Editor’s note: In January 2019, we published a research project “Identifying and Transmitting the Culture of Emergency Medicine Through Simulation”. I highlighted some of the theory behind this work in an earlier post you can access here. In true anthropologic style, our research team has continued to consider our positioning in the project – how we affected the research and how the research continues to affect us. The below is a reflection from Dr. Charlotte Alexander (@CharAlexander) who collaborated on the project. I hope you enjoy reading her thoughts as much as I did. We start to see that the process might just be as important as the outcomes…
If you asked me twelve months ago what ethnography was, I would have looked at you blankly. Today, it’s changed my perspective. But I’ve gotten ahead of myself…let me go back to where it started.
Four years ago, I was an eager third year medical student taking part in a simulated emergency department exercise. We had a two-hour shift during which we saw patients within a mock department complete with actors playing patients, task trainers for procedures, and staffed by real ED nurses, registrars and consultants who would guide us along the way (as they still do for me today!). I can’t remember all the details of the patients I saw that day. What I can remember was the immense sense of belonging I felt working as a team with an ED registrar and nurse. I remember feeling extremely nervous when I had to call an ‘inpatient registrar’ and the terror I felt when they asked me questions I didn’t know the answers to. As much as I practiced the application of my medical knowledge and skill, I also soaked in how the doctors and nurses spoke and acted. I felt like this could be my tribe and I had to learn its rules.
Fast-forward four years and I’m a junior doctor in ED continuing to enjoy the satisfaction of working with a team, and still, occasionally, getting nervous calling inpatient registrars. Our department has had a visiting Canadian emergency registrar and anthropologist, Eve Purdy, who I have worked with on the floor but also on a couple of research projects. When Eve heard of the simulated ED the university runs for it’s students she saw a gold mine of cultural data and encouraged me to join on the project!
Ethnography, I’ve learned, is the study of a group’s culture. We all recognize our specialty as having a specific culture – but defining it can seem impossible. Even anthropologists, who are literally the experts on the subject, have trouble giving culture a precise definition. In general, it is agreed to be a shared and learned set of values, beliefs and practices shared amongst a group. These values, beliefs, and practices then influence how any member of that group thinks and acts.
The simulated ED intrigued our research group because it had the potential to act as a mirror to see our own ED culture. When people already indoctrinated into the culture of emergency medicine create a ‘mock’ emergency department it might illuminate what that group values. What type of patients fill the bays? How does an emergency registrar act when in their own role compared to when they’re imitating a cardiology registrar? What is the physical layout like? Why does that matter? What tasks are vital for the students to do and what can be forgone? All this would give an insight into what we value, what we believe and what we do.
So, I re-entered the SimED four years after I was a participant in the exercise. For two days I became a participant-observer for an ethnographic study of emergency medicine culture and how we transmit that culture to students. For details of our results check out the study itself. What I gained more than anything however, was the process. The act of looking for the underlying values that can drive our thoughts and behaviors has helped me attune to when these help us, and when they don’t. When beliefs are solely based on what our ‘tribe’ believes and not necessarily what is true and when are practices are purely for the ritual.
For example, during the simulation I noticed doctors (with no involved students) doing a paper round of the department despite there being no real patient danger, pressure for time, or bed block. Could a paper round sometimes be just a ritual? What significance does it hold? When the emergency registrars impersonated their inpatient colleagues they often felt they had to be more ‘mean’ towards the students. Do we really believe all our inpatient colleagues are mean while we’re always friendly? I know this isn’t true.
A few weeks later I was sitting on my couch listening to the distressed lament of a friend of mine from a different service – a surgical registrar. She had been caught in the middle between her consultant wanting a CT and the emergency consultant refusing. Completely unbeknownst to the patient whom would ultimately get the scan, the argument became far more than a simple difference of opinion. It’s an argument I’ve seen many times. Different patients, different settings and yet it usually runs the same. From the narrative I heard, it seemed each party might have assumed the worst of their colleague’s motivations. It struck me that this was not really about the scan at all, but rather a difference in values and beliefs – a cultural misunderstanding – about what that scan would add to the clinical picture and why it was or was not important. Too often, I find we don’t give those outside our specialty the benefit of the doubt as we would our own colleagues. A recipe for disaster when our values, beliefs, and practices differ.
I listened to her story not as an emergency doctor, but as her friend, and with a new anthropologic lens. I could see exactly where she was coming from. I could feel her distress. More than disagreeing about medical management, she was hurt by the way she had been treated by the emergency department. Despite some competing demands and goals, doing the best for patients really is a common thread. We need to sort out how to navigate differences while retaining that perspective. Maintaining relationships, especially in moments of conflict (which are inevitable and not inherently bad), is critical to our work as physicians and as members of functional healthcare organizations. I wonder if we could have a friendly helpful surgical registrar in emergency simulations? I wonder if surgical simulations could have knowledgeable emergency doctors? I wonder if when we are reviewing areas of shared expertise in teaching, all relevant parties could be present? I wonder, if we could view our differences with curiosity rather than hostility. I certainly know we can try.
Culture contributes significantly to who we are and how we behave. It guides – sometimes gently and sometimes forcefully – what is important, what to do and how to act in any given situation. Medical students learn specialty cultures to allow them to survive and thrive in the medical world, our simulation exercise expedited that process. The vast majority of what we found in this hidden curriculum was positive, but recognizing our culture’s influence on us is a powerful step to catching when it can lead us astray – and when we might need to change.
Featured Photo via pxhere