Sociocultural perspectives on the medical encounter Flashcards
What does the patient-doctor encounter reflect?
The patient-doctor encounter reflects larger societal and cultural concerns. Notable examples include:
- Guilt meeting shame in encounters with Indigenous people
- Patronage expectations in refugee health
Define reflexiveness
Self-Reflexiveness: Medical students have a unique opportunity to be reflective observers due to their position and training.
Institutions socialise us and insulate us from self-reflectiveness.
Medical students are in ideal positions to be reflective observers.
Describe structural violence
Structural Argument
Structural violence is defined as the “avoidable impairment of fundamental human needs” or “impairment of human life which lowers the actual degree to which someone is able to meet their needs below that which would otherwise be possible”
It is often embedded in stable institutions and normalized by social structures.
Describe patronage
support and guidance
Describe Agency arguments and the limitation of agency
Individual agency plays a crucial role in challenging and reforming structures. Personal and social behaviors are intertwined.
Describe structural and agency arguments regarding the Voice
- Yes: advocated by structural advocates and advocacy advocates
- No: counter-advocacy argument: it won’t help people on the ground, and, counter-structural argument “Canberra bureaucracy”
- Abstention: structural grounds (“treaty instead”)
Discuss the micropolitics of client-patron relationships
The micropolitics of client-patron relationships reveal the weak reach of the state into the local level, highlighting vertical relationships formed with individuals of higher status based on reciprocity. This is particularly relevant for refugees, as their survivorship often depends upon patronage.
- State: Influence over aspects like shelter, work, income, and health
- Patron: Individuals providing support and guidance
- Person: The individual seeking patronage
Provide example of refugee health
Somali Refugees in Melbourne
Somali refugees in Melbourne face unique challenges, including cultural and societal factors that influence their perceptions:
- Concerns about vaccines containing pig components: Islam and Outsidership
- Experiences of mistreatment of black babies in hospitals: Connections are drawn between experiences of Aboriginality and Africanness
- Distrust of government information: Refugee Experience
What are approaches medical professionals can take to better understand the context of medical encounters?
- Defamiliarize Yourself: Approach situations with fresh eyes, like encountering a new workplace, technologies, or language.
-
Self-Reflexiveness: Medical students have a unique opportunity to be reflective observers due to their position and training.
Institutions socialise us and insulate us from self-reflectiveness.
Medical students are in ideal positions to be reflective observers.
Encoded Authority in the Medical Encounter
Authority is encoded in medical encounters, often evident through interactions involving technology and language:
- The use of computers in consultations can shape the dynamics and authority within the encounter.
Language and Communication
Australia’s multilingual nature and the importance of language in healthcare:
- Australia’s diverse linguistic landscape, with English being dominant but not exclusive
- The role of interpreters in bridging communication gaps, especially for Indigenous languages
Self-Awareness in Medicine
The importance of self-awareness in the medical profession:
- A call for doctors to introspect and improve self-awareness
- Nurturing the inner journey alongside the professional journey
Describe refugee health expectations
Refugee health
1. Newly arrived refugees are often dissatisfied with their health care, expect their doctor or support to provide more than they can e.g. rapid access to public housing
2. Gifts from the very poor
Consider the Australian Olympic swimming team. Classify as “structural” or “agency” the following reasons advanced for the team not performing as well as expected?
1 The players were too engaged with social media during the Olympic Games
2.The funding for coaches is insufficient to keep excellent ones in Australia.
3. The average swimmer earns less than $20,000 a year
4. Several key players in the team were too complacent about their abilities
5. They were insufficiently encouraged by media commentators
6. The rest of the world has now started to focus on training swimmers
7. The swim meet starts too soon after the opening ceremony.
8. Some of the swimmers were overweight
9. National expectations were falsely high
- Agency
- Structure
- Structure
- Agency
- Agency (here, agency is attributed to both the commentators and the swimmers)
- Structure
- Structure
- Agency
- Agency, if you believe that someone intentionally set the national expectations high (politicians, media commentators, swimming organisations). Structure, if you believe the reasons for falsely high expectations lie in structural reasons (eg 6).
Which of the following is/are examples of structural violence?
1. The failure of the Australian Olympic team to finish in the top six on the medal tally
2. High rates of HIV among prostitutes in Bridge Road, Nairobi
3. Airline policies for men not to sit beside unaccompanied minors
4. Under-representation of indigenous persons in medical schools
5. Exclusion of children of asylum seekers from schools
Correct answers are 2, 4 and 5. [1] may have a structural explanation (see question above), but it is not an example of structural violence because there is no fundamental human need that is served by coming high in an Olympic medal tally. (Remember that Galtung’s definition was that structural violence is the avoidable impairment of fundamental human needs which could otherwise have been met within a society. This kind of impairment often occurs through societal structures that we take for granted and may not question). [3] is not an example of structural violence at present, but rather an idiosyncratic piece of policymaking by airlines which has been condemned on human rights grounds.
[2] is an example of structural violence because prostitutes have reduced access to protection under the law, and because of entrenched male/female atttitudes, and poverty, they have less bargaining power when it comes to making men wear condoms or having access to female condoms (as a side note, the failure of HIV/AIDS aid organisations to support the wide distribution of female condoms to brothels in developing countries – where it is known to be accepted and wanted – is emerging as a contemporary scandal).
