Levels of explanation and cautions for a critical clinical anthropology

0277-9536/90 S3.00 + 0.00 Copyright C 1990 Pergamon Press plc

Sot. Sci. Med. Vol. 30, No. 9, pp. 1001-1009. 1990 Printed in Great Britain. All rights reserved

LEVELS OF EXPLANATION A CRITICAL CLINICAL

AND CAUTIONS ANTHROPOLOGY

FOR

IRWIN PREss University of Notre Dame, Notre Dame, IN 46556, U.S.A. Abstract-The

appearance of a critical approach to clinical anthropology raises a question of relevance. Critical medical anthropology itself has developed with a primary concern for the impact of capitalism on Third World health, the inequality of medical resource distribution both in the U.S. and abroad, and the hegemony of Western biomedicine over local medical systems. Such an orientation may be of but modest relevance for an understanding of clinical phenomena in the heartland of capitalism itself. In the U.S., both patients and clinicians tend to share multiple values, including commitment to capitalism and the biomedical paradigm. Moreover, various negative behavioral characteristics visible in the clinical setting (such as racism) are common outside medicine, and may not be profitably understood through usual critical orientations. A heuristic model that gives excessive weight to a single element (capitalism) of a single (macro) level of explanation may not be as useful as one that utilizes a multi-level, multi-element approach. The argument is made that such a broader, more holistic approach may offer greater understanding of so-called micro level processes-specifically the patient/clinician interaction in specific clinical settings. An example is provided from a midwest hospital. It is suggested that if change in the biomedical system is a goal of a critical clinical anthropology, the impact will be greater where objective and broad causal connections can be demonstrated with minimal use of rote or polemic arguments.

Key Izords-critical

anthropology,

biomedicine, holism, clinical interaction

lNTRODUCHON Is ‘critical clinical Anthropology’ a viable and useful subfield of a broader critical medical anthropology? Critical medical anthropology itself has been concerned most commonly with (a) the effect of capitalism, imperialism and/or Western technology upon health status, typically in Third World nations; (b) the logistics, availability, distribution of, and access to biomedical resources, both in the Third World, and in lower income regions or urban neighborhoods of industrialized nations such as the U.S.; and (c) the role of biomedicine as an agent of world capitalism. Clinical anthropological studies most commonly involve the nature of interactions between patients and care givers within the biomedical, clinical setting. This setting is usually in the U.S. or other industrialized, capitalist nation. I suggest that some perspectives of the parent ‘critical medical anthropology’ may be inappropriate to understanding clinical phenomena. This may be particularly the case at the so-called micro level, the locus of clinical encounter between patient and professional within our own society. At this level, clinicians and patients often share cultural (specifically economic and medical) values and expectations. Conceptual tools developed for the analysis of health care in Third World settings-where biomedicine is usually imposed upon a quite variant medical system-may not be appropriate to the investigation of clinical care in the capitalist heartland. The almost exclusive focus upon capitalism and power for interpreting clinical organization and patient management strategies, limits the potential breadth and sophistication of our insights. It distracts our attention from the manner in which the clinical encounter is affected

by other broad values and structures such as medical professional socialization, health organization culture, and both patient and staff world views. Critical approaches often begin with the assumption that health and nutritional deficits [l, 21, asymmetry in availability of health resources [3], medical management strategies, interactional asymmetry [4], medicalization [S, 61, sexism [7], racism [8], classism [9], social control [lo, 1I]-all are a function of capitalism. Although Singer suggests the need for uniting macro and traditional micro approaches, he defines the foci of a critical medical anthropology as largely macro level-global social relationships, their dependency upon capitalism, and the net effect on health and health care. Referring to biomedicine as “bourgeois medicine”, he suggests that a critical approach must recognize biomedicine’s key role in “the promotion of the hegemony of capitalist society generally, and the capitalist class specifically” [12].

PROBLE.MS WITH THE APPROACH

Such views of a critical medical anthropology direct the bulk of explanatory attention to large-scale social and economic factors. These higher-level explanatory models illuminate to some extent the availability and gross organization of medical care, yet offer little insight to ‘on the ground’ medical organization, staff/patient interaction, and the culture of patienthood in specific cases of disease or illness. Zola argued that “by locating the source and the treatment of problems in an individual, other levels of intervention are effectively closed” [ 131. Similarly, by locating the determinants of medical interaction style in the encompassing systems of

