A certain art of uncertainty: case presentation and the development of professional identity
Introduction
Acute-care medicine is fundamentally about action. Doctors must act to intervene in a patient's clinical course, and such intervention depends on the intersections of three fundamental attributes: knowledge (an understanding of relevant anatomical and biomedical domains), skill (an ability to perform required procedures) and attitude (an orientation or stance that facilitates the appropriate clinical action). Clinical training has traditionally tended to focus on knowledge and skill. Consequently, medical educators have paid little attention to how attitudes are reflected in and reproduced by their practices. Yet appropriate attitude is essential to effective clinical action.
One attitude that has drawn research attention is that of “uncertainty”. The articulation of uncertainty as an essential and defining component of clinical practice has provoked a rich literature in medical anthropology. In a seminal 1957 study, Fox (1957) articulated three origins of uncertainty: limitations of individual knowledge, limitations of knowledge in the field, and the challenge of distinguishing these two. She described how the approaches to uncertainty taken by students evolve throughout medical training, from an anxious focus on individual limitations of knowledge towards an acceptance and accommodation of limitations in the field. Similarly, Light (1970) broadly outlined the strategies medicine employs in response to uncertainty, such as a focus on technique and a tendency towards interpersonal dominance (p. 316). Others have argued that the “tolerance for ambiguity” is a necessary characteristic for quality care of ambiguous medical conditions (Geller, Faden, & Levine, 1990). In reaction to Fox, Atkinson (1984) has reasoned that the presence of uncertainty in medicine does not necessarily mean paralysing doubt. In fact, certainty reigns in spite of limited knowledge, since, while “medical knowledge and practice [may be] inherently ‘uncertain’… the ‘certainty’ of dogmatism and personal judgement are responses to that on the part of the clinician” (p. 954). As these positions illustrate, the attitudes of uncertainty and certainty are central and potentially problematic in clinical discourse; in fact, Lester and Tritter (2001) have recently connected the “the use doctors make of uncertainty” (p. 859) with patterns of medical error. The importance of how uncertainty is approached and portrayed reflects the rhetorical nature of doctors’ talk about patient cases: it is not only descriptive but also constitutive and persuasive within the organizational nature of medicine, what Atkinson calls “the collective and dispersed character of clinical work” (Atkinson, 1995, p. 53).
The case presentation is an inter-professional form of communication that facilitates the collection, construction, transportation and presentation of medical data to varying audiences during the course of a patient's care in the hospital. Thus, the clinician's ability to manage the attitudes of uncertainty and certainty in the case presentation is essential to successfully inducing the cooperative activity of the team on behalf of the patient. This paper examines the rhetorical and linguistic features of uncertainty and certainty in case presentation, and considers how students learn to reproduce these features in their own discourse. Further, it explores the pragmatic and problematic implications of this discursive, attitudinal learning for students’ professional socialization.
As it functions across the medical community, the case presentation form reflects what Schryer (1994) has characterized as genre's “inherently ideological” nature: it “[embodies] unexamined or tacit ways of performing some social action” (p. 108). The case presentation is rarely questioned by healthcare providers: it is, simply, “common sense”, the way things are done when patient information needs communication to another member of the healthcare team. But, as genre theorists in many professional domains are discovering, such common sense forms of discourse are situated and situating: they both respond to and reproduce the communities that they serve (Pare, 1993; Segal, 1993; Giltrow & Valiquette, 1994). Form is more than merely formality. Genre theory approaches formal structures as rhetorical, arguing that standardized ways of communicating that users take to be common sense are motivated by and responsive to particular audiences, purposes, occasions, and contexts of situation.
“Motive”, a pivotal term in rhetorical theory, refers to the purposeful nature of language, used to induce change in attitude or action in the listener/reader (Burke, 1969). Whether they are conscious of it or not, students’ and physicians’ language is always motivated, arguing for some interpretation or another, some action or another. Many studies of case presentation illustrate the rhetorical nature of this standardized healthcare discourse, its motivatedness (Hunter, 1991; Arluke, 1977; Anspach, 1988; Lingard & Haber, 1999; Pomerantz, Ende, & Erickson, 1995; Atkinson, 1995; Cicourel, 1986; Haber & Lingard, 2001). One dominant set of motives is the production and protection of scientific objectivity. For instance, Hunter (1991) finds that the way physicians “story” patient experience as a “case” is reflective of their values and attitudes towards subjective experience of illness and the priorizing of objectively assessed signs over subjectively recounted symptoms. Similarly, Arluke (1977) suggests that medical accounts in morbidity and mortality rounds are presented as objective, factual reports of patient data for the purpose of deflecting blame for and reinforcing the sense of natural inevitability (not human fallibility) associated with undesired medical outcomes such as death.