Although Indigenous persons in 2014 are at last not under-represented in medical schools, this was the case until 2011. [4] is an example of structural violence because it points to inequalities in access to education and resources which would have made medical school an achievable and sustainable option of Indigenous people
Shame is a central idea that is often called into play in encounters between Aboriginal people and the health service. Which of the following describes the way shame operates for indigenous people?
- It is the sense of embarrassment Australian non-indigenous people feel when they are asked overseas about the life expectancy gap between indigenous and non-indigenous persons.
- It is the internalised feeling of guilt experienced by non-indigenous people when meeting an indigenous person in an impoverished town camp
- It is the indigenous person’s realisation of the pity of health workers.
- It is the social feeling of being shy about an element of oneself which drives one to withdraw from the interaction
- It is the disinterested frustration felt by non-Indigenous persons of goodwill when they are asked to feel personally responsible for the indigenous health gap.
Correct answer is 4. Shame is a social emotion, in that reflects a culturally-moderated way of feeling about oneself in relation to society. In this case, it often elides with the concept “being shy”, which is its superficial meaning when indigenous people use it to explain, for example, why they didn’t ask a doctor a question, or attend hospital when very ill. There is a deeper meaning of shame, which may be the way that it enables a series of displacements from the mainstream to be internalised and turned into a way of responding to the larger society.
Shame occupies a complex position in sociological theories, particularly in relation to marginalised persons. See http://www.soc.ucsb.edu/faculty/scheff/2.html - an essay by the sociologist Thomas Scheff where he very lucidly places shame in social context, and critiques some of the more individualised psychoanalytic approaches which haven’t understood the social roots of shame.
Some of the other answers (eg [1], and [2]) reflect the disquiet of non-Indigenous people when faced with indigenous disadvantage. [5] is frequently raised by persons of goodwill in the health sector, but is disingenuous. When John Howard stated that he had never personally oppressed any Aboriginal person because there weren’t any in his suburb when he was growing up, the true question to be asked is Why weren’t there Aboriginal persons in his suburb? Because society was organised in such a way that their disadvantage and his own advantage were entrenched, and the beneficiaries of that social stratification probably should feel discomforted, even if they were personally quite benign.
You are Bettina Woo, a newly graduated doctor. Lama Tenzing is a newly arrived refugee who has come for an assessment of shooting pain in his legs to see you. Lama Tenzing is a Tibetan. You speak Mandarin, which you learned during your youth in Hong Kong. Lama Tenzing, to your surprise, walks out of the room when you walk in to call him.
List possible reasons Lama Tenzing may have been reluctant to continue the consultation.
- Lama Tenzing may feel uncomfortable with a woman doctor, as there is a religious proscription against women touching monks.
- He doesn’t understand your Mandarin
- It is insensitive to use Mandarin
- You remind him of Chinese oppressors, and he has instinctive difficulty trusting you.
This question is about issues encroaching on the consultation which have nothing to do with the doctor’s attitude, capability or intent. I want to make the case that pragmatic solutions that work then and there are usually the best.
I hope you worked out the first and the third as possibilities. Bettina of course is a very nice doctor, but in this case, it may well be better for her not to be his doctor until he has learned to trust the service, and then can extend that trust to her. Tibetan monks do have a proscription against being touched by women, but [in my experience] are quite culturally adaptable and can adjust to being treated by female doctors. As he is a refugee (ie escaping from a country in which China has been the oppressor) using Chinese to communicate is not ideal, and you would need to check with him if he was willing to use that language, and of course, if you could understand each other. If not use the telephone interpreter service. 131450.
The following are a set of images of patients and doctors in clinical consultations. Rank them in order of (a) autonomy of the patient in the consultation; (b) perceived satisfaction to the doctor in the consultation. (We are seeking here your immediate attitudes, so don’t worry that you don’t know the whole story – just look at the image
and respond)
- Patient: lady in blue standing against bed.
- Patient: lady visible in computer screen (patient in stroke ward).
Example of teleconsultation (resident and patient on screen are responding
To consultation with specialist on the skype) - Patient: young boy injured in Iraq; being carried by doctor
- Patient: woman in intensive care in Ottawa.
Reflection: The autonomy gradient runs: 1-2-4-3, with the lady chatting in outpatients to the heath workers up the top, and the boy requiring rescue by MSF at the bottom. Whether a patient is wearing their own clothes or pyjamas is a good marker of their autonomy. The child in Iraq is an outlier as the social world (not just the hospital) has robbed him of autonomy.
In relation to which seems most satisfying: as in the questions for lecture 10 there is no correct answer here. The point is to note your own strong feelings about where you would locate yourself. A common belief of junior doctors is their sense that international health, especially in war zones, is “real medicine”. Others may feel that the woman in intensive care who requires highly sophisticated technology also displays “real medicine”. Others may feel that being one step away from the patient as in the computerised consult is a step away from “real medicine” as the direct patient contact is lost.
All these pictures illustrate real medicine in action. If you are captivated by the MSF picture, have a think about what it is about it that gets you – it may be the fantasy of rescue, which we are all prone to as doctors. (I speak as someone who spent most of her junior medical years trotting back and forth to African health services, so I have come face to face with the rescue fantasy in myself!). People do need to be rescued sometimes, but the doctor adjusting the lady’s tube in ICU, the group discharge planning for someone’s granny, and the neurosurgeons looking at a screen are also doing something very real and medical.