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industrial manufacture, finance, trade and political parties that make nation states and international organizations capitalistic, we lose sight of the culture of patienthood and the metaphors of illness at play in clinical settings [14, 151. In a recent critique of dependency theory, Morgan [16] cautions against a monofocal view of the impact of capitalism on Third World health systems. “The rather imprecise relationship between socioeconomic formations and medical practice must not be glossed over when analyzing [other medical systems]“. Most critical approaches are uniformly imprecise in specifying the manner in which a capitalist world system shapes or influences the organization of health care at the level of interaction with patients. Singer’s view that “critical medical anthropology struggles to synthesize the macro level understandings of the political economy of health with the micro level sensitivity and awareness of conventional medical anthropology” (121. expresses an ideal rather than actual practice. The imprecise relationship between political/ economic and medical-interaction factors offers the most serious challenge to a critical clinical anthropology. Particularly when the locus of study exists within an archetypically capitalist society (such as ours), this relationship becomes even more problematic, as does the ‘proper’ object for study and the ultimate goal of the analyses produced. If, as Lazarus and Pappas suggest, the goal of a critical theory is to provide “for a more rational, consensual, egalitarian direction for the [Western] health care system” [17], the linkages between phenomena must be clearly identified. and a monofocal approach to causal explanations avoided. If criticism is to have effect, it must be reasonable, and reflect demonstrable, rather than assumed relationships and causal entities. An overly broad criticism results in little understanding of the many factors that inform the playing out of medical and patient roles within specific settings. Much critical theory appears to single out biomedicine as a unique and often Machiavellian institution. Like Redfield’s [18] ideal urban society (that could taint the folk society through mere contact), Western biomedicine is often viewed as a tainter of local medical culture. Studies such as those of Singer er al. [19], suggesting that replacement of indigenous health behaviors with biomedical practices reflects biomedical hegemony, offer limited insight into the complexity of day-to-day patient decision-making and health-seeking. Limited insight also results from stressing the role of biomedicine in “reproducing class structure” [20] or in reinforcing “the hegemonic ideology emanating from other institutions-the family, schools, mass media and so forth-that pervade a society” [20]. Such rote arguments ignore the fact that all institutions in all societies replicate the basic values and social structure of the society in which they function. This patterning is a familiar-indeed, necessary-characteristic of culture in general [2l]. Nor is it unusual that marriage, work place, religion, recreation and all other institutions in our society-including medicine-help perpetuate both class and economic organization. If they did not, the result would be anomie. Similarly, the appearance in biomedicine of dominant social values, coupled with the medicalization of

PRESS

various sociomoral institutions, is hardly remarkable. A large body of medical anthropological research has been devoted to demonstrating the powerful social control and value maintenance functions of medical systems in primitive and peasant societies [22-261. In comparison with many other systems, Western biomedicine exhibits such medicalization and general value maintenance on a much reduced scale. In Western society, the official medical system is effectively isolated from daily community and family functions, and biomedical practitioners have little effective feedback to patients’ significant others. Critical excess is also exhibited where biomedicine is treated as uniquely racist, sexist, classist, or ageist. Unfortunately, all of these ‘isms’ are part of the U.S. societal base. The general public (including patients), no less than physicians or hospital board members, exhibits these values. Our attention must therefore be focused upon the particular manifestation of these values within the clinical encounter, rather than upon their existence, per se, within the clinical setting. For example, racism in the wider society is ubiquitous, and exhibited by all social institutions. It is typically expressed through differential hiring, promotion and layoffs in the work place, red-lining in mortgage allocation, turf protection and intergroup violence in the streets, school district and political ward gerrymandering, racial endogamy in dating and mating, etc. Less than 35 years ago racism was official policy in many public services and facilities. It is misleading to look to the clinical setting, or to capitalism for that matter, for the source of racism. Recent racial antagonism directed toward African students in China cannot be attributed to capitalism. In the U.S., racism is brought from home to the medical setting by staff at all levels, and by patients. The issue that should concern us is the manner in which racism in this specific setting is generated and manifest. In the clinical interaction, it is frequently expressed through stereotypic preliminary diagnoses (such as PID for single black women presenting with abdominal pains), interpersonal coolness or discourtesy, delay in attention or treatment, harsh or minimally palliative procedures, etc. However, it is not only race itself that triggers such staff behaviors, but assumptions about specific medically relevant phenomena associated with specific races or classes. Lower income blacks, for example, are commonly viewed by white clinical staff as sexually promiscuous and VD-prone, poorly nourished, medically naive and self-abusive in terms of health related social behaviors. Many white staff routinely assume that blacks are likely to be Medicaid recipients, and thus ‘deadbeats’. Moreover, they are often viewed as ungrateful to providers in the bargain. Here, racism is medically phrased, yet not caused by the medical system to any significant extent. Racism, however expressed, is not the only variable at work in guiding the interaction of staff with patients in any specific situation. The patient may be black and perceived as self-abusive, but the staff member in addition may be experiencing a stressful interaction with a supervisor, and facing undesirable shift changes. In other words, staff perceptions of

