Researching Medical Culture

MCL Guidance

By Dan Dohan

Medicine and healing create powerful social relationships for doctors and patients. These relationships become a focus for scientists and the lay public as well as in politics and the arts. At its best, qualitative research on medical culture can bridge these diverse audiences.

Qualitative studies of culture are resonant and compelling for politicians and novelists. But scientists and laypeople are a tougher audience. They may question whether qualitative findings about culture are reliable. They may hesitate to trust study conclusions and advice. “Beyond Exploratory” addresses the question: how do such studies convince a skeptical audience? It is guidance for scholars who wish to design a qualitative project that speaks to skeptics.

One source of skepticism is culture itself. Culture changes with context; it means different things to different people at different times; it is hard to pin down. Qualitative researchers use an interpretative approach to capture this slipperiness. It is an approach the Anthropologist Clifford Geertz described as "thick description."  In a famous passage, he showed how thick description distinguishes a blink from a wink. Culture connects “winker” and “winkee” through shared webs of meaning. These shared meanings mean each player in the winking drama understands how to wink, when to wink, and what it means to send or receive one. Thick description peels back the layers of culture to show how it operates in real life.

Ethnographers, novelists, even politicians, love the layers of culture. They are fodder for intellectual exploration and artistic expression. They provide a common ground to connect, exchange ideas, and find agreement. Geertz used a metaphor from Indonesian cosmology to describe these layers. There is an understanding that our world rests on the back of a turtle. That turtle stands upon another turtle which is on another turtle and so on. What is at the bottom? It is turtles all the way down. There is always another turtle, always another meaning to interpret. Analyzing culture never delivers a final truth nor bottom line. So the meaning of culture shifts with context and there is no ultimate bottom line. How do we communicate that to scientific and lay audiences? The first step is to stop expecting scientists and lay people to embrace research that is exploratory and interpretative. Different audiences ask and respond to different questions about medical culture. Each brings a unique lens to their questioning. Qualitative scholars can do research that scientists and lay people can bring into focus. It just needs to be something that goes beyond exploratory interpretation. To engage these broader audiences, it is helpful to consider how to “thin” one’s analysis. One strategy is comparison. Look at turtles in different stacks rather than diving ever deeper into a single pile of reptiles. When we analyze culture across groups or settings, we have to do so in a responsible fashion. We must acknowledge the legitimacy of cultural difference. And we can't shortchange the depths of cultural meaning.

Analysts must be self-reflexive as they draw up cultural comparisons. Before doing thin analysis, a researcher needs to invest time in thick description. A researcher who digs into a single stack of turtles can appreciate how to make sensible and legitimate comparisons. They are then ready to test their insights in a descriptive research project.

In a descriptive project, researchers use insights from one group or setting to learn about another group or setting. Do the ideas and meanings from one place make sense in another? For example, is the culture of an academic cancer clinic of any use when trying to understand care in the safety-net? Audiences with little patience for exploratory case studies may be more receptive to descriptive work.

Finally, a scholar may be ready to compare culture across groups or settings. In comparative studies, scholars compare cases head-to-head. But they do so with an appreciation of the internal dynamics of each. Responsible comparison means recognizing and understanding differences across cases. Comparative ethnography shows academic and safety-net clinics have different cultures. Great start. It is also crucial to interpret and explain these differences on their own terms. How are these differences established and maintained? What practices can be legitimately and meaningfully shared from one to the other? Comparative analysts need to comfortably move within layers of culture. They should know enough to move up and down a single stack of turtles even when they are most interested in comparing a turtle in one stack to a turtle next door.

Unfortunately, it is tempting to jump immediately to thin analysis. Analysts start comparing stacks of turtles they don't understand. They produce rote analyses that are legitimate from the perspective of research culture. But are they legitimate? They align with science but do violence to the cultures they claim to understand.

It is easy to do poor thin analysis when comparing cultures of different racial or ethnic groups. The groups are easy to define. Cultural values, beliefs, and practices are easy to measure. It is easy to draw comparison without considering the deep turtles involved. These turtles include group history, institutional context, and structural situation. I have also seen misguided thin analyses of clinics -- high-performing versus low-performing. It is easy to do thin analyses of private versus public organizations or urban versus rural communities. Scholars may hypothesize that these people, organizations, or places differ in commonsense ways. These hypotheses are often easily confirmed. But responsible scholars of culture have the humility to be patient. They dig down the stack of turtles first. They test out comparisons with a descriptive analysis. They probe their analytic assumptions as they undertake comparisons.

“Beyond Exploratory” tries to be ecumenical about research design. Exploratory analysis often resonates among anthropologists, feminist and critical scholars, and historians. Sociologists, policymakers, and lay audiences may appreciate descriptive studies that blend analysis and context. Health economists, basic scientists, and clinician-investigators want comparative analyses that feature causal explanations.

A  final thought. The statistician George Box pointed out that all models are wrong and some are useful.   "Beyond Exploratory" encourages scholars to analyze culture in ways readers find useful. An interpretative approach, such as thick description or grounded theory, may be more complete and less "wrong." But Box offers a relevant cautionary observation. He said that elaborating a model does not necessarily improve it. If culture is turtles all the way down — and I’ve yet to see evidence to the contrary — better description of deeper turtles will always be possible. But describing ever-deeper turtles may not produce a better understanding of medical culture.

Scholars of medical culture should take a risk on thinner approaches to cultural analysis. The insights they produce may prove sensible, convincing, and useful to many stakeholders.