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GMS Zeitschrift für Medizinische Ausbildung

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 1860-3572

Participant observation and change of perspectives: Medical Anthropology and the encounter with socially marginalised groups. First experiences with a new teaching concept

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  • Berit Mohr - Universität Gießen, Institut für Geschichte der Medizin, Gießen, Deutschland
  • Peter Hovermann - Frankfurter Verein für Soziale Heimstätten e.V., Frankfurt/Main, Deutschland
  • corresponding author Volker Roelcke - Universität Gießen, Institut für Geschichte der Medizin, Gießen, Deutschland

GMS Z Med Ausbild 2012;29(5):Doc66

doi: 10.3205/zma000836, urn:nbn:de:0183-zma0008366

This is the translated version of the article.
The original version can be found at: http://www.egms.de/de/journals/zma/2012-29/zma000836.shtml

Received: January 30, 2012
Revised: June 22, 2012
Accepted: June 25, 2012
Published: November 15, 2012

© 2012 Mohr et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Abstract

This paper examines the new teaching concept “Providing medical care on the fringe of society: Participant observation and change in perspectives” in the context of the interdisciplinary field of Querschnittsbereich 2/Q 2 (the transdisciplinary section under AOÄ, the German Regulations for licensed physicians) that explores the history, theory and ethics of medicine. The disciplinary approach usually adopted in Q 2 is supplemented with concepts from medical anthropology; in addition students will be exposed to people in extreme social situations. The aim is to make students aware of and invite them to reflect upon:

1.
the importance of participant observation in the specific on-site setting of medical thinking and acting;
2.
the importance of the subjectivity of all those involved in doctor/patient interaction; and
3.
the fact that key medical terms (such as the “need” as seen by the physician vs. the need as seen by the patient) are essentially context-dependent in their interpretation.

At a more general level students will learn how to put themselves in the position of different protagonists in a range of medical settings, and practice the skill of reflecting critically upon putative conceptual/theoretical and normative-ethical assumptions in medicine.

Keywords: Medical Humanities, Medical Anthropology, participant observation, counter-transference, homeless people


Introduction

We all have a very different understanding of how we define a “need for help”. This is most clearly felt when encountering individuals who, despite outside temperatures below zero, prefer sleeping rough in the street over the warm place in an overnight homeless shelter that a social worker or other care worker has offered them. If they additionally show no response to medical diagnoses such as open ulcers, flu infections or severe breathing difficulties, we can safely say that this person’s behaviour deviates fundamentally from the expectations and understanding that health professionals would normally associate with “need for action”.

Being exposed to people who reject such support services, which seem well-motivated and necessary from a medical point of view, is only one of several fruitful challenges that are deliberately provoked as part of the new teaching concept in the Institute for the History of Medicine at Giessen University. The objectives are as follows:

1.
to get students to reflect systematically and critically upon conventional and thus familiar ways of thinking and acting, expectations and beliefs in medicine;
2.
to get students to reflect upon central concepts such as “Bedarf/Bedürfnis” (needs in “objective” vs. “subjective” terms) that are normative in character and have a structuring and guiding effect on medical care services;
3.
to advance and refine students’ “soft skills”, including the ability to put themselves in the position of other people, in particular those using medical services;
4.
to employ the method of participant observation in order to gain awareness of patients’ concrete social and environmental living conditions, in this case people on the fringe of society; and
5.
to raise students’ awareness of what can be deemed suitable support services for people whose behaviour is not consistent with the conventional expectations of health professionals.

These teaching objectives are implemented and pursued, among others, in the interdisciplinary field Querschnittsbereich 2 / Q 2 “History, Ethics and Theory of Medicine” [17], [21] that is part of the Approbationsordnung für Ärzte/(AOÄ: regulations for licensing doctors) (AOÄ, 2002). As a matter of fact, some of the objectives are also presented and discussed in some medical school-curricula in medical sociology and psychology, as well as in community medicine/public health, however, in these contexts, the primary emphasis here is on the methodological and conceptual repertoire from their related disciplines, sociology and psychology. - Similar teaching concepts as those presented in Q 2 can also be found at an international level, where they tend to be associated with the concept of “Medical Humanities” ("Kulturwissenschaften in der Medizin”) [2], [16]. Medical faculties vary in their interpretation and weighting of these teaching concepts; however, in the context of research and debate in medical education, the main focus is on the relationship between the three approaches (history, ethics, theory: additive or integrative; weighting of individual components), which are specified explicitly in the AOÄ and which intend to introduce a reflective perspective on current medicine [17], [21].