Critical clinical anthropology (both specific race or class stereotypes and in general) are further structured by the hospital’s organization and culture, staff relationships and tensions, personal professional identity, plus family/ ethnic values, peer pressures, role stresses and other ‘external’ factors. The point to be made is that the clinical setting is the focal point of numerous ideological and behavior patterning vectors that impinge upon institutional organization and staff roles. The same holds for patients, who also share a significant number of values with biomedical representatives. These vectors emanate from numerous social structural levels. ‘Macro’ and ‘micro’ are too imprecise to describe them adequately. Moreover, multiple sources of values and behavior exist at each level. It is unrealistic to focus exclusively upon one vector among many originating at the broadest level of generalization about social organization (capitalism, for example), and to assume its dominance (hegemony) over value and behavioral vectors at all lower levels of generalization about social structure. In order to describe more precise relationships between the different levels of generalization about the clinical encounter, a critical clinical anthropology must attend to a range of causal factors within each of a number of levels. Of course, no single investigation need be so broad, but each should add insight to the linkages between these factors. Ultimately, if our goal is indeed to ‘change the system’, our criticisms must have an aura of objectivity, be fully informed, and thus persuasive to the appropriate gatekeepers (cf. Press [ 171 for a discussion of the utility of arguments expressed in terms meaningful to hospital or medical school administration). patients

LEVELS

OF ANALYSES

The necessity for multi-level critical analysis has been noted by others. Lazarus [28] suggests that we consider not only the interaction between physician and patient, but also the “institutional level or intermediate level between the medical system and the doctor-patient relationship”. Baer et al. [29] propose an expanded analytical scheme with the following levels: 1. Macro-capitalist world system; corporate and state sectors. 2. Intermediate-the hospital; poiicy; administration/staff interactions. 3. Micro social-the doctor/patient interaction. 4. Individual-the patient’s support network; patient’s experiential response to disease; human psychobiological system. Missing from this proposal is an appreciation for independent variables that describe values and social structural imperatives other than political/economic ones. Missing at the lower levels of analysis is a concern for patient and community cultures. This scheme nonetheless directs our attention to the operation of multiple levels of explanation for clinical behaviours and values. To comprehend the nature of clinical interactions, we must examine at least five conceptual levels of independent causal variables, each level

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consisting of multiple broadly reflect:

causal

subelements.

These

a. Societal or large scale historical factors (including shared values and social structure as well as political/economic phenomena. Capitalism is but one among a number of factors, along with nationalism, Islam, Christianity, demography, individualism, etc.). and profession-defining factors b. Institutional (including the structure and values of social institutions such as medicine, and the socialization and value formation of professions). factors (that include C. Local/environmental community type, local economy, neighborhood organization and layout, ethnic identity and availability of health care resources). d. Organizational factors (that include historical, structural and organizational characteristics of the specific clinic or hospital). e. Small scale factors (that center around the clinical interaction-personalities, roles, social support, and world views of the participants, plus the actors’ medical culture, expectations about sickness and definitions of the interaction situation). Various subdivisions could be assigned to each conceptual level, and each furthermore has its impact upon the clinical interaction. The discussion that follows is presented to indicate the complexity of possible causal levels and vectors, and the difficulty in assigning primacy to any single factor in the explanation of clinical behaviors. It deals only with some of the more obvious causal elements within each level, and refers exclusively to Western industrial society. It is an example, rather than a definitive listing. SOCIETAL LEVEL FACTORS

At this, the level of broadest causal explanation, we consider national values, social organization, and social structural input to the clinical interaction. It is important to recognize that these are largely shared by all members of our society. Like Linton’s ‘core’ values, they are not the exclusive property of any one social sector. Autonomy, competition, universalistic interaction, specialization and achievement (versus ascription) are values and organizing principles characteristic of our entire society. Most Americans are committed to these. That the health professions should reflect these values and structural principles is unremarkable. Ours is also a capitalist society. It is characterized by differential access to sources of capital and power, market competition for all goods and services, monetary reward for work, conspicuous differential consumption reflecting differential earnings, and specialized professions controlling access and demanding exceptional income. Not only is the society organized in this manner, but the majority of Americans are committed to, and wish to participate in this structure. That the health professions should reflect specialization, demand high monetary reward and control access to membership through costly and time-consuming training is to be expected, and

