, and the medical student into an identifiable, professional future physician.

Learning the moral economy of commodified health care: "community education," failed consumers, and the shaping of ethical clinician-citizens.

Leaders of health professional schools often support community-based education as a means of promoting emerging practitioners' awareness of health disparities and commitment to serving the poor. Yet, most programs do not teach about the causes of health disparities, raising questions regarding what social and political lessons students learn from these experiences. This article examines the ways in which community-based clinical education programs help shape the subjectivities of new dentists as ethical clinician-citizens within the US commodified health care system. Drawing on ethnographic research during volunteer and required community-based programs and interviews with participants, I demonstrate three implicit logics that students learned: (1) dialectical ideologies of volunteer entitlement and recipient debt; (2) forms of justification for the often inferior care provided to "failed" consumers (patients with Medicaid or uninsured); and (3) specific forms of obligations characterizing the ethical clinician-citizen. I explore the ways these messages reflected the structured relations of both student encounters and the overarching health care system, and examine the strategies faculty supervisors undertook to challenge these messages and relations. Finally, I argue that promoting commitments to social justice in health care should not rely on cultivating altruism, but should instead be pursued through educating new practitioners about the lives of poor people, the causal relationships between poverty and poor health, and attention to the structure of health care and provider-patient interactions. This approach involves shining a critical light on America's commodified health care system as an arena based in relations of power and inequality.

The ethical self-fashioning of physicians and health care systems in culturally appropriate health care.

Diverse advocacy groups have pushed for the recognition of cultural differences in health care as a means to redress inequalities in the U.S., elaborating a form of biocitizenship that draws on evidence of racial and ethnic health disparities to make claims on both the state and health care providers. These efforts led to federal regulations developed by the U.S. Office of Minority Health requiring health care organizations to provide Culturally and Linguistically Appropriate Services. Based on ethnographic research at workshops and conferences, in-depth interviews with cultural competence trainers, and an analysis of postings to a moderated listserv with 2,000 members, we explore cultural competence trainings as a new type of social technology in which health care providers and institutions are urged to engage in ethical self-fashioning to eliminate prejudice and embody the values of cultural relativism. Health care providers are called on to re-orient their practice (such as habits of gaze, touch, and decision-making) and to act on their own subjectivities to develop an orientation toward Others that is "culturally competent." We explore the diverse methods that cultural competence trainings use to foster a health care provider's ability to be self-reflexive, including face-to-face workshops and classes and self-guided on-line modules. We argue that the hybrid formation of culturally appropriate health care is becoming detached from its social justice origins as it becomes rationalized by and more firmly embedded in the operations of the health care marketplace.

"Not here": making the spaces and subjects of "global health" in Botswana.

This essay argues that what makes "global health" "global" has more to do with configurations of space and time, and the claims to expertise and moral stances these configurations make possible, than with the geographical distribution of medical experts or the universal, if also uneven, distribution of threats to health. Drawing on a study of public-private partnerships supporting Botswana's HIV/AIDS treatment program, this essay demonstrates ethnographically the processes by which "global health" and its quintessential spaces, namely "resource-limited" or "resource-poor settings," are constituted, reinforced, and contested in the context of medical education and medical practice in Botswana's largest hospital. Using Silverstein's work on orders of indexicality, I argue that the terms of "global health" are best understood as chronotopic, and demonstrate how actors orient themselves and others spatio-temporally, morally, and professionally by using or refuting those terms. I conclude by arguing that taking "global health" on its own terms obscures the powerful forces by which it becomes intelligible. At stake are the frames within which medical anthropologists understand their objects of study, as well as the potential for the spaces of "global health" intervention to expand ever outward as American medical personnel attempt to calibrate their experiences to their expectations.

A broader discussion of authorship.

While it may be useful to consider the development of new topics in teaching the responsible conduct of research (RCR), it is perhaps equally important to reconsider the traditionally taught core topic areas in both more nuanced and broader ways. This paper takes the topic of authorship as an example. Through the description of two specific cases from sociocultural anthropology, ideas about credit and responsibility are examined. It is suggested that placing more focus on the array of meanings found in the act of authoring might help students see themselves as part of a wider community both of scientists and beyond science.

Lonely drinking fountains and comforting coolers: paradoxes of water value and ironies of water use.

