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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Reply privileges

In my early twenties, that guy was me.  These days, I pick my battles.

At any given time, I have a lot on my mind or in my notebook, and not enough time/energy to write it up.  What I love about Facebook and blogging is that I get to talk to amazingly smart people, all around the world, about stuff we care about.

When someone misrepresents me, or tries to drag me off topic, they’re trying to waste my time on correcting them or fighting on multiple fronts.

In my head, people who do that lose their ‘reply privileges’.  Not their right to reply — which is endless — but their claim on my attention, time and energy.

If I post another message in the same thread, it will be for the audience, because I truly believe they’re smart enough to figure out what’s happening and discount it accordingly.  In gay men’s health, there’s so much we need to talk about, there’s just no point getting bogged down fighting old battles with people whose opinions are never going to change.

Rising infections in gay men under 30

If current rates continue in 2009, new cases of HIV in gay men under 30 will be double their number in 2007. That goes against the overall trend for gay men in Victoria, which levelled off in 2008.

I have expressed concern in a couple of interviews about the lack of campaigns targeting gay men under thirty — I think the last one was in the nineties. That gets taken as an attack on the current Victorian AIDS Council campaign using porn images, but I actually think the plateau in overall infection rates shows the current mix of campaigns is doing good.

I also acknowledge the Victorian Government Department of Health for funding and coordinating a reinvigoration of our state’s HIV response.

While I think the explicit sexual imagery matches the sexual confidence and sophistication of men in their thirties and above, it doesn’t work as well with younger men, who are generally less confident, more conservative, and dealing with different issues, like coming out and the gay scene.

Not invariably, but generally.

That’s not just my opinion: it shows up in the social research. Garrett Prestage from the National Centre in HIV Clinical and Epidemiological Research has reported that while they have around the same total number of sexual partners as men in older age brackets, younger men tend to organise their sex lives differently, practicing “serial monogamy” (long strings of short, supposedly monogamous relationships).

Campaigns targeting young gay men need to include relationships and the scene as themes, and they need to address prevention issues relevant to guys in relationships.

Older men might remember the campaign advising men in relationships to close out the HIV test “window period” before they stopped using condoms with each other, but there hasn’t been a campaign about that since the nineties; how is a 23yo guy supposed to know that?

I feel quite uncomfortable raising the alarm about rising infection rates, because I don’t think infection rates should be the focus of campaign strategy in the first place.

The cultural processes that influence sexual behaviour are like a P&O cruise liner: they take a long time to stop. So by the time infection rates begin to rise, you’ve got a big job ahead of you, just trying to turn them around; and you are no longer doing prevention, only damage control.

In their report on The Contemporary Context of HIV Infection in Victoria, researchers Sean Slavin and Marian Pitts quote one young newly HIV-positive man saying:

Then I had my risk re-evaluation. I think a lot of people have it in
their early twenties. As a teenager I was really a safe sex fundamentalist. I redrew my risk profile a bit and started taking more mid-level risks, which were fine by themselves. They probably wouldn’t have caused me to convert. Then I started to top bareback. (p17)

Many of the attitudes our campaigns target in men aged 30 plus were formed in the intense sexual and social learning process men undergo in their twenties. It’s just good sense to invest in campaign work specifically targeting gay men under 30. I am only forced to make a fuss about the infection rate because that good sense has not yet been acknowledged.

Rattling bones

Two great moments took place in 1996. One was the famous Protease Moment, when scientists electrified the Vancouver AIDS Conference with the announcement of the first truly-effective HIV treatment protocol, using a combination of 3+ meds including a protease inhibitor. The other was an Australian social researcher, Gary Dowsett, standing up at the same conference saying the young men in his research study were post-AIDS. They had grown up and come out and learned how to have sex with HIV always in the background; it was nothing new, not a crisis, and didn’t form the centre of their gay existence.

One man in the audience was the gay writer Eric Rofes, and he got the significance of both moments immediately. Within two years Rofes had written and published one of the great classics, Dry Bones Breathe (Haworth, 1998). He castigates “AIDS Inc” for its insistent reliance upon a crisis mentality, and the failure of the “brain trust” to respond to those two great moments. At an AIDS org in SF, he sees all the classics* sitting on a bookshelf, but a staffer tells him nobody there has any time to read them. That sounds familiar, I thought, having worked for the AIDS council in my home state at a time when HIV infection rates were rising.

I had coffee on Friday with a colleague from a PLWHA org in another state who’s working on a project about what sector shorthand calls ‘interesting times’ – a constellation of trends including the normalisation of gay, the declining relevance of community, increasing UAI and serosorting, criminalisation, public health, the Internet, and so forth. It calls for an open mind about how all of these things interact in the current moment, but crisis thinking admits no subtlety and takes no prisoners; at some point in the past 11 years of the culture wars, advocacy became a blood sport.

By “crisis thinking” I don’t mean we’re all still running around waving our hands in the air, although I have seen that happen. I mean the strategic deployment of outrage in response to anyone who questions the norms underpinning the community-based response to HIV. The ever-percipient Rofes called the institutional actors on the conservative moral underpinnings of their insistence on the need for gay men to take personal responsibility for the epidemic, pointing to its continuity with a contemporary moral panic about sex.

That panic was still going strong eight years later, when I made it the focus of a 2006 conference paper on “Barebacking and Bugchasing: Images in a Jurisprudence of Desire”. Without question it underlies much of the argument for gay marriage and the criminalisation of HIV transmission. The problem for the HIV sector in Australia (and elsewhere) is that a full decade later most of our key decision-makers are still no closer to understanding the points Rofes made in 1998 and Dowsett made even earlier.