Reflecting on medical socialisation

My dad is a sociology lecturer.  When I was a kid, he used to bring me and my brother to work quite often.  So I’ve never had any illusions about how unglamorous an academic’s working life can be.  But there’s one part of it that appeals to me, deeply — teaching.

A few years ago, when Dad started tutoring in a health sociology subject for first-year med students, he began inviting me along, once a year, to run a scenario or hypothetical for his classes.

Total nepotism, but not too dodgy, since I don’t get paid, apart from the enjoyment I get from doing ‘bring your kid to work day’ at 30 years of age.

This week, I presented a scenario on hep B, which is almost non-existent in Anglo-Australians but prevalent around 10-12% in South-East Asian migrants.

I gave students background information on hep B in Australia and asked students to imagine themselves as GPs from clinics with many culturally diverse patients, invited to present their perspective at a consultation forum intended to plan a collaborative multi-disciplinary response to the hep B epidemic in Victoria.

The scenario is pretty true to life — right now, there are working groups and committed practitioners in different disciplines, working to ‘agenda set’ hep B as a priority, or in other words, construct it as a problem in sector discourse.

Note for the positivists: in cultural analysis, ‘constructed’ does not mean ‘not real’; we argue all real things are constructed symbolically, since (to drop into biological essentialism for a moment) everything we know is only available to us through perceptual processes that are highly shaped by mental frameworks and past experience, including socialisation in ideologies like positivism.

One of the challenges in building that multi-disciplinary response is the fact that we speak in different professional languages.

And there’s another layer of our communication, i.e. affect, that seems (in some undefined way) to be really essential to the formation of consensus between players who are all on the same team with regard to getting shit done about hep B.

The idea that you might customise your argument and speak in the same language as the people you are trying to persuade is, to a counsellor or health promotion worker, kind of ‘well, der’.

But it’s less comfortable for some other professions, who see themselves as talking in the neutral, objective language of Science.

Recently I had a disagreement with a doctor — a hero of mine, someone who has done more than anybody else to build evidence and raise awareness around hep B — and it ended with him implying I wanted to ‘ignore people unnecessarily dying’.

Ouch.

People sometimes struggle to customise their arguments because they have an implicit expectation of emotional matching, i.e. that the language and imagery will express the intensity of how they feel about the subject matter.

You see this every time public health practitioners launch a hideously stigmatising fear campaign, despite all the evidence showing that fear campaigns backfire, and then seem all surprised and wounded when the community doesn’t appreciate their sincerity.

In my scenario with the med students, I asked five questions:

  1. What ONE key message would you want to communicate?  (Picking an issue or angle from the scenario text.)
  2. What is our role as doctors participating in a multi-disciplinary consultation?
  3. Which disciplines will be easy to convince, and which harder?
  4. How can we customise our argument to persuade participants from other disciplines?
  5. Which of the readings offered the best framework for identifying barriers to access and possible solutions?

First-year med students are not representative of doctors, because the bulk and most intensive parts of their professional socialization are yet to come.

But it was striking how easily the students accepted the idea that hep B had been pretty much ignored just because it mainly affected an ethnic minority population.

For me, that realisation marked the point when I converted from being professionally interested in hep B to being personally outraged about it.

(The affective dimension, once again.)

But for the med students, it seemed the idea that minority status led to poor health outcomes had been thoroughly naturalised, and there was no outrage.

Maybe that’s an unintended consequence of teaching health sociology to first years?  (Discuss.)

Out of ten small groups, one group (in the first class) did identify ‘frustration’ as part of their key message for the consultation (and I nearly cheered).

Others saw their role as representing the experiences and needs of marginalised communities, contributing practical wisdom from their clinical experience, and acting as intermediaries between public health and everyday people.  (All sophisticated answers.)

In our whole-group discussion, they clearly understood the ethical and empirical difficulties inherent in ‘representing the other’.

As I expected, when it came to customising the message, personality had a strong influence on the communication approaches they preferred.

A couple of extremely bright analytical thinkers, two guys who had wanted all sorts of extra information about hep B before making up their minds, recommended we use statistics to persuade the rational-minded health workers.  One suggested we persuade the higher-up decision-makers, ‘because then everyone else will have to follow’.

By contrast, another couple suggested figuring out what our hypothetical consultation participants’ underlying objectives were, and customising our arguments to those, as well as the policy level on which they worked.

The second class had quite a different group culture, dominated by the cool kids on the middle table, and despite their rebellious stylings, their answers were a lot more formulaic.

Message: community awareness. Our role: medical experts.  Yawn.

Six weeks into first year, some were already beginning to feel aggrieved about ‘doctor-bashing’, and while they could easily imagine perverse incentives for drug companies (“there’s more profit in not finding a cure!”) they had a harder time imagining the same motives influencing medical specialists.

They nonetheless understood that different forms of knowledge are more or less persuasive for different professions and personalities, such as cost-benefit analyses for public health, real life stories for frontline workers, and emotional matching for change agents.

And they quickly understood how getting comfortable in a certain level of discursive power could prevent someone from acknowledging their ‘unknown unknowns’, along with the role of sociological analysis in helping them understand how medical socialization produces tacit  but influential ‘unknown knowns’.

Then we briefly discussed the usefulness of different readings on access, equity and health needs for the hep B consultation.

My argument about sociology was fairly pragmatic.  Being able to analyse your own and others’ disciplinary frameworks can make it easier to diagnose the sticking points in your communication attempts.

Choice of theory is heavily influenced by your personality, and as long as it works (and you check if it does) there is no need to get uptight or religious about it.

This is all very preliminary — more thoughts to follow as they organise themselves in my head! — but I’m really curious whether final year med students would have the same kind of responses to the scenario.

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