This paper sets out to discuss the possibility of supplementing the above-described methods with methodological approaches and concepts from another discipline based in cultural studies, namely medical anthropology (or medical ethnology), and to apply these in the context of a specifically designed form of experience to which students are exposed. Outside of Germany, medical anthropology is an established discipline in university departments, degree courses and associations. The seminar “Medical Care on the Fringes of Society: Participant Observation and Change in Perspectives” has been designed with these approaches and experiences in mind. It has been offered as a seminar option in Q 2 at the Medical School of Giessen University since the 2010-11 winter semester.


Project description

The new teaching concept was developed on the basis of the following findings and considerations:

1.
In the standard degree courses required by the regulations for licensing doctors medical students will get to experience doctor-patient interaction almost exclusively in a hospital setting or in doctors’ surgeries, in other words, in institutional environments which in terms of their organisation and management of internal procedures are driven by the rationality of medical thinking (in addition to political and economic requirements). As a result, the focus is on “problems” as defined by physicians as well as related activities (diagnosis, therapy, consulting). The doctors and other medical staff working in such contexts are naturally familiar with the environment, but those who come to these institutions complaining of being unwell or suffering from acute illness (“patients” from a doctor’s point of view) will often be new to this environment. This in itself can indeed become a source of additional stress, leading to feelings of, among others, uncertainty, anxiety and reluctance in doctor/patient interaction. The asymmetrical relationship between doctors and patients that is predefined by polar concepts such as ailing/healthy, laypeople/experts, those seeking help/those providing help is further exacerbated by the lack of familiarity/familiarity in the actual setting.
2.
As has been repeatedly demonstrated, the problem definitions employed in medical settings revolve around specific illnesses, perceptions of the body und self-images that have been defined by doctors and through medical research. However, they do not necessarily reflect how those attending medical care institutions would themselves define their problems and concerns. The priorities for action that result from the individual “illness” of the patient not seldom deviate from the priorities that are deduced from a scientifically based perception of disease in medicine [18], [20]. In recent years, the debate has become increasingly systematic, for instance in relation to the treatment of patients suffering from chronic illness, e.g., acute pain syndromes, or advanced stages of cancer: It became clear that procedures that are primarily rooted in medical rationality (maximum diagnosis and therapy including all available possibilities afforded by science and technology) not seldom contradict the need of the patient, which is to live their remaining life as fully and comfortably as possibly given the circumstances – according to their own subjective criteria [20], [19]. However, the issue of systematically considering and ultimately prioritising the patient’s perspective still continues to be on the periphery in medical training. The same applies to medico-ethical considerations and evaluations, which too will yield different conclusions if, for example, the “risks” of therapeutic or research interventions are systematically understood not as predefined medical entities (e.g., by way of morbidity and mortality rates for specific medical complications), but viewed and evaluated instead from the point of view of the patient [20]. The above-outlined problem becomes clear if we consider the different aspects of meaning inherent in the conceptual pair “Bedarf“/„Bedürfnis“, terms referring to needs in the perspective of the physician, or the patient respectively: While the use of the term “Bedarf” presupposes (scientific) objectivity and is therefore widely employed in the sense of measurable and essentially quantifiable entities in medical and political debates on medical care, the term “Bedürfnis” is far more closely linked to the subjective perception of an individual or a particular predefined group.
3.
Empirical research on medical care for people with migratory backgrounds in a number of different health care systems strongly points to the fact that the issues and “problems” as regards medical or health care services that become apparent with socially marginalised groups are by no means exclusively limited to these. On the contrary, these “problems” tend to be phenomena of a ubiquitous nature that apply universally in the context of medical care and doctor/patient interaction, which become strikingly apparent when dealing with socially marginalised groups. If looked upon closely, in the German health care system such phenomena, including, for example, that patients do not fully understand the medical information that is given them, or that patients’ perceptions of their body, and the way in which they describe illness or pain is considered inadequate by medical staff, are by no means limited to people of exotic or migratory backgrounds, but can equally be observed with native users [1], [14]. Moreover, there is evidence that medical staff tends to de-individualise, standardise and in part stigmatise behaviour of people with a migrant background. Such behaviour is frequently perceived as “exotic” and therefore attributed to the “culture” or supposed biological disposition. Upon closer inspection, such stereotyping and stigmatising perceptions and evaluation may also be observed in relation to certain patients from within the own society: Ample evidence in support of this is provided by patients suffering from chronic pain or obesity. Another striking example are socially marginalised groups such as black Americans in the United States (e.g., [3], [9], [19]); but this too happens in the German health care system [1], [7], [15]. Medical workers’ attitudes can even lead to changes in therapy. Stereotypical ways of thinking and acting as well as implicit normative assumptions, which act as a potential source of misunderstandings, conflict or problems in medicine, can therefore be illustrated and reflected upon using the example of socially marginalised groups.

