Analytic Ethnography and Medical Culture

MCL Guidance

By Dan Dohan

People everywhere are pre-equipped to navigate and understand culture, including the culture of medicine. If you have been a patient, if you have helped a family member or a friend when they were a patient, or if you have provided professional care for a patient, you have navigated medical culture. Navigating is different from understanding – a reality that is regrettably overlooked at times. This post focuses on how we can better understand medical culture.

At the medical school where I work, my clinician and health policy colleagues are unsure what culture is and how it works. They know that one studies culture using ethnography. Most have heard or seen that ethnography is time-consuming and difficult. Reading ethnographic articles or books reinforces this sense that it is a dark and magic art. They find jargon that seems disconnected from their everyday experiences of medical education, biomedical research, and clinical practice. Culture seems accessible only via special training, language, and techniques. They accept this; why should it be different than other scientific sub-fields?

This is far from ideal for scholars of medical culture. Clinicians and policymakers shape and control healthcare. When ethnographers engage them, it can help translate our findings about medical culture into changes in medicine and health. It also is a matter of respect. Those we study should be able to understand what we’ve learned.

This challenge can be framed as follows: How can we build a practical understanding of medical culture? Just doing more ethnography will not do so. Like any scholars left to their own devices, ethnographers will develop a more precise and nuanced understanding of their world. They will coin new concepts and language. They will refine their findings and extend their theories until they rest firmly in areas beyond practical understanding. Without intending to alienate lay people, science and scholarship nearly always do so.

Ideally, ethnography would make medical culture easier to understand and less mysterious rather than the opposite. It would show how patients’, caregivers’, and providers’ beliefs and behaviors influence one another. Insights would feel familiar and resonate with everyday experience.

Ethnography is capable of producing cultural insights that lay audiences understand. The ethnographic study that drew me into the field is Charles Bosk’s Forgive and Remember, which used everyday language to show how surgeons dealt with medical error. His work helped the specialty understand its own work in new ways, and he helped inspire and implement efforts to improve surgical safety culture – a movement he never found entirely satisfying even as it produced better patient outcomes. Authors of other ethnographies of medical culture – Boys in White, which examined how students were socialized to become doctors, and Awareness of Dying, which analyzed how hospital cultures respond to patient death and pioneered the grounded theory approach – had a similar ability to communicate understandings of culture to lay audiences.

These studies are part of an approach to analyzing culture that was common in twentieth century sociological ethnography – an approach that has been termed analytic ethnography. But as Bosk was doing fieldwork and writing his book in the 1970s, ethnography was experiencing a critical turn as it came to grips with its own history. Ethnographers learned to engaged communities in new ways – entering the field more aware of power and more conscious of privilege. Their analyses increasingly acknowledge their own relationships and standpoints to the worlds they studied. As ethnographic writing came to reflect these complex realities of fieldwork, its language became more accurate and precise. But, compared to the style of analytical ethnography, it also became less accessible to lay audiences, including audiences of patients and doctors.

What if we combined analytic ethnography’s lay-accessibility with the self-reflective practices and precise language of the critical turn? This could help patients, doctors, and policymakers understand key questions in the culture of medicine. When, in the course of a terminal illness, do certain patients and families question whether to pursue more treatment? Why do well-meaning innovations such as quality measurement and evidence-based guidelines sometimes spark burn-out among the health professionals they are meant to help? How do experiences of anti-Black racism in housing connect to Black patients’ trust in their doctors? 

These kinds of questions should animate ethnographers who aim to understand medical culture in order to change it. Analytical ethnography describes and understands the mechanisms of everyday life. Some of these mechanisms guide individuals as they navigate the world – they help us understand why daughters care for ailing mothers or how a visit to the doctor’s office becomes so stressful. Some of these mechanisms help us understand how complex institutions, such as a hospital clinic or the profession of medicine, sustain themselves over time. In some of my own work, I’ve attempted to approach the study of medical culture in this way, e.g. pointing out how medical education helps resolve dilemmas of charity care or by suggesting how patients’ socio-cultural orientations may drive clinical trials recruitment alongside biomedical inclusion criteria.

Analytic ethnography approaches studies of culture with a distinct style. I’ll discuss four elements of that style next. After that, I’ll examine some essential lessons from ethnography’s critical turn. These lessons should be integrated into an analytic approach that aims to be a responsible agent for positive change in medical culture.

A pithy summary of the analytical style is: care deeply about each research process. Develop a thoughtful design; select the right sites; collect sound data; analyze data using the right model of causality.

Develop a thoughtful design. MCL authors have suggested that qualitative research generally emphasizes either exploratory, descriptive, or comparative work. Descriptive and comparative designs are best suited for analytic ethnography. These designs include data and analysis from multiple sites or cases. The approaches differ in how firmly the research focus is deductively specified in advance. The focus in comparative designs is more settled than in descriptive work. But both designs allow new, inductive insights to emerge during fieldwork.