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IRWlN PRESS

is accepted by most citizens. AII professions do this. Electrician’s unions are probably more notorious than biomedicine for monopoly of access to membership. A typical citizen cannot wire (nor plumb) another’s home for profit. The professional monopoly of licensed electricians and plumbers (who, on occasion, become clinical patients) is enforced by most local governments, just as biomedicine’s monopoly over various curative recourses are protected by official agencies. At the macro level in American society we also encounter racism, class prejudice, ageism, sexism and a host of other ubiquitous isms. As with capitalism, these are in no way the property of biomedicine, or even particularly characteristic of it. Patients (i.e. the general public) as well as health professionals share them. The difference lies only in the context and manner in which the ‘isms’ are phrased. They ‘explain’ biomedicine no more than they explain sports or moving pictures. The chronic elderly patient may be called a ‘gomer’ in the hospital, and receive less inclusive care. Outside the hospital, the elderly person is an ‘old goat’, or ‘dirty old man’, depending on context. Mandatory retirement and ageist birthday cards clearly reflect negative status in the wider society (see Press and McKool [30] for a discussion of the relationship between status of the aged and societal type). Similarly, emergency department staff disdain the black mother whose daughter is brought in with suspected PID. She is suspected of condoning ‘inappropriate’ sexual behavior. At the same time, this woman is no less disdained by the white supermarket clerk for purchasing ‘inappropriate’ food items with her food stamps. The racism is the same, though the context and phrasing are nonmedical. Finally, Americans share a wide range of values and expectations about the ‘good life’, the nature of work, and the nature of social institutions. Many of these values have been erroneously described as ‘middle class’, as though only the middle classes held them and behaved in accordance with them. These values are societal-wide referents--ideal behaviours and goals that may often be unachievable by middle as well as lower classes. They include the values of permanent monogamous marriage, pregnancy within marriage, nurturant child care, nonviolent social interaction, dignified work, freedom from welfare and dependency, abstention from alcohol and drug abuse, etc. These values are widely held by blacks and Latinos of all socioeconomic levels, as well as white angles, and are lamented in the breech by all groups. They are neither the property of, nor universally exhibited by any single sociocultural or racial sector. When expressed by clinicians, these values are in no way alien to those being sanctioned. Certainly, clinicians exert significant control over the medical management of patients. However, the effectiveness of attempts at broader social control or sanctioning must not be exaggerated. As indicated earlier, clinical personnel are not significant others to most patients. Attempts at control of nonmedical social behaviors would not likely result in patient behavioral change outside the clinical setting. Health and medical concepts are also shared widely in our society. Aside from a minority of ethnics, most Americans view disease as impersonally caused and

curable by recourse to mechanical and chemical intervention alone. In other words, the basic paradigm of biomedicine is generally shared by both patient and biomedical professional (3 I]. The impersonality and

mechanical bias of practitioners is consistent with the paradigm and consistent with the universalistic nature of most other services in our society. Too often the anthropological literature fails to distinguish between clash of basic medical paradigms, and clash of specific explanatory models within a single paradigm. Within the shared biomedical paradigm there is vast room for disagreement over specific cause and etiology. Too often, as well, we generalize from our unacculturated Mexican Americans, Vietnamese, or Haitians and imply that biomedicine’s impersonal paradigm and role structure are shared by few outside the health professions. Clinical care would thus ostensibly involve the imposition of alien causal and curative concepts upon most if not all U.S. patients. INSTITlJTIONAL/PROFESSIONAL

FACTORS

The medical system is one of many institutions in our society that share basic values and organizational principles. Biomedicine (as the official organizer of health care) consists of a number of professions and technical roles, controls access to these, and is responsible for legitimating and policing its members. Organized religion has similar autonomy. So too does railroad engineering. As with most professions in our society (or jobs of any kind, whether well or poorly paid), the constituent professions of official biomedicine are hierarchically organized, and differentially rewarded. Conflicts within biomedicine create problems that affect professionals as well as patients. For example, the autonomy, special controls and high rewards allocated to physicians, have led nursing to a recent re-evaluation of its professional status [32]. Attempting to increase its leverage with physicians and the hospital (where nurses are employees subservient to non-nursing administrators), nursing has recently undergone an identity crisis that spawned a successful move to limit professional access to 4-year college graduates. The 4-year baccalaureate nursing program has a new emphasis upon managerial skills, reflecting the many crises afflicting hospitals since the malpractice and cost-conscious era began in the early 1970s. The new qualifications will make ‘technical’ nurses out of those with diploma and associate (2 and 3 year) degrees, in contrast to ‘professional’ nurses with 4years of university training. Two- and threeyear programs and schools are closing throughout the country, and numbers of their graduates are resigning rather than suffer loss of status and access to higher earnings. In a number of communities, the resulting nursing shortage has led to the hiring of agency nurses at higher wages than regular employees, and implementation of ‘bounties’ or up-front bonuses to attract new nurses. House nursing staff deeply resent these moves, as well as the added workload, and increasingly perceive themselves to be abused by administration. These perceptions, too, lead to resignations.