Another cluster of motives underlying case presentation is professional socialization. Anspach (1988) explored the values embedded in grammatical features such as the passive voice and verbal account markers, considering how “the case presentation serves as an instrument for professional socialization” (p. 372). Lingard and Haber (1999) found that both the structures of relevance in case presentation format and the current trial and error approach to learning how to determine relevance when composing a presentation may “result in the acquisition of unintended professional values” (p. 313). And Pomerantz et al. (1995) suggested that the discursive exchange surrounding the case presentation provides a means for “educators [to] get novices to discover for themselves precisely what the professionals hold should be discovered” (p. 163). Similarly, Atkinson's (1988) work considered the discursive strategies “whereby students are coached to recognize and describe the manifestation of disease” (p. 179) through the “joint display of clinical reasoning” orchestrated in the “shared talk at the bedside” (p. 186).
Another aspect of the “motivatedness” of case presentation is its regulatory function within the established medical community. For instance, Cicourel (1986) argues that shared talk at the bedside teaches that medical decisions are “constrained and facilitated by interactional and bureaucratic regularities and practices” (p. 110). In this capacity it acts like an official language, which Bourdieu (1991) characterizes as a legislative and communicative code that “[ensures] among all members of the ‘linguistic community’…the minimum of communication which is the precondition for economic production and even for symbolic domination” (p. 45). Professional membership is regulated and evaluated by reference to an established set of community standards and values that are reflected in the presentation genre. In this respect, the case presentation is a critical genre for initiates to master, because it influences not only their entrance into this professional community but also their sustained success in it.
The case presentation serves the apprenticeship activity as it simulates the professional presentation while allowing for guidance, error, play and performance. The case presentation is neither strictly a school genre, with their contrived, displaced nature, nor stringently a workplace genre, with their rich inter-textuality and multiplicity of audiences and purposes (Dias, Freedman, Medway, & Pare, 1999). In reality, the case presentation is both a school and a workplace genre: it legitimately engages students in the activity system of “cognitive apprenticeship” (Brown, Collins, & Duguid, 1989).1 The presentation is contrived in that student presenters are being guided through the motions of diagnosis and persuasive argument but have none of the responsibilities associated with either. Yet it is always also a vehicle for medical work, even when performed by a student, as the morning rounds presentation is often the staff physician's first introduction to the newly admitted patient.
As Lave and Wenger (1991) report, citing Jordan, “learning to become a legitimate participant in a community involves learning how to talk (and be silent) in the manner of full participants” (p. 105). Thus, “for newcomers…the purpose is not to learn from talk as a substitute for legitimate peripheral participation; it is to learn to talk as a key to legitimate peripheral participation” (p. 109). “Talk” is the glue that holds collaborative healthcare together. Trying out this talk in their reports of patient histories, requests for laboratory services, and orders for specialty consultations, students experience the role of talk in the distribution of labor, the inducement of cooperation, and the negotiation of responsibilities. In learning to talk, as Lave and Wenger so pointedly put it, the novice physician acquires a feel for—and a place in—the “long-term, living relations between persons and their place and participation in communities of practice” (p. 53).
Section snippets
Objectives
This study is part of a multi-disciplinary, multi-institutional research program investigating the role of case presentation in the socialization of the healthcare professional. It explores: (1) how novices learn the strategies associated with the situated language practice of case presentation and (2) how this language acquisition shapes novices’ developing professional identities.
Setting
The study was conducted within the context of the third-year pediatric clerkship at an urban, tertiary care,
Information handling
Transcript analysis yielded results on two dimensions: evidence of case presentation “moves” or “strategies” and evidence of the teaching and learning of these moves or strategies. Five dominant themes were apparent across these two dimensions: Thinking as a Student, Thinking as a Doctor, Strategies of Case Presentation, Teaching Strategies, and Identity Formation. The last three of these five categories are beyond the scope of this paper and will be taken up elsewhere; this paper considers the
Acknowledgements
This research was funded by a grant from the Social Sciences and Humanities Research Council of Canada (#410-00-1147).
References (42)
Training for certainty
Social Science & Medicine
(1984)- et al.
Tolerance for ambiguity among medical studentsImplications for their selection, training and practice
Social Science & Medicine
(1990) Strategies of influence in medical authorship
Social Science & Medicine
(1993)Notes on the sociology of medical discourseThe language of case presentation
Journal of Health and Social Behavior
(1988)Social control rituals in medicineThe case of death rounds
The clinical experienceThe construction and reconstruction of medical reality
(1981)Discourse, descriptions and diagnosis
Medical talk and medical workThe liturgy of the clinic
(1995)- et al.
Boys in whiteStudent culture in medical school
(1961) Forgive and rememberManaging medical failure
(1979)
Situated cognition and the culture of learning
Educational Researcher
A rhetoric of motives
The reproduction of objective knowledgeCommon sense reasoning in medical decision making
The scope of grammarA study of modern English
Worlds apartActing and writing in academic and workplace contexts
Training for certainty
Anyone for tennis?
Genre and knowledgeStudents writing in the disciplines
Learning medicineThe constructing of medical knowledge at Harvard medical school
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