PPHHYYSSIICCIIAANNSS OOFF WWEESSTTEERRNN MMEEDDIICCIINNEE CULTURE, ILLNESS, AND HEALING Studies in Comparative Cross-Cultural Research Editor-in-Chief" ARTHUR KLEINMAN Harvard University and Medical School, Cambridge, Massachusetts, U.S.A. Editorial Board: LEON EISENBERG Harvard Medical School, Boston, Massachusetts, U.S.A. NUR YALMAN Harvard University, Cambridge, Massachusetts, U.S.A. MORRIS CARSTAIRS Royal Free Hospital Medical College London PHYSICIANS OF WESTERN MEDICINE Anthropological Approaches to Theory and Practice Edited by ROBERT A. HAHN Department of Psychiatry and Behavioral Sciences, School ofM edicine, University of Washington, Seattle, WA. and ATWOOD D. GAINES Departments ofA nthropology and Psychiatry, Case Western Reserve University and Medical School, Cleveland, OH. D. REIDEL PUBLISHING COMPANY tit A MEMBER OF THE KLUWER ACADEMIC PUBLISHERS GROUP DORDRECHT/BOSTON/LANCASTER Library of Congress Cataloging in Publication Data Physicians of western medicine. (Culture, illness. and healing; 6) Ie card. no. 84-26436 ISBN-13: 978-90-277-1881-5 e-ISBN-13: 978-94-009-6430-3 001: 10.1007/978-94-009-6430-3 Full details appear on a separate card. Published by D. Reidel Publishing Company. P.O. Box 17,3300 AA Dordrecht, Holland. Sold and distributed in the U.S.A. and Canada by Kluwer Academic Publishers, 190 Old Derby Street, Hingham, MA 02043, U.S.A. In all other countries, sold and distributed by Kluwer Academic Publishers Group, P.O. Box 322, 3300 AH Dordrecht, Holland. All Rights Reserved © 1985 by D. Reidel Publishing Company. Softcover reprint of the hardcover 15t Edition 1985 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner TABLE OF CONTENTS PREFACE vii SECTION I: INTRODUCTIONS 1. ATWOOD D. GAINES and ROBERT A. HAHN / Among the Phy- sicians: Encounter, Exchange and Transformation 3 2. THOMAS W. MARETZKI / Including the Physician in Healer-Centered Research: Retrospect and Prospect 23 SECTION II: CORE MEDICINE 3. ROBERT A. HAHN / A World of Internal Medicine: Portrait of an Internist 51 SECTION III: MEDICAL SPECIALTIES 4. MARGARET LOCK / Models and Practice in Medicine: Menopause as Syndrome or Ufe Transition? 115 5. WILLIAM RITTENBERG / Mary; Patient as Emergent Symbol on a Pediatrics Ward: The Objectification of Meaning in Social Process 141 6. PEARL KA TZ / How Surgeons Make Decisions 155 7. WILLIAM RITTENBERG and RONALD C. SIMONS / Gentle Interro- gation: Inquiry and Interaction in Brief Initial Psychiatric Evaluations 177 8. BYRON 1. GOOD, HENRY HERRERA, MARY-JO DELVECCHIO GOOD and JAMES COOPER / Reflexivity, Countertransference and Clinical Ethnography: A Case From a Psychiatric Cultural Consulta- tion Clinic 193 9. ATWOOD D. GAINES / The Once- and the Twice-Born: Self and Practice Among Psychiatrists and Christian Psychiatrists 223 SECTION IV: INTERRELATIONS OF MEDICAL SPECIALTIES 10. MARY-JO DELVECCHIO GOOD / Discourses on Physician Com- petence 247 11. THOMAS M. JOHNSON / Consultation-Liaison Psychiatry: Medicine as Patient, Marginality as Practice 269 T ABLE OF CONTENTS 12. CECIL G. HELMAN I Disease and Pseudo-Disease: A Case History of Pseudo-Angina 293 LIST OF CONTRIBUTORS 333 AUTHOR INDEX 335 SUBJECT INDEX 341 PREFACE After putting down this weighty (in all senses of the word) collection, the reader, be she or he physician or social scientist, will (or at least should) feel uncomfortable about her or his taken-for-granted commonsense (therefore cultural) understanding of medicine. The editors and their collaborators show the medical leviathan, warts and all, for what it is: changing, pluralistic, problematic, powerful, provocative. What medicine proclaims itself to be - unified, scientific, biological and not social, non-judgmental - it is shown not to resemble very much. Those matters about which medicine keeps fairly silent, it turns out, come closer to being central to its clinical practice - managing errors and learning to conduct a shared moral dis course about mistakes, handling issues of competence and competition among biomedical practitioners, practicing in value-laden contexts on problems for which social science is a more relevant knowledge base than biological science, integrating folk and scientific models of illness in clinical communication, among a large number of highly pertinent ethnographic insights that illuminate medicine in the chapters that follow. The contributors are to be congratulated for their apt and telling case illustra tions, several of which are likely to stay with the reader well after he or she finishes the book. In keeping with the genius of descriptive ethnography, we get to see and experience local contexts of action - a cystic fibrosis clinic in which a fundamental staff conflict discloses the nature of medical interactions in patient care, a busy surgical department attempting to carry out both research and clinical practice while economic, personal and moral issues set the stage for crisis and confusion, a complicated illness trajectory from general practitioner to specialists in which disease and illness become inseparably intertwined, twisting together like a double helix under the pressure of distinctive and conflicting clinical realities. These and other local contexts are interpreted to reveal large themes that link the macro-social world with micro-clinical events: physicians' talk about professional competence, the non-medical determinants of clinical decision-making, the complex, pluralistic practice worlds of everyday medical work, the moral structure of doctoring .... The upshot is a rich, variegated, provocative perspective on medicine that will push readers to begin to rethink conventional wisdom about illness, care and doctoring. In this respect, this large volume does justice to the field of medical anthropology, which, though at an early stage of research on Biomedicine, and following in the footsteps of medical sociology and medical history, but with culture as its subject, demonstrates that Biomedicine is an integral part of local contexts of meanings, norms and power, contexts that provide it with particular and differing styles of action and significance (see Kleinman 