Critical clinical anthropology Hospitals are dependent upon third party payers with the power to limit reimbursement and thus shorten patient stays. Private sector HMO patients spend fewer days in hospital. Payments for government sponsored Medicare and Medicaid patients are limited by DRGs, resulting in fewer days in hospital. PPO, VIP and other cost-cutting incentive programs of the Blues, put further pressures on hospitals to cut costs by limiting service and discharging patients sooner. Empty beds have led to the closing of wings and the layoff of administrative personnel. The unprecedented competition for patients has placed new burdens on formerly miniscule advertising and marketing budgets. Additional economic pressure derives from a continuing malpractice crisis (the General Accounting Office, in a 1987 report, noted that malpractice insurance costs for physicians and hospitals almost doubled between 1983 and 1985 [33]). It can be argued that malpractice suits are an archetypically capitalistic recourse by patients to the monopoly and organization of biomedicine. Pressures such as these have forced hospitals to hire new types of personnel (such as risk managers, utilization review, patient representatives and quality assurance directors), as well as fire other staff. The growing financial pressure on hospitals has led to an increased emphasis on ‘costing’, often requiring nursing staff to keep strict account of time spent on each task, with little clear reward for ‘hand holding’ or ‘coddling’ patients. Add to this the demand for risk-management mandated ‘incident reports’ (a self-critical accounting of each error of omission or commission), and the alienation grows deeper still. Even the newly popular (among administrators) ‘guest relations’ programs that train staff to interact with patients in a more sensitive manner (cost to implement: $lO,OOO-$100,000 for consultant and audio-visual aids, plus several FTEs for instruction and continued training) may irritate nursing and other personnel. Such programs are often referred to as ‘smile school’ and resented by those who believe themselves to be quite sensitive to patient culture and communication needs in the first place. All of these issues at the national institution/ profession level have an impact upon the localized clinical interaction. While it is certainly true that the ultimate source of these issues and responses is our capitalist economy, this overriding fact does not contribute significantly to our understanding of their specific manifestations and effects upon clinical interactions. In many ways, biomedicine (including clinical physical plant layout as well as personnel) reflects common pressures, demands and crises experienced by other professions and institutions in different form. Differences result from specific manifestations of common societal themes, values, and organizational principles. Capitalism, racism, ageism, the structuring of roles, etc., are expressed in ways specific to biomedicine. One of most potent factors shaping the institution and profession of biomedicine has nothing to do with political/economic issues. This is the special ideology underlying biomedicine. Health professionals belieoe in the truth of the biomedical paradigm, and in the objective truth and efficacy of biomedical methods

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and products. Health care delivery-as well as medicalization of new social or physical realms-thus becomes an altruistic act. Katz [34] speaks of the ‘silent altruism’ of physicians who truly wish to help patients, are convinced that their skills can work. yet who believe that the patient. knowing nothing. has no need for excessive information or active participation in the cure. Medical training creates a value complex that easily overrides political/economic issues in individual clinical situations. For example. Lazarus [26, p. 381and others describe the way in which obstetrical training teaches young physicians to view pregnancy as a real or potential ‘pathological medical episode’. I noted this socialization among medical residents in the obstetrics program at a large inner city medical school hospital. Numbers of women with little or no prenatal care presented in labor, and exhibited a significant number of complications. Commented a senior attending obstetrician: “We can’t accept midwives or ‘simple’ home birth in our society. There musr be an obstetrician present. Too many things can go wrong. Why should we go back to the eighteenth century?” He was sincere, altruistic. his belief complete. It is most doubtful that even unconsciously was he motivated by a desire to control or monopolize childbirth. Whatever the original reasons for the medicalization of labor and delivery, individual biomedical practitioners today sustain this monopoly largely on the basis of medical altruism and belief in their paradigm-not their political or economic concerns. Commitment and altruism, coupled with clinical organizational imperatives, may explain far more specific clinical behaviors than do societal-level political or economic factors (specifically. the capitalistic nature of health care). LOCAL/ESVIRONMENTAL

FACTORS

At the local level, values, institutions and professions converge within a specific community and physical location for actual health care delivery. Neighborhood ‘function’ (i.e. retirement, poverty catchment, residential, entertainment), ethnicity, income, job sources, population and class stability, etc., affect residents’ health status, health beliefs and hierarchies of medical resort. At the same time, these factors influence the number and types of local medical practitioners and services (especially hospitals) that can survive economically in the neighborhood [35]. The effect of the broader capitalist economy is perhaps most visible at this local level, where income and resource distribution create distinct patterns of health, morbidity and recourse to health facilities. It is common for blue collar hourly laborers with no health insurance or sick leave to put off health care consultations until they are no longer capable of working. Clinicians thus see them when they are significantly ill. The result, often, is disdain by the clinician for these patients’ ability to make rational health care decisions. At the same time, income alone does not account for decisions to delay health-seeking behaviors, or seek alternative routes to cures. Ethnicity and acculturation differentials may intervene. Different local patient constituencies