The three findings outlined above provided the basis for a teaching concept that incorporates the educational potential provided by concepts and procedures used in medical anthropology. Moreover, it draws on the specific experience that students gathered working with people from socially marginalised groups, or more precisely: without a permanent address. The aim was to systematically draw students’ attention to the following aspects and dimensions:

  • The significance of each particular life situation, experience of suffering and particular ways of patients’ interaction in order to design (medical) support services that will pick up on their specific needs; in this context the concept and method of field research and participant observation from (medical) anthropology is taught;
  • The unsettling impact an unfamiliar setting can have in the context of doctor/patient interaction, and as a consequence gaining awareness of the importance of one’s own subjectivity (i.e., of the medical staff) in one’s dealing with persons requiring help; in this context the modified concept of counter-transference from Ethno-Psychoanalysis (following Devereux) is addressed;
  • Getting to know and “immersing” themselves in the living environments, health problems and specific needs of people living on “the fringe” of society following the model of “cultural immersion” approaches [4], [6]: Aside from more general phenomena such as poverty and physical neglect, we are dealing here with precarious conditions in terms of hygiene and nutrition, multimorbidity, often coinciding with psychiatric comorbidity, along with the effect of stigmatisation and shame over the (non-)use of available (medical) support services. The aim is to “look closely” at that which is (supposedly) exotic and bewildering, and to overcome the fear of entering unfamiliar territory;
  • Exposing the problems of the concept “need for help” in the context of the concrete state of a concrete individual (using the conceptual pair Bedarf/Bedürfnis): On the one hand, the focus here is on analysing central guiding concepts in medicine that bear relevance in relation to medical theory; on the other, the intention is to draw students’ attention to the fact that the medical perspective on the discomfort presented (on scientific grounds, “objective”) needs to be meaningfully and systematically complemented by including the patient’s perspective (“subjective”, in the context of their biography and life situation, partly ambivalence/rejection of support services).

In achieving these objectives, as briefly outlined above, in addition to the medical body of knowledge, concepts and methods from (medical) anthropology were introduced as central components of the seminar. This essentially involves the method of field research including participant observation [8], [11]: Central to this method is that those at the focus of medical attention will be visited in their everyday living settings. An additional effort is made to find out about their physical and social environment and their daily routines in order to comprehend the importance of these factors in relation to the patients’ perceptions of their body and state of mind, and in relation their help-seeking behaviour. In addition to visiting the living environment of those affected, systematic monitoring and – as far as possible – participating in their everyday lives, interviewing informers from the group in focus, together with the systematic documentation of experiences and reflections, form essential elements of this method [8], [11]. This will enable students to get a better grasp, for example, of the behaviour displayed by the strangers they encounter (which at first glance may often seem obscure and inadequate) within the logic and conditionality of the particular contextual setting.

Students will also be introduced to the central concept and methodological approach of counter-transference (as modified by the ethnologist and psychoanalyst George Devereux): According to this concept – contrary to a widely shared assumption – researchers and other professionals working with people too respond emotionally to these persons and the conditions or behaviours observed in connection with them. Such emotional responses range from sympathy to various feelings of ambivalence to fear or aggression, which can impact upon professional interaction as well as prolong or shorten it, or even lead to selective perception and specific interpretation of observed behaviours and even persons. Following Devereux, researchers or doctors are asked to systematically observe and reflect upon their own subjectivity and employ their findings, as it were, as an examination tool in its own right that will – in addition to other methods – yield a more holistic and rounded image of the other [5]. Encounters with homeless people can – as a result of their often radically different way of living and occasionally extreme physical neglect etc. – trigger particularly striking responses from those providing help; a situation that serves well as an introduction to systematic self-reflection, among other things, on behavioural patterns that are likely to result from such emotional responses.