This article focuses ethnographically on Americans and technologies of drinking water, as tokens of and vehicles for health, agency, and surprising kinds of community. Journalists and water scholars have argued that bottled water is a material concomitant of privatization and alienation in U.S. society. But, engaging Latour, this research shows that water technologies and the groups they assemble, are plural. Attention to everyday entwining of workplace lives with drinking fountains, single-serve bottles, and spring water coolers shows us several different quests, some individualized, some alienated, but some seeking health via public, collective care, acknowledgment of stakeholding, and community organizing. Focused on water practices on a college campus, in the roaring 1990s and increasingly sober 2000s in the context of earlier U.S. water histories of inclusion and exclusion, I draw on ethnographic research from the two years that led up to the recession and the presidential election of 2008. I argue for understanding of water value through attention to water use, focusing both on the social construction of water and the use of water for social construction.

Feet and fabrication: footbinding and early twentieth-century rural women's labor in Shaanxi.

The early twentieth-century transformations of rural Chinese women's work have received relatively little direct attention. By contrast, the former custom of footbinding continues to fascinate and is often used to illustrate or contest theories about Chinese women's status. Arguing that for rural women at least, footbinding needs to be understood in relation to rural economic conditions, the authors focus on changes in textile production and in footbinding in two counties in Shaanxi province. Drawing on historical sources and their own interview data from rural women who grew up in this period, the authors find evidence that transformations in textile production undercut the custom of footbinding and contributed to its rapid demise.

Backstage discourse and the reproduction of white masculinities.

This article documents the shared patterns of private white male discourse. Drawing from comparative ethnographic research in a white nationalist and a white antiracist organization, I analyze how white men engage in private discourse to reproduce coherent and valorized understandings of white masculinity. These private speech acts reinforce prevailing narratives about race and gender, reproduce understandings of segregation and paternalism as natural, and rationalize the expression of overt racism. This analysis illustrates how antagonistic forms of "frontstage" white male activism may distract from white male identity management in the "backstage."

The evolution of human warfare.

Here we propose a new theory for the origins and evolution of human warfare as a complex social phenomenon involving several behavioral traits, including aggression, risk taking, male bonding, ingroup altruism, outgroup xenophobia, dominance and subordination, and territoriality, all of which are encoded in the human genome. Among the family of great apes only chimpanzees and humans engage in war; consequently, warfare emerged in their immediate common ancestor that lived in patrilocal groups who fought one another for females. The reasons for warfare changed when the common ancestor females began to immigrate into the groups of their choice, and again, during the agricultural revolution.

The first rite of passage: baptism in medieval memory.

This article is part of a wider study that examines over 10,000 jurors' testimonies in proof-of-age hearings from 1246 to 1432, which were conducted to determine the legal majority of heirs-in-chief of the crown. It looks specifically at more than 1,500 references to the ceremony of baptism and tries to build up a picture of what the service was like in the memories of the participants. It reveals the haste and sometimes confusion of the preparations beforehand, the naming of infants, the role of godparents, the use of writing and the giving of gifts to record the birth, the celebrations that accompanied it, and details of the ceremonial itself, including the processions with lit torches and the crowds that often gathered. Despite the stereotypical nature of much testimony, it attempts to capture the atmosphere of what went on and what stuck in the minds of jurors.

Fertility decline in rural China: a comparative analysis.

Many models have been proposed to explain both the rapidity of China's fertility decline after the 1960s and the differential timing of the decline in different places. In particular, scholars argue over whether deliberate policies of fertility control, institutional changes, or general modernization factors contribute most to changes in fertility behavior. Here the authors adopt an ethnographically grounded behavioral-institutional approach to analyze qualitative and quantitative data from three different rural settings: Xiaoshan County in Zhejiang (East China), Ci County in Hebei, (North China), and Yingde County in Guangdong (South China). The authors show that no one set of factors explain differential timing by a combination of differences in social-cultural environments (e.g. spread of education, reproductive ideologies, and gender relations) and politico-economic conditions (e.g. economic development, birth planning campaigns, and collective systems of labor organization) during the early phases of the fertility decline.

Ready, willing, and able to divorce: an economic and cultural history of divorce in twentieth-century Sweden.