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present local clinicians with the raw material for stereotypes concerning their medical merit and moral worth. ORGANlZATlONAL

FAflORS

At this level, community demographic/cultural characteristics, hospital size and economic structure, hospital social organization and employment history, produce an idiosyncratic configuration that also has complex impact upon clinical interactions. Hospital characteristics affect organization at all levels. Size and type (i.e. community, voluntary, for-profit, religiously affiliated, teaching), etc., have impact upon staff interaction, respect for patients, and style of medical management. Staff are part of a hierarchical organization with competitive demands on time and performance standards. There are frequent opportunities for professional identity infringement. and for the generation of interpersonal conflict and resentment. The patient is one element of the clinical experience that all can control. One need not look to larger political/philosophical arguments for reasonable explanations of this control, particularly when paridigmatic commitment and altruism factors are added to local organizational factors. Finally, all hospital organizational factors are expressed in a specific physical locus. Building size, age. appearance, waiting room facilities, signs and physical organization have further impact upon both staff and patients. S.MALL SCALE (MICRO) FACTORS

This is the level of direct interaction between patient and clinician (as well as between patient and clinic physical organization). Each actor brings a panoply of values and expectations (some of which have already been mentioned), each perceives and reacts to the other’s presentation of self. At this level, all of the professional values, biomedical explanatory models, local organizational stressors and personal world view factors (structured by family, class, social network, etc.) combine to inform the clinician’s perception of the patient’s disease, as well as perceptions of the patient’s sociomoral status, motives for seeking care and worthiness for medical treatment. Thus, in a perverse way (and contrary to what we glibly claim), it can be said that clinical staff regularly respond to the Mvhofepatient presentation of self, not merely to the disease. We must not minimize the impact of staff disdain, for it is backed by power in the clinical setting. The power is real, and it can affect medical outcome. At the same time, we must not generalize upon the impact of this power. Like the patient’s family or gossip chain, the hospital staff’s power of social control and sanctioning is highly situational and contextually limited. It is nor a general power, and (we cannot reiterate this enough) the nonmedical values it reinforces are shared by the wider society. Thus its gross effect on the patient’s extraclinical life must not be reified. At the level of clinical interaction, too, the patient’s personal world view (shaped by work, family, ethnicity, class, network etc., and at least partially shared

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with clinicians), habits, illness beliefs, expectations of biomedical care (building and facilities, practitioners, method, outcome) and definitions of the present situation (i.e. ‘emergency’, ‘chronic’, ‘inconvenient’, ‘uncomfortable’, etc.) come together to structure the presentation to clinicians. It should be noted that patients have some power of choice over various elements of this presentation. Thus, to a certain extent they are able to exert control of their own over the clinical encounter. Selection of symptoms and EMS, the decision to seek care, selection of presentation time, choice of language to describe the problem, personal demeanor and interaction style, plus post-interaction compliance-all are under patient control. We know much about compliance rates, but little is known of the manner in which patients develop and employ strategies of presentation and compliance. We are often too preoccupied with the obvious power displayed by the clinician. A view of the clinical encounter as being under the exclusive control of the biomedical practitioner distracts our attention from the interache nature of the encounter and from the complexity of the motives and expectations of both participants. CESERAL

HOSPITAL-AN

EXAhlPLE

General is a 400 bed not-for-profit hospital in a small sized midwestern city with five other hospitals. Top heavy with Medicare patients (over 45% of admissions. with resulting DRG pressures for earlier discharges and emptier beds), and in a highly competitive market with the other hospitals. it has had to lay off a number of mid-level administrators and nurses in the past 6months. With cost containment in mind, the hospital has maintained a bare-bones nursing staff. This leads to frequent needs for shiftchanging, and moving of nurses around from service to service as vacations, sick days, and resignations create unpredictable gaps in staffing. Nurses viewing themselves as specialized for particular services feel their special professional identities threatened by cross-service staff movements. “How can they expect an OB nurse to work our Cardiac Care Unit with any kind of competence?’ Morale is further threatened, rather than strengthened. by the new guest relations program that requires a round of workshop attendance by all staff, regardless of self-perceptions as ‘sensitive human beings’. Nursing complains that they’d like to spend more ‘personal time’ with patients, “but we don’t get rewarded for it, and we certainly don’t usually have the time for it”. Further resentment results from the lack of physician participation. “They’re the ones who need it most!” is the common complaint of staff who recognize-and resent-the fact that private physicians cannot be compelled to participate for fear they will be angered and direct their patients to a competing institution. Communication between different ranks and types of staff is poor, few knowing the work pace and performance standards established for others. Emergency nurses frequently complain that lab is slow in getting their tests back. “The lab sits on them for awhile, waiting for other tests to come down so they can batch them.” Lab technicians complain that