In addition to concepts and methods based in anthropology/ethnology and ethno-psychoanalysis, the seminar also teaches the basic principles about the general social, economic and legal conditions affecting the life of people without a permanent address. Cooperation with relevant institutions plays a major role in this: Our main partner is Frankfurter Verein für soziale Heimstätten e.V. (FV), in the summer semester we additionally have Elisabeth Strassenambulanz (ESA) (backed by: Caritasverband Frankfurt/M.) on board. The FV is an institution that has close ties with the City and offers an extensive range of services to different groups of homeless in Frankfurt/Main. During the winter months FV social workers drive the Kälte-Bus to those spots where the homeless are known to congregate and, if required, supply them with tea, blankets and sleeping pads. The social workers are the first points of contact for the homeless and, if required, will arrange placements offering follow-on support services, including transport organisation. The ESA provides services aimed at improving the health of women and men in housing difficulties, bearing in mind the unusual living conditions of these people. That a profound knowledge of the particular needs of homeless people as well as of institutional and legal possibilities in dealing with homeless people plays a central role in designing and implementing meaningful teaching concepts has been widely discussed in Anglo-American literature [11]. However, the focus there was on teaching concepts that concentrate mainly on providing medical treatment for socially marginalised groups, and less on the meta-level of systematic self-reflection and the ability to take on a different perspective, which is the focal point of the project presented here.


Implementation

The seminar is structured into a preparatory theoretical-methodological module, a practical module, namely the field work (in the winter semester with the Kälte-Bus, in the summer semester visiting social work in the context of the ESA), and a follow-up module. The seminar groups consist of around 10 students; this figure is based upon the limited number of individuals when accompanying the Kälte-Bus and in the context of the ESA (one student per appointment).

The first part of the preparatory sessions (2 hours) takes place in the classrooms at Giessen University. Here students are informed about the legal, social and medical situation of people “on the fringe of society”; previous experience and expectations from students are likewise discussed. In addition, students are familiarised with the experience of patients rejecting their offer of support, which can often be disconcerting; this includes introducing them to the different perceptions people have of “illness”, and to the concept of “counter-transference”. The structure of the responsible social institutions, particularly those based in Frankfurt (FV, ESA; among others) is presented and practical information on the planned field trip given. Students are invited to pay particular attention to “people on the fringe of society”: “The field work starts now.”

The second part of the preparatory session (2 hours) takes place on site in the rooms of the FV in Frankfurt – a preliminary stage of the field trip: The students leave their familiar environment in order to gain new and unfamiliar impressions. In the rooms of the overnight shelter, amidst the homeless persons staying there, FV social workers provide in-depth information interspersed with specialist and personal contributions. They also shed light on the medical and social situation of the individuals in the shelter and discuss expectations and particularities as regards the organisation of this part of the field work with the students.

The “field work” proper does not take place in the group setting, but students go out invidudually: One student at a time accompanies the FV or ESA social workers on their on-site visits to homeless people. A 6-hour period is scheduled for this hands-on experience; in the winter months it includes a trip on the Kälte-Bus between 8 p.m. and 2 a.m.; in summer the field trip lasts just as long but takes place during the day or in the evening. Students accompany the social workers on their visits on foot or by bike or in the car; some students get to attend call-outs on the ESA’s medical bus.

During the feed-back sessions (2x2 hours) students relate the different impressions they have had, contextualise them and explain how they felt, thus creating a wide spectrum of different impressions, evaluations and responses, which provide ample opportunities to reflect upon ways of action and potential changes in perception when dealing with patients. Possible essay topics (the seminar is assessed by essay) begin to take shape; these are discussed in-depth and in relation to how individual students approach their work, as well as formal specifications. In the essay students are asked to present their own personal observations and experiences during the field trip (e.g., feeling insecure in the unfamiliar environment, personal responses to coming face to face with the living environment, the appearance and behaviour of homeless people); in a second step the aim is to reflect upon these observations and their significance for medical thinking and acting.


Evaluation

Given the limited number of participants (ten students per semester) and the relative short period for which the seminar has been available (since the 2010-11 winter semester; only three seminar groups have fully completed the class) we are thus far only able to qualitatively comment on the course; the total number of participants is still too low to allow for any meaningful quantitative-statistical analysis.

To date, 31 students overall have participated in the seminar: 16 women and 15 men. The anonymous written evaluation contained three open questions (“Positive aspects include …”; “Negative aspects include …”; “What do you take out of this experience for your further studies?”) and nine questions to be answered by way of a graded scale (school grades A to F). Among these, three questions were of a general nature (“Please assess how much you have learned”; “Relevance for training as a medical doctor”; “Overall school grade”), six related to specific aspects of the seminar, such as design and structure of the teaching concept, preparation of the lecturer, availability and comprehensibility of relevant information/literature or learning environment.