1980; Weisberg and Long 1984). vii viii PREFACE For those hearty souls who can read through it in a single sitting, Hahn's massive report on the worldview, trade, craft and character of an internist will tell them more about internal medicine than anything short of field work. Margaret Lock's masterfully balanced account of medical views on menopause shows the marvelous discrepancies, alternatives, conflicting models, and changing explanatory systems of obstetricians, family doctors and others. Helman's analysis of pseudo-angina is a compelling and exhaustive display of differential constructions of a single illness event and their practical significance for patient and health care system. Rittenberg and Simons disclose the psychiatrists' method is not all that dissimilar (yet dif ferent enough to make a difference) from the ethnographer who is working up an indigenous ethnographic category. Pearl Katz must make us all flinch at the social forces driving the surgical knife. There is more besides, including Johnson's masterful depiction of the difficult situation of consultation-liaison psychiatry as a portrait of the ironic confrontation of the "soft" (psychosocial) and the "hard" (biomedical) streams in medicine, which is the best analysis I know of that captures this crucial symbolic contradiction in the odd positioning of a meaning centered psychiatry in the interstices of a high technology, tertiary care medicine that regularly denies and defeats the human element of care. I should not forget either, Gaines' rich cultural account of the complexities of even this marginal though essential field, psychiatry, that make strict "secular"/"Christian" labels a distortion of a many-sided, negotiated world of practice. The Goods and their collaborators offer us an intricate understanding of counter-transference on three interrelated levels - intrapsychic, interpersonal, cultural - that should dispell forever simplistic models of what the therapeutic process entails, and disclose how difficult it is to avoid at least temporary misadventure, even with a combina tion of sensitive clinical and cultural understanding, when participating in inter cultural healing and applying a self-reflexive orientation. The volume is a case-book filled with stunning illustrations to provoke problem based learning. Unlike a sociology text or a medical monograph, most of what we read are single-case studies analyzed in depth. Ethnography and interpretation, and to a much lesser degree, cross-cultural comparison, are the chief methods. This is highly appropriate because these are the core methods of anthropology. Here they are deployed by researchers who have had extensive experience working in medical settings. Reading the chapters as an anthropologist-physician I can almost experience each of the settings and the problems: the accounts are con vincingly valid and evocative of major questions in Biomedicine. Clinicians and medical students should find these clinical cameos an appropriate format for learning about the social origins and cultural constructions of illness and clinical praxis. Anthropologists will get a sense from them of the cultural discourses and social realities that constitute Biomedicine as an anthropological subject. General readers will also find the chapters of interest; the latter provide an appropriately concrete grounding for different kinds of social analyses and interpretations, all of which should produce disquiet and concern in the reader about the nature, struc ture, and significance of various key elements of Western professional medicine. PREFACE ix The chief achievement of this volume is that it is the state of the art in the anthropology of Biomedicine. That state is still more a line of inquiry (and a wavy line at that), very early findings rather than an established body of theory, and heuristic insights, not replicated data or tested hypotheses. But it is remarkable how much ground has been covered in so short a time. After reading the final chapter, I put down the manuscript feeling that I was witnessing an important professional development in medical anthropology: namely, the coming to terms with mundane and ubiquitous Biomedicine in Western society by a field heretofore seemingly obsessed with esoteric culture-bound disorders, foreign folk healers and extra ordinary healing rituals. This anthropological encounter with our medicine (with the medically commonplace along with the medically unusual) is significant more for what it portends than for what it actually accomplishes. Clearly we are seeing the beginnings of several new anthropologies: the anthropology of the professions and the anthropology of science. I leave it to the chapters that follow to display what we learn from the an thropology of Biomedicine. Not the least of what I think we learn is the liberating notion that medicine - the whole of it, from sicknesses to therapies and including medical settings, roles and attributions - can be (and should be) rethought in the language of social structure and cultural norms, of interpersonal transactions and differential access to resources, of cultural symbols and social action. And this process of making our medicine into a subject of social enquiry (like other ethno medicines) is significant also because it creates practically useful knowledge, knowledge perhaps that holds the potential of eventually being applied to liberate physicians as well as patients from narrow, dehumanizing forms of medical praxis that are unhelpful, iatrogenic and that systematically perpetuate dangerous direc tions in our society's political and moral economy. In this respect too, the an thropology of Biomedicine has the opportunity of intensifying anthropology and its effects. Departments of Anthropology, Psychiatry, ARTHUR KLEINMAN, M.D., M.A. and Social Medicine, Harvard University and Harvard Medical School REFERENCES Kleinman, A. 1980 Patients and Healers in the Context of Culture. Berkeley: University of California Press. Weisberg, D. and S. O. Long (eds.) 1984 Biomedicine in Asia. Special Issue. Culture, Medicine and Psychiatry 8 (2). SECTION I INTRODUCTIONS