A Spy in the House of Healing

Transcription

1 A Spy in the House of Healing Fiona Webster, PhD Assistant Professor, Department Family and Community Medicine University of Toronto Cross-appointed: IHPME, IMS, Wilson Centre, Surgery

2 Presentation Overview Autobiographical Research Narrative The Embedded Social Scientist Role Politics of Identity The Scientist Question Ethics of Field work Institutional Capture The role of the academy and research funding

3 Four types of reflexivity Confessional Theoretical Textual Deconstructive Douglas Foley, Critical ethnography: the reflexive turn in Qualitative Studies in Education, 2002, Vol. 15, No. 5.

4 Auto-ethnography/Standpoint Two main moments in academic life in which I experienced bifurcated consciousness and also moved into sociology as a discipline Feminist theory for me was radicalizing and helped me make sense of my life Smith s work in particular resonated

5 Standpoint Critical to Smith s conception of the social Always begin in actual experience as a starting point Speaking to people as competent practitioners of their everyday lives/work But this is starting point Want to learn how things are organized or put together or coordinated through text

6 The Embedded Social Scientist Role Emerging interest in qualitative research (not the same as social science research) Qualitative research from a positivist model Qualitative research as procedural (Eakin & Mykhalovskiy, 2005) Increasing MD interest in this approach Not a corresponding increase in publications in medical journals

7 Identity Politics But you re not a real scientist, are you History of the struggle for legitimacy between physicians and scientists has been well documented But also long history of struggle between natural science and social science Marx, Durkheim both positivists Weber argued that research is scientific if it offers a systematic approach to researching questions and problems.

8 Identity Politics Debates continue Scientist or researcher? Although our knowledge of the external effects and reception of science have increased, our understanding of the complex activities which constitute the internal workings of scientific activity remains undeveloped. Latour No one really knows what it is that scientists do

9 Identity Politics Notion of soft science Challenges from without: subjectivity and bias Challenges from within: qualitative research vs critical qualitative or social science research

10 Identity Politics But are you a real social scientist? Qualitative research vs critical or social science qualitative research Challenges from without: subjectivity and bias Challenges from within: qualititive research vs critical qualitative or social science research Another struggle for legitimacy

11 Politics of Identity Becomes more urgent with the rise of clinicians conducting QR in health sciences, shift from SSHRC to CIHR for funding, and changes in academia But why is this occurring?

12 The rise of QR The most difficult barrier to sociological fieldwork in health care is likely to be encountered in clinical medicine. The research method that is least acceptable to clinicians is the qualitative method. Daly/McDonald, 1992

13 The rise of QR The [1992 paper] went on to suggest that qualitative methods should be taken more seriously. Since then qualitative research methods have become far more widely accepted in health services research Although it seems that qualitative research is established in healthcare settings, we are not convinced that it is always conducted appropriately. Pope and Mays 2009

14 Rise of EBM and KT Attempt to Standardize medical practice The gold standard Dissemination through clinical guidelines and other tools Tensions within EBM re: clinical autonomy Grey zones

15 Critiques of EBM RCT s Not always appropriate Not always possible Design and conduct can be flawed Difference between average or ideal study patients and real life patients 15

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17 CIHR Definition KT is a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system. This process takes place within a complex system of interactions between researchers and knowledge users which may vary in intensity, complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge user. 17

18 Models of KT Knowledge to Action Cycle (Graham et al. 2008) Theoretically designed framework to direct how we can think about KTE how we can practice KTE how we can research KTE 18

19 The fall of KT Most interventions effective under some circumstances, none effective under all circumstances Evidence is sparse for many strategies Mixed evidence as to the effectiveness of multifaceted interventions Generalization from trials and systematic reviews difficult due to poor understanding of determinants of professional behavior and barriers to research uptake Grimshaw et al. 2004; Grimshaw, Eccles, Thomas et al. 2006; Hakkennes & Dodd 2007; Wensing, Bosch & Grol

20 Fall of KT/Rise of QR Increasing interest in social determinants of professional behaviour and barriers to research uptake This is qualitative research with an agenda Must lead to product, production and be developed with a knowledge user Mixed methods Ministry evaluations

21 Working with physicians Have you done those 50 interviews yet? Complex and busy clinical environments Increasing demands, some caused by policies such as wait times Credential creep Tend to work very quickly, with increasing focus on efficiency Quantitative studies can often be produced rapidly

22 Working with physicians In hospital settings, most roles are designed to support the staff physician role Nurses, physio-therapists, social workers, medical students, residents Tendency to look for ways that you might support them Notions of academic autonomy remote

23 Working with physicians Highly intelligent, well trained, responsible and committed professionals Increasingly not rewarded for providing good clinical care St. Michael Marmot interview

24 Working with physicians Increasing levels of fear Be careful. You don t want to upset our funders (the Ministry) Language of accountability

25 A day in the life How do you know that people are telling you the truth? Knowing by the numbers Pain scales and other virtual realities You cannot manage what you cannot measure Ontario's stroke care system is already having a positive impact through, among other things, reducing the time it takes for patients needing life-saving clot-busting drugs to receive treatment by 35% since 2000.

26 A day in the life Could you add a bio-statistician to the team? Focus on doing qualitative research by quantitative methods

27 A day in the life Stop being critical and add something constructive Increasingly less room for resistance, for critical reflection, for social action Constant need to improve and speed up Issue of clinical well-being

28 So where are we now? The sociological imagination Isolation Gender, race, heterosexism, homophobia fell away Am I a sociologist, an ethnographer, a health services researcher, a social scientist, a critical qualitative researcher or a social work?

29 Ethics In most accounts of the other, the dominant group is writing Douglas Foley the hybrid voice This opens up new possibilities

30 Private troubles Job insecurity Pressure to be relevant Pressure to create (and market!) a product Pressure to be innovative Pressure to use updated references Pressure to receive grants No time to think, reflect, read

31 Broader context - academia Public education and civic, participatory social science are in jeopardy. Academics and pacifists critical of the war on terrorism are branded traitors. More and more restraints are being applied to qualitative, interpretive research, as conservative federal administrators redefine what is acceptable inquiry (Lincoln and Cannella, 2002; Shavelson and Towne, 2002). Norman K. Denzin (2003): Performing [Auto] Ethnography Politically, Review of Education, Pedagogy, and Cultural Studies, 25:3,

32 Broader context - academia We re living in a moment when, for the first time, capitalism has become a truly universal system. Capitalism is also universal in that its logic the logic of accumulation, commodification, profit-maximization, competition has penetrated almost every aspect of human life and nature itself. Meiksins-Woods, E(1997). Back to Marx, Monthly Review (49) 2,1.

33 Why do it? Thanks for saying that, I knew what I meant but didn t know how to explain it

34 Anthropology that does not break your heart is not worth doing. Ruth Behar

35 THANK YOU!