This is the fourth post in our blog series designed to help you link your teaching with the 2016 Annual Meeting theme, Evidence, Accident, Discovery. The series offers relevant teaching resources to instructors of undergraduate and graduate courses on methods, ethics and theory. Think of it as a week’s course readings in a (virtual) box…
This week’s post comes from Mara Buchbinder, Sue Estroff, and Barry Saunders at the University of North Carolina, Chapel Hill.
Teaching evidence in medicine
As medical school faculty members, we teach first-year medical students in a year-long, interdisciplinary course in social medicine, the first third of which focuses on the sociocultural dimensions of illness, medicine, and healing. One of our sessions on the culture of biomedicine addresses the role of evidence and “ways of knowing” in medical practice. In their clinical training and basic science courses, medical students are exposed to biomedical epistemologies and ideologies that privilege the randomized controlled trial as the “gold standard” in evidence-based medicine and a major source of authoritative knowledge (Timmermans and Berg 2005). Our goal is to explore and challenge some of the implicit assumptions about accuracy, validity, and objectivity that underpin understandings of evidence in medical education, research, and practice.
Informed by perspectives from science and technology studies and the history of science, we encourage students to see that science does not stand apart from cultural influence. Instead, we explore how the production, application, and implementation of medical evidence are shaped by value judgments that infuse every step of the scientific method, from study design to measurement to writing up results, as well as policies that occur much further upstream, such as NIH funding priorities, corporate investments, and peer review standards. We also discuss how the bedrock of evidence-based medicine has been destabilized by the crisis of replicability in the natural sciences (cf. Lehrer 2010).
Another strand of thought that we pursue in this unit concerns the special status of visual forms of evidence in bioscience and clinical practice—as distinct from statistical forms of evidence. This strand draws on anthropologies of sensory perception and tacit modes of knowing. Further, it draws on Foucault’s (1994[1973]) insights about cultural and historical shifts in biomedical epistemology during the late 18th century, which have informed anthropologists’ and historians’ considerations of biomedicine’s highly specialized ways of visualizing the body through imaging technologies and their associated interpretive practices and ritual performances. This approach dovetails nicely with students’ first forays into the cadaver lab, which anthropologists have also analyzed to show how the cadaver lab experience offers socialization into new forms of “professional vision” (Goodwin 1994).
A focus on evidence opens a critical space for addressing other central themes in the anthropology of biomedicine, such as diagnostic uncertainty and medical rationalities. We have found that evidence provides a strong conceptual foundation for unpacking and analyzing medicine’s “hidden curriculum,” and encouraging students to think critically and reflexively about their medical training and ongoing socialization into new ways of seeing and knowing. We have likewise found it useful to revisit these ideas and critical frameworks in the third year, when students intensify their forays into clinical wards and begin to engage with medical evidence in their everyday practice. This is where they encounter and reflect on health care system structures, health policy and insurance: key mechanisms through which evidence meets patients.
Readings:
Blume, Stuart. The Politics of Endpoints. In Devices and Designs: Medical Technologies in Historical Perspective. Carsten Timmermans and Julie Anderson, eds. Pp. 249-272. Palgrave MacMillan.
De Vries, Raymond and Trudo Lemmens. 2006. The Social and Cultural Shaping of Medical Evidence: Case Studies from Pharmaceutical Research and Obstetric Science.” Social Science & Medicine 62: 2694–2706.
Foucault, Michel. 1994[1973]. The Birth of the Clinic: An Archaeology of Medical Perception. Vintage Books, New York.
Good, Byron. 1994. How Medicine Constructs is Objects. In Medicine, Rationality, and Experience: An Anthropological Perspective. Cambridge: Cambridge University Press.
Goodwin, Charles. 1994. Professional Vision. American Anthropologist 96:606-633.
Jones, David. 2000. Visions of a Cure: Visualization, Clinical Trials, and Controversies in Cardiac Therapeutics, 1968-1998. Isis 91:504-541.
Lambert, Helen. 2006. Accounting for EBM: Notions of Evidence in Medicine. Social Science & Medicine 62:2633-2645.
Lehrer, Jonah. 2010. The Truth Wears Off. Is There Something Wrong with the Scientific Method? The New Yorker. December 13.
Montgomery, Kathryn. 2006. Clinical Rationality. In How Doctors Think: Clinical Judgment and the Practice of Medicine. Pp 37-41. Oxford: Oxford University Press.
Munro, Geoffrey. 2010. The Scientific Impotence Excuse: Discounting Belief-Threatening Scientific Abstracts. Journal of Applied Social Psychology 40:579-600.
Porter, Theodore. 2005. Medical Quantification: Science, Regulation, and the State. In Body Counts: Medical Quantification in Historical and Sociological Perspective. Gerard Jorland, Annick Opinel, and George Weisz, eds. Pp. 394-401. Montreal: McGill–Queen’s University Press.
Rhodes, Lorna, et al. 1999. The Power of the Visible: The Meaning of Diagnostic Tests in Chronic Back Pain. Social Science & Medicine: 1189-1203.
Saunders, Barry. 2008. Reading and Writing. In CT Suite. Durham: Duke University Press.
Timmermans, Stefan and Alison Angell. 2001. Evidence-based Medicine, Clinical Uncertainty, and Learning to Doctor. Journal of Health and Social Behavior 42:342-359.
Timmermans, Stefan and Marc Berg. 2005. The Gold Standard: The Challenge of Evidence-Based Medicine and Standardization in Health Care. Philadelphia: Temple University Press.
Interested in attending the 2016 AAA Annual Meeting? Register at www.americananthro.org/aaa2016.
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