This study outlines a long history of divorce in Sweden, recognizing the importance of considering both economic and cultural factors in the analysis of marital dissolution. Following Ansley Coale, the authors examine how a framework of multiple theoretical constructs, in interaction, can be applied to the development toward mass divorce. Applying a long historical perspective, the authors argue that an analysis of gendered aspects of the interaction between culture and economics is crucial for the understanding of the rise of mass divorce. The empirical analysis finds support for a marked decrease in legal and cultural obstacles to divorce already during the first decades of the twentieth century. However, economic structures remained a severe obstacle that prohibited significant increases in divorce rate prior to World War II. It was only during the 1940s and 1960s, when cultural change was complemented by marked decreases in economic interdependence between spouses, that the divorce rate exhibited significant increases. The authors find that there are advantages to looking at the development of divorce as a history in which multiple empirical factors are examined in conjunction, recognizing that these factors played different roles during different time periods.

Divorce and social class during the early stages of the divorce revolution: evidence from Flanders and the Netherlands.

In times of low divorce rates (such as the nineteenth century and early twentieth century), the authors expect higher social strata to have the highest divorce chances as they are better equipped to break existing barriers to divorce. In this article, the authors analyze data from marriage certificates to assess whether there was a positive effect of occupational class on divorce in Belgium (Flanders) and the Netherlands. Their results for the Netherlands show a positive association between social class and divorce, particularly among the higher cultural groups. In Flanders, the authors do not find this, but they observe a negative association between illiteracy and divorce, an observation pointing in the same direction.

Divorce in early modern rural Japan: household and individual life course in northeastern villages, 1716-1870.

Drawing data from the local population registers in two northeastern agricultural villages, this study examines the patterns and factors associated with divorce in preindustrial Japan. Divorce was easy and common during this period. More than two thirds of first marriages dissolved in divorce before individuals reached age fifty. Discrete-time event history analysis is applied to demonstrate how economic condition and household context influenced the likelihood of divorce for females. Risk of divorce was extremely high in the first three years and among uxorilocal marriages. Propensity of divorce increased upon economic stress in the community and among households of lower social status. Presence of parents, siblings, and children had strong bearings on marriage to continue.

The con man as model organism: the methodological roots of Erving Goffman's dramaturgical self.

This article offers a historical analysis of the relationship between the practice of participant-observation among American sociologists and Erving Goffman's dramaturgical model of the self. He was a social scientist who privileged ethnography in the field over the laboratory experiment, the survey questionnaire, or the mental test. His goal was a natural history of communication among humans. Rather than rely upon standardizing technologies for measurement, Goffman tried to obtain accurate recordings of human behavior through secretive observations. During the 1950s, he conducted three major studies as a participant-observer, disguised from those studied through insincere performances. As originally presented, his dramaturgical theory did not draw upon the theater as the governing metaphor, but rather the confidence game. It is suggested that Goffman's writings exemplify what Gerd Gigerenzer calls the tools-to-theories heuristic. Goffman's depiction of the confidence man's behavior closely mirrored how he and his fellow sociologists described the practice of participant-observation. Both were represented as embedded and attentive yet coolly detached observers skilled at playing different roles as the situation necessitated. The similarities between his own professional behavior and the activities of the confidence man may have suggested to Goffman the latter as a model for human nature.

Networks, narratives and territory in anthropological race classification: towards a more comprehensive historical geography of Europe's culture.

This article aims to integrate discourse analysis of politically instrumental imagined identity geographies with the relational and territorial geography of the communities of praxis and interpretation that produce them. My case study is the international community of nationalist scientists who classified Europe's biological races in the 1820s-1940s. I draw on network analysis, relational geography, historical sociology and the historical turn to problematize empirically how spatial patterns of this community's shifting disciplinary and political coalitions, communication networks and power relations emerged, were structured, persisted, changed, interacted and disappeared. I focus especially on core-periphery relations. I argue that if local historical spatial patterns affect those of later phenomena, geographies like that of European integration should be understood in the context of Europe's complex historical cultural geography. Unlike discourse deconstruction alone, this complementary relational de-essentialization of geography can identify large-scale, enduring associations of cultural patterns as well as cultural flux and ambiguity.

Of poisoners, tanners and the British Raj: redefining Chamar identity in colonial North India, 1850­90.

This article explores colonial representations of the crime of cattle poisoning and uses it as a starting point to investigate questions related to the formation of Chamar identity. Starting from the 1850s, it looks at the process whereby the caste group was imbued with certain undesirable traits of character. Simultaneously, it also explores the larger trend towards fixing the caste with certain occupational traits, so that it began to be identified completely with leather work by late nineteenth century. The role of new specialisms such as ethnography, toxicology and medical jurisprudence in the formation of new definitions about Chamars is also highlighted. The overall aim of the article is to reveal the complexities involved in the formation of colonial discourse about caste and caste groups.