Critical clinical anthropology administration is pressuring them to be more cost effective, and that emergency personnel don’t understand their needs. “Everything is ‘stat’ with ER, even when it doesn’t have to be.” Task differentiation is frequently a result of defensive practices with unclear rationale. Dietary administrators complain that patients blame their staff for cold food, in spite of the fact that hospital rules (resulting from the malpractice crisis) prevent dietary personnel from placing food trays in front of patients. Some nurses justify the policy by claiming that “we’re the only ones who know whether patients should really be eating, and whether they’re capable of coping with their trays by themselves. Dietary should bring them up-but not distribute them”. Others would be happy to pass this task back to dietary. There is no concensus. Similarly, housekeeping (now calling itself ‘Environmental Services’ to enhance its image) resents the complaints of emergency room nurses and admitting clerks when there are delays in readying rooms for new admissions. “We do get the rooms done quickly, but tce’re not allowed to phone emergency to tell them a room’s ready. We have to tell the floor nurses, and only they are allowed to relay room-readiness info~ation to emergency!” FIoor nurses jealously guard their monopoly over certification of empty beds. Earlier layoffs and a recent increase in patient load has led to frequent staff shortages. To fill the gap, General has been hiring private agency nurses. Resentment against them is high, as they earn $2 per hour more for the same work. Recently, to compete with local agencies, General has organized its own private nursing agency (“Why shouldn’t we get some of the money back?” says the C.E.O.). ‘Sabotage’ is not an uncommon response, as when regular staff fail to tell the agency nurse about a patient’s bed sores at shift-change. It is hoped the agency nurse will overlook it, and subsequently ‘look bad’ to administrators. Staff shortage in the emergency department has resulted in a $1200 bonus offered to new nurses. *‘Hell, I’11just quit and re-sign up” is a common response from old-line personnel. In the emergency department, female staff resent the lone male nurse who ‘sexist’ physicians often single out to discuss an ‘interesting’ case. One of the five physicians constantly criticizes nurses, often openly. Nurses retaliate by failing to inform him promptly of patient needs, and by performing minimal tasks for him. The head nurse has a 3-year associate degree, and took over the ED 6 years ago when a mandatory 4-year baccalaureate degree was still a pipe dream. Today she galvanizes opinion of the majority of her staff (few of whom have 4-year degrees) against the coming 2-tier system. “The only thing these 4-year students get that’s different from my training is more management courses so they can cope with the paper work. We do the same paperwork and we all have to pass the same state exam. We’re as good as they are.” The majority of nurses at General Hospital come from lower and lower middle class backgrounds, are predominantIy white, and very proud (among their relatives and friends) of their nursing and professional identity. They also feel themselves to have special knowledge and abilities. It came as a shock to most that their ‘special’ skills were often

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unappreciated by patients. “We heard nothing about this in nursing school. it was all ideal there.” They resent patients who are perceived as abusing themselves, or ignorant of ‘basic health concepts’. Uniformly, they estimate that the great majority (variably stated as 3 to i) of patients ‘abuse’ the emergency room (and thus, the nurses) by presenting inapprop~ately, or using it as a substitute for private physicians or simple home care. They feel their professional training to be wasted on, and betrayed by drunks, addicts, ‘freeloaders’, and ‘mothers with dribbly-nosed kids’. When the young mother brings her baby in at two in the afternoon “because he didn’t eat lunch, and I think there’s something wrong with him”, they roll their eyes upward and make her wait. Their disdain of mothers whose children consumed some harmful though common household chemical or drug is easily perceived by observers-including the mothers themselves. “What kind of mother is this, who leaves the bleach out?!” An attempt at social control, certainly. But no more than the mother’s neighbor expresses in the local gossip chain. Emergency nurses (and physicians, of course) bring common outside values to work-as do ail society members. In General Hospital, nurses’ disdain of unmarried mothers or assumedly sexually promiscuous black teen-aged girls is no less than that of the nurses’ nonprofessional friends and relations. Here, this disdain is given clinical relevance as nurses disgustedly inform the physician that the IQyear-old black girl presenting with sharp abdominal pains is ‘another crotch case’. The girl is directed to a roomlet that is typically reserved for ‘delicate’ cases of rape, abuse and venereal disease. The label is implicit. In turn, the physician’s diagnostic hierarchy may be subtly influenced, and attention directed to possible PID before cysts, tumors, flu, or digestive disorders are investigated. Moreover, before the physician enters the treatment cubicle he whispers to a colleague, ‘Brown alert!’ -signifying a Medicaid patient (and referring to the color of feces). At General Hospital the emergency triage desk is within earshot of the waiting room. Privacy is impossible, and patients with ‘sensitive’ complaints find they have to lean over and whisper. or look around before presenting their problems. The waiting room itself is organized with chairs in a circle facing each other. Privacy for waiting patients or anxious relatives is thus also impossible. The ambulance entrance shares a common entry hall with the waiting room and triage desk, subjecting everyone in the area to the spectacle--often grizzly--of critically sick or mangled patients. Inside the treatment area space is at a premium. As in most hospitals, General’s ED occupies less than 3% of total building space, yet accounts for over 50% of total patient contacts. Beds are separated by curtains which are often left openparticularly when staff are at their busiest-again, privacy is minimal. While emergency department physical organization may certainly be dehumanizing, the reasons behind this are not clearly a reflection of latent or manifest desire (by whom?) to control the patient. The architects, physicians and administrators who designed the building were constrained by budgetary limitations that are not unique to capitalism. They were also most likely guided by a common