The overall feedback on the structure of the course, on the preparation of the lecturer (B.M.) and on the learning environment was between positive and very positive (grade B or A in analogy to the school grading system). The questions “Was the seminar interesting?” and “The seminar encouraged reflection” received the top grade (“A”). Somewhat in contrast – likewise an unanimous perception – the relevance for hands-on practical application (“… relevant for my training as a doctor”) was recognised but felt to be less positive (grades B and C). In answering the open questions, the “on-site” experience with social workers and (in a different response) the “individual tuition” as a result of this was perceived to be particularly worthwhile. Another positive comment was that attention was drawn to how a person’s concrete living environment affected their health. Finally, “the opportunity to “look outside the box” was felt to be a “profound experience” that would shape the students’ further course of studies. The essays too contained statements that reflected the intensity of the seminar and the potential inherent in the anthropological approach complemented by field work and participant observation. The following statement has been taken from the discussion section of one of the essays: “Never before did I look at Frankfurt’s Bahnhofsviertel in this way […]. It’s a completely different world.” Another participant in the seminar felt that the field research method “opened up an exotic world [for him]. The human being that crosses our daily horizon as a penniless and neglected figure on the periphery suddenly gets to be at the heart of our attention.” Both in the evaluation and occasionally also in the essays the wish was expressed to actually extend the practical part of the seminar.

Arrangements for receiving written feedback from seminar participants at predefined intervals (one, two and five years) have been made, and interviews about the long-term effects of learning and reflection processes are planned with focus groups. The findings will potentially be presented and debated by way of future publications.


Discussion

The preliminary experiences we gained with the teaching concept “Providing medical care on the fringe of society: Participant observation and change in perspective” illustrate that the spectrum of methodological approaches in Q 2 (AOÄ) can indeed be complemented by concepts from medical anthropology, in combination with exposing students to people in extreme social situations. The objective of getting students to reflect systematically upon historical, ethical-normative and theoretical foundations in medicine can therefore be extended and intensified in particular as regards the following three aspects:

1.
making students aware of the importance of the specific local setting in medical thinking and acting (aided by the concept of participant observation and field research from ethnology),
2.
the importance of the subjectivity of all those involved in doctor/patient interaction, including medical staff (aided by the modified concept of counter-transference from ethno-psychoanalysis), and
3.
the fact that key medical terms (such as medically defined need vs. individual needs of the patient) are essentially context-dependent.

At a more general level students will learn how to put themselves in the position of different protagonists in a range of medical settings, and practice the skill of reflecting critically upon putative conceptual/theoretical and normative-ethical assumptions in medicine.

The teaching project therefore ties in with international models that likewise seek to integrate these teaching objectives in their medical training. The method of field research (or inspired by this in the context of medical training that of “cultural immersion”) has proven to be very helpful for understanding the perceptions and needs of socially or ethically marginalised groups, and in principle all other groups in health care [4], [6], [10], [12], [13][. In relation to this in the context of the new teaching concept the attention on “social determinants of health” and how they impact on the pathogenesis and course of health conditions yield synergies with other teaching concepts, for example in medical sociology, community medicine/public health or general medicine [10], [22], which focus on similar matters. Collaborations with community medicine practitioners working for example at technical colleges/Fachhochschulen or other institutions outside universities could likewise bear relevance.

The teaching concept is essentially transferrable. In order to do so, it will be necessary to know and familiarise oneself with the central (medical) anthropological concepts and methods. Further, opportunities will have to be created that will enable cooperation with such institutions that are willing to set up the organisational framework and make available their expertise to enable the direct contact of students with people on the fringe of society in their everyday living environments.


Acknowledgement

The new curricular option described here could only be realized through the co-operation and engagement of many members of staff at the Frankfurter Verein für soziale Heimstätten e.V. as well as the Elisabeth-Straßen-Ambulanz Frankfurt/M. (ESA). We want to express special thanks to Heiko Ewald and Christine Heinrichs, together with the staff of the “Kältebus”-Project, the Ostpark-Project, the Beratungszentrum für Aufsuchende Sozialarbeit, as well as Dr. Maria Goetzens and her team at the ESA.


Competing interests

The authors declare that they have no competing interests.


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