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A Heart for the Work: Journeys Through an African

Medical School

- Chapter 4-

Today’s Outline

1. The Bodies of Doctors

2. The Habitus of Doctors

Becoming Doctors

Becoming Doctors Wendland is doing a lot in this chapter.

• She is taking us through the next step of the story: what happens in the first stage of medical education for med students in Malawi — the pre-clinical years.

• A lot of things happen, and she is being a great ethnographer and taking us into several different social contexts and showing the richness of this time in these students’ lives.

• She is also continuously making sure to point out how what is happening compares to what we know about this stage in the trajectories of med students in the Global North.

Becoming Doctors I am going to focus on two of the main things she is doing:

1. Showing us how this stage of medical education happens through bodies (the students’ own bodies and the cadavers).

2. Showing us how this stage of medical education happens consists of the taking on of a new habitus (which is also an embodied thing).

The Bodies of Doctors

The Bodies of Doctors

• In this chapter, Wendland shows us that the medical education that she studied does not just happen in the mind: it is a deeply embodied affair.

1. Their bodies turned into the bodies of doctors through learning how to perform the bodily skills of doctors.

2. They started to see and experience their own bodies in entirely new ways.

The Bodies of Doctors

• Through their difficult learning conditions they grew excellent embodied attention: “The capacity to exclude outside distractions would be helpful to them later in the heat of the operating theater or as they examined one patient at a time in a crowded ward” (91).

• Through their lab training (and later on the ward), they trained their senses (hearing, smell, sight, touch) to be sensitive to what doctors need to sense (93). “[T]hey learned the metallic rotten-meat smell of a gastrointestinal bleed and the foul stench of an infection caused by aneaerobic bacteria…” (93).

The Bodies of Doctors

• Through their difficult learning conditions they grew excellent embodied attention: “The capacity to exclude outside distractions would be helpful to them later in the heat of the operating theater or as they examined one patient at a time in a crowded ward” (91).

Wendland points out that while the first years of med school are grueling anywhere, the difficulties faced by Malawian students is unparalleled in the Global North. She says that this “worked rapdily toward cementing students’ sense of professional community” (93). It’s also clear that the scarcity these students are working under is direct preparation for their work as doctors in the resource-scarce Malawi.

The Bodies of Doctors

• Through their lab training (and later on the ward), they trained their senses (hearing, smell, sight, touch) to be sensitive to what doctors need to sense (93). “[T]hey learned the metallic rotten-meat smell of a gastrointestinal bleed and the foul stench of an infection caused by aneaerobic bacteria…” (93).

Wendland notes that they share this with med students from the Global North: “These students, like medical students around the world, also used their senses of smell, hearing, and touch.” (93) What is different, however, is the conditions and diseases that they become quickly familiar with.

The Bodies of Doctors • Wendland shows us that in this period of their education,

medical students began experiencing their own bodies in new ways —and doing so in relation to the bodies of others.

- They experience their own bodies as instances of the anatomy and physiology they were learning in class (“‘the greatest thing is that you find your self more interesting” [93]).

- They train their own bodies to sense the pathology of others (as “normal controls”) (94)

The Bodies of Doctors

Wendland notes, however, the clear differences between the bodies that these med students learned on and those that are learned on in the Global North (e.g. heavy, fatty, older, cardiovascular diseases, cancer vs. skinny, wasted, young, malaria, AIDS) (p. 91-92). No body is a perfectly typical “normal,” but the bodies these students came to see as as close to normal as they could get differend substantially from those used to train doctors in the Global North.

The Bodies of Doctors Another (probably even more) important difference (112-113):

“Researchers studying preclinical training among North American students have consistently described a profound emotional detachment that comes with the process of examining the disembodied body. The detachment or “hardening” taking place in the cadaver lab, in much of this research, is the beginning of a process by which doctors become fundamentally different from other humans…” (112)

• Wendland does not see this kind of emotional “distancing” and “detachment” with the student she studies.

• She suggests this may be to a) more exposure to dead bodies, b) different cultual perspectives of corpses (e.g. witches) .

The Habitus of Doctors

The Habitus of Doctors “Habitus” The embodied disposition that is an

individual’s way of “interpreting and interacting with the world” (94).