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medicocentric (not capitalist) value: the patient is concerned with important issues of diagnosis and treatment, not with the trivia of privacy, dignity, comfort, or decor. Resources are better allocated to quality equipment and technological sophistication. The door from the emergency department to the adjoining radiology lab is electrically operated. To open it, one must press a square metal plate on the wall. On the door is a sign reading: ‘To open door, press disk’. Patients are frequently confused by this sign, as they look in vain for a round object (disk) to push. Staff may become irritated with patients seeking instruction for operating the door. Here, patients are blamed, not the administrative employee in charge of hospital signage who views ‘disk’ as the symbol for any broad, flat pushbutton. CONCLUSIONS

A critical approach in clinical anthropology is new and in search of a clear goal and conceptual coherence. I have suggested that some of the perspectives of the parent ‘critical medical anthropology’ may not be useful for an understanding of clinical phenomena, particularly the interaction between patient and clinicians. A host of national level values and structural/organizational principles inform most, if not all institutions (including biomedicine), and receive commitment from most societal members. This suggests that a concentration of attention upon capitalism and its assumed by-products of impersonality, classism, racism, etc., as key explanatory factors for the configuration of biomedicine, is misguided insofar as such factors are in no way unique to biomedicine. Rather, they underly the structures of most of our institutions-from marriage to religion. At the broadest explanatory level, therefore, the traditional capitalism-focused critical approach offers no special insight to the understanding of health care organization, values and clinical interactions within the heartland of capitalism itself. If traditional critical perspectives are to be used for the analysis of biomedicine within its own cultural, political and economic bailiwick, they must also be carefully modified to reflect the shared nature of values and world views that link the majority (including patients and clinicians) in common understandings and life strategies. If the goal of a critical clinical anthropology, ultimately, is change in the biomedical system, it is most readily achieved when our analyses and arguments are unassailably comprehensive, and ostensibly objective. Key clinical gatekeepers will pay scant attention to our arguments if analysis is accusation and “etiology includes blame” [36]. No argument can be proposed that does not exhibit a sophisticated grasp of hospital organization. The same can be said for specific linkages between macro level values or structures and specific elements of both hospital organization and professional/patient interaction. Our methodological forte has been holism, and there is no advantage to abandoning it for a critical anthropology. The multi-factorial approach suggested here is consistent with our holistic orientation. While this may indeed increase the level of complication and

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‘noise’ in our data, it provides insight to elements in the biomedical enterprise and encounter that can realistically be addressed. By understanding the predatory aspects of national or world capitalism. we gain little insight to specific changes we may effect in a specific clinical setting. On the other hand, through understanding the interaction and expression of malpractice, cost-containment and nursing crises in both hospital organization and staff attitudes, and the impact of these on hospital competition for patients, we possess insight of direct relevance to the growing industry concern for a more humane and ‘customer oriented’ approach to health care. From a strictly applied perspective, the rise in the past decade of a flourishing ‘guest relations’ consulting industry offers various opportunities for anthropological intervention of a type that can result in immediate changes at the hospital policy level (for examples, see Press [37]). Such practical outcomes of anthropological insight are more likely to result from multi-level, multi-factorial analyses that also appear objective to the targeted clinical gatekeepers. As critical analysis strictly for the sake of criticism has little useful place in our discipline, it would seem that a critical clinical anthropology must view change in the biomedical system-particularly in the organization of clinical care-as a desired goal. It thus serves an applied perspective, regardless of how broadly or theoretically phrased. Precisely how the philosophical basis of a critical clinical anthropology can be integrated with an applied goal awaits further clarification. One thing is certain. The linkages between variables at all levels of analysis must be clearly demonstrated if either heuristic or applied goals are to have an impact. REFERENCES

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