Select the right sites. Selecting appropriate sites is all-important. First, do not select sites with the goal of achieving representativeness. Mario Small has pointed out the folly of that approach. He notes that sites matter in ethnography because of what they tell us about social context. So, when deciding how many or which sites you want, do a thought experiment. Imagine you have completed fieldwork. Imagine the stories you have heard, experiences you have witnessed, and background you have learned at each site. Now, imagine those stores, experiences, and backgrounds are substantially similar — and the reverse, that they are all substantially different. Do they provide the insight you need about when, how, or why social life works itself out one way or another? Pick sites that give you the best chance of a successful outcome to that thought experiment. If you find your question requires too many sites or sites you can’t get access to, refine your thoughtful design so that it addresses a question you can answer.

Collect sound data by embracing fieldwork. Robert Emerson offers four points of guidance. First, spend lots of time in the field. More time with subjects leads to more complete understandings of their lives as well as more opportunities to witness change and contingency. Second, focus on issues of importance. Everyday life generates a firehose of information; novice fieldworkers are overwhelmed as they try to capture it all, e.g. my PhD fieldwork experience. Fieldworkers must decide how to focus their energy and invest their time. It is best to make these choices explicit according to the study’s research focus. Third, attend to subjects’ meanings. Ethnography is unique in its ability to learn from listening to what subjects say and attending to what they do. Researchers’ energy and time mustn’t be so focused that they overlook matters that could alter their study’s process or findings. Good fieldworkers regularly try to take a few steps in subjects’ shoes and spend the occasional afternoon chasing down some rabbit holes. These habits enhance study rigor and also make the fieldwork more enjoyable and less stressful. Finally, Emerson reminds us that fieldworkers’ essential job is to document how people make sense of the world. Subject data in field notes and interview transcripts are essential raw data. To place these data in context, researchers’ memos and reflections are invaluable. His book on how to take field notes (with Fretz and Shaw) is essential reading in the craft.

Analyze data using an appropriate model of causality. Quantitative social sciences statistically analyze and adjust data to try to identify and isolate how X affects Y. Such association models consider cause and effect in terms of numeric patterns in data from a representative sample. In ethnography, Mario Small points out, we use qualitative data gathered from a modest number of purposefully selected sites. Under these conditions, quantitative models don’t work. But there are other ways to understand and investigate causality. Stefan Timmermans and Ido Tavory describe a pragmatic approach that focuses the connection between X and Y in everyday life. As they notice such connections during fieldwork, ethnographers should assess what these connections mean to subjects as well as how regularly they occur (and when they don’t). Sharing with other scholars helps ethnographers assess the plausibility and power of these causal explanations. Ultimately, the value of a pragmatic explanation turns on its utility. There is no standard test for causality in ethnographic data — no p<0.01 — so the plausibility and acceptance of a pragmatic claim rests with a community of practice or inquiry.

And now a reminder. These four pointers do not constitute recipe for the scientific study of culture. They are not a spell that will magically resolve the problems of medical culture. They are but one approach for understanding culture. Ethnographers must implement and tailor these approaches according to their objectives, capacities, and research settings. They must do so while keeping in mind that culture is always in flux. As the people under study question, re-examine, and re-interpret their experiences, ethnographers have to draw on all of their tools to understand medical culture as a dynamic force, which changes even as they work to characterize it. 

Ethnography provides a holistic and humanistic account of culture in a particular setting, group, organization, or community. It uses qualitative research to produce narrative, multi-vocal data — data that can be interpreted differently by diverse audiences. Ethnography elevates experiences of oppressed people and marginalized perspectives. It supplies context for other kinds of research, especially quantitative research. It connects readers, authors, and subjects.

The critical turn of the late 20th century reshaped broad swaths of the social and humanistic sciences, and analytic ethnography must heed its wisdom. Ethnographers who focus on the mechanics of social life must exercise good judgement. From the 18th to mid 20th century, it was common for ethnographers to classify and objectify non-white, non-European peoples. They claimed native, tribal, first-peoples, and aboriginal life was inferior and primitive compared to the culture of imperial Europe. Starting in the 1960s, however, anthropologists called out and rejected this use of ethnography. They were quickly joined by scholars in other disciplines.

Today, responsible scholars reject studies that rank or judge cultural beliefs and practices. They refuse to objectify culture because they recognize that culture reflects power. Our beliefs about others are shaped by hierarchy. Our work to learn about others is constrained by inequality. There is no objective, power-free perch from which to learn about others — much less rank or judge them.

Analytic ethnographers in the twenty-first century thus tread a fine line. They work with thick, descriptive, narrative. They critically relate those narratives to power and inequality. Mindfulness of change and contingency keep them forever humble. Ideally, they end up with findings like, “it seems like folks in this community have arrived at belief X for these reasons, while folks in this other community seem to endorse Y because of these other reasons.” They recognize that social life is not mechanical. But they still aspire to – and regularly do – point out elements undetectable through other methods that explain how belief and behavior work themselves out in everyday life.