“One’s habitus is in part consciously acquired, in larger part learned through unconscious imitation. It reflects one’s membership in certain class, family, educational, and other social categories, but varies among individuals and also in response to external conditions. It is structured, then, a product of the individual and collective past, and structuring, a mode of perception that reproduces groups and classes. One’s habitus is durable but not fixed (…) never simply a conscious product of adherence to rules. It sets the conditions for one’s perceptions of and actions in the world…” (94)

• In addition to the bodily experiences we’ve gone over, Wendland isolates 3 major forces as shaping the formation of these medical students’ habitus:

1. The transition from social differences to homogeneity (in terms of dress, language, behavior) in order to perform a “consistent self-presentation” (95-101)

2. The growing sense of themselves as both true citizens of Malawi, as well as holding a status that set them apart (“citizen-doctors”). (101- 108)

3. A strong sense of their own knowledge and mastery. (108-113)

The Habitus of Doctors

The Habitus of Doctors “Consistent self-presentation” (95-101)

“[T]hese Malawian students moved more or less consciously toward a common way of behaving. Their language, dress, and patterns of interaction converged around a norm (…) [T]hey felt strong internal drives to attain the neat appearance, quiet (but not too quiet) manner, good social skills, and character traits they saw as essential to being a doctor” (100).

• Wendland claims this is in line with the “overt encouragement of conformity to work together to mold students into professionals who share a collective identity “ that has been observed in medical students in the Global North.

• However, her ethnography shows the particularly Malawian forms of difference these students embodied and the particular processes through which those differences came to be homogenized.

The Habitus of Doctors Citizen-Doctors (101- 108)

Wendland claims that in this phase of training, students experience a dual process of both “‘learning to be Malawian’”(101) (largely trough “Learning by Living”) and simultaneously gaining a new status that distances them from most of their country-people.

She notes that in Malawi, the status of medical student was essentially the same as doctor, which meant that these students were already being called “doctor” and treated very differently in the communities they visited (and in their home communities).

In medical training in the Global North, this kind of separation is linked to workload, not to status: the students she studied started thinking of themselves, and taking on the role of doctors, much earlier than med students in the Global North (105-106).

The Habitus of Doctors A powerful sense of knowledge (108-113)

One of the reasons that these students started to seriously take on the role of doctors was their sense of having control of important knowledge that most others didn’t.

They “relished their growing deep knowledge of the human body and saw it as a key component of their ‘doctor’ selves” (108).

“The depth of their scientific knowledge was particularly important to these fledgling physicians because it was the only thing that reliably separated them as doctors from the lower level of practitioners, whose training was more procedurally oriented and less grounded in basic science…” (111)

The Habitus of Doctors A powerful sense of knowledge (108-113)

This bioscientific knowledge also transferred important biomedical values: showing the “truth” of pathology to be located at the individual, physiological level:

“When students talked about medical knowledge, their emphasis was squarely on individualized curative medicine and not—despite the efforts of community health faculty—on public health and preventative medicine. The fundamentals of bioscience training, its focus on hormones and bones and genes, ensured that students absorbed an underlying model of illness as bounded by the individual body” (108-9).

(Remember reductionism, materialism, secularism and individualism?)

The Habitus of Doctors A powerful sense of knowledge (108-113)

In Malawi, this shift has different significances and different effects than in the Global North:

• These students experience this biomedical knowledge as letting them see “through” “traditional health beliefs” (109). “[d]uring their training period, students felt a need to reject pluralism for a biomedical orthodoxy, at least in most of their conversations with me” (110).

• It did not cause an emotional “hardening,” as has been observed in med students of the Global North. Their new sense of knowledge was only felt as a positive, not as a shift that had difficult emotional consequences (this is distinct from their shift in status [110]).

The Habitus of Doctors A powerful sense of knowledge (108-113)

“This was hegemonic knowledge in the making, the exclusion of other possible epistemologies and the elevation of a medical reality in which reductionist empiricism became the only sensible way to see the world” (114).

Summary

Excellent summary p.113 -115.

“The students (…) enthusiasm for the science of medicine was palpable in these interviews, and they eagerly anticipated the opportunity to put their scientific theory into medical practice as their training continued.” (115)

Something to leave off on moving into Chapter 5…