‘You’re judged all the time!’ Students’ views on professionalism: a multicentre study

Medical Education 2010: 44 : 814–825 Objectives This study describes how medical students perceive professionalism and the context in which it is relevant to them. An understanding of how Phase 1 students perceive professionalism will help us to teach this subject more effectively. Phase 1 medical students are those in the first 2 years of a 5‐year medical degree. Methods Seventy‐two undergraduate students from two UK medical schools participated in 13 semi‐structured focus groups. Focus groups, carried out until thematic saturation occurred, were recorded and transcribed verbatim. Data were analysed and coded using NVivo 8, using a grounded theory approach with constant comparison. Results From the analysis, seven themes regarding professionalism emerged: the context of professionalism; role‐modelling; scrutiny of behaviour; professional identity; ‘switching on’ professionalism; leniency (for students with regard to professional standards), and sacrifice (of freedom as an individual). Students regarded professionalism as being relevant in three contexts: the clinical, the university and the virtual. Students called for leniency during their undergraduate course, opposing the guidance from Good Medical Practice. Unique findings were the impact of clothing and the online social networking site Facebook on professional behaviour and identity. Changing clothing was described as a mechanism by which students ‘switch on’ their professional identity. Students perceived society to be struggling with the distinction between doctors as individuals and professionals. This extended to the students’ online identities on Facebook. Institutions’ expectations of high standards of professionalism were associated with a feeling of sacrifice by students caused by the perception of constantly ‘being watched’; this perception was coupled with resentment of this intrusion. Students described the significant impact that role‐modelling had on their professional attitudes. Conclusions This research offers valuable insight into how Phase 1 medical students construct their personal and professional identities in both the offline and online environments. Acknowledging these learning mechanisms will enhance the development of a genuinely student‐focused professionalism curriculum.     

‘…it shows that there's no limits’: the psychological impact of co‐production for experts by experience working in youth mental health

Co‐production is commonly conceptualised as a more equal sharing of power and decision‐making between a dichotomy of service user and service provider, each bringing valuable and different assets to the process. Experts by experience lie in the overlap between this conceptually created duality, providing the services they now do by virtue of having once used services themselves. Previous related studies suggest that their involvement in co‐production could impact positively on their social capital, self‐esteem, self‐efficacy and life skills. However, no studies have been explicitly psychological or phenomenological in nature, and the theoretical basis for such outcomes remains under‐developed. This phenomenological study explored the psychological impact of co‐production for young people who were paid experts by experience for a young person's mental health charity in a large and diverse urban area in the UK, looking at the what of psychological impact, as well as the theoretical why and how. Semi‐structured interviews were conducted with a convenience sample of five males, with a mean age of 25 years. Interpretative phenomenological analysis yielded three master themes: the co‐production approach, I'm a professional and identities in transition. Participants valued a collegiate organisational approach that prioritised empowerment, agency and equality between experts by experience and ‘experts by qualification’, leading to a positive impact on their self‐efficacy and self‐esteem. Co‐production impacted fundamentally on their identity structure, enabling them to explore a new identity as a ‘professional’. The results are framed within identity process theory and point to the potential benefits of this model to co‐production.     

The social utility of community treatment orders: Applying Girard’s mimetic theory to community‐based mandated mental health care

Serious mental illness (SMI) has long posed a dilemma to society. The use of community treatment orders (CTOs), a legal means by which to deliver mandated psychiatric treatment to individuals while they live in the community, is a contemporary technique for managing SMI. CTOs (or a similar legal mechanism) are used in every province in Canada and in many jurisdictions around the world in the care and management of clients with severe and persistent mental illness (most frequently schizophrenia) who have a history of treatment non‐compliance and subsequent relapse. Although there is ongoing controversy around CTOs, their use continues to be on the rise. René Girard's mimetic theory, in which he posits the social utility of the scapegoat mechanism, may shed some light on how established cultural patterns contribute to contemporary responses to SMI: how culture depends on the reproduction of certain narratives, and how these act to shape the identity of those involved. The CTO specifically can be seen to act as a scapegoating mechanism, wherein, by singling out and controlling individuals who appear to threaten social order, social order is restored. This paper reviews Girard's theory, looks at how it has been applied to SMI, and then considers how it may illuminate the social role of the CTO. This examination may provide mental health nurses with insight into the constructed identities of their patients, as well as the role of mental health care within broader cultural narratives.     

The role of ‘social support’ in the experience of fibromyalgia – narratives from South Africa

This paper focuses on the role of ‘social support’ in the experience of fibromyalgia (a musculoskeletal pain disorder) in South Africa. In‐depth semi‐structured interviews were used to collect narratives from 15 participants. Sources of social support constitute important mechanisms for coping with the illness experience of fibromyalgia. In providing a space for consultation and validation of the diagnosis of fibromyalgia, and the person living with the condition, people giving support fulfil a critical role in shaping the experience. The findings show how support from family, partners, and peers plays an integral role in the process of accepting fibromyalgia diagnosis, adapting to the demands of the condition, and seeking help from healthcare providers. The findings also show the ways in which people with fibromyalgia provide support for others with the condition, and the importance of this peer network in shaping the paths and outcomes of this illness experience. The findings of this study corroborate existing evidence that show fibromyalgia to be a complex condition to manage, due to the multiplicity, uncertainty and contestation that feature in the experience of the illness. Additionally, this study presents the challenges related to the limitations of access to healthcare in the South African context, and the utility of narrative approaches in garnering insight into the ways in which social support is harnessed in this environment.     

‘I'm just a walking eating disorder’: the mobilisation and construction of a collective illness identity in eating disorder support groups

The increasing visibility of support groups has prompted a flurry of sociological investigation, much of which explores how groups benefit participants. What researchers have failed to consider is the group itself. Bringing social movement theory to bear on the case of eating disorder support groups, this study seeks to explore how support groups attract and sustain adequate participation. Participant observation in an eating disorder support group reveals that broad diagnostic and prognostic frames, coupled with strong motivational framing and collective identification on the basis of a shared disordered self, promote support group participation. The very processes that enable support groups' successful mobilisation, however, simultaneously construct a collective illness identity, which in turn serves as the basis for participants' individual‐level identity work. More specifically, support group mobilisation processes construct eating disorders as highly consequential, highly symptomatic, chronic, rooted in the self, and uncontrollable. Such findings suggest that support groups may have unanticipated and potentially adverse consequences for participants and thus build on previous work highlighting the unintended health consequences of framing processes. Such findings further contribute to our understanding of how macro‐social forces shape illness experience.     

HIV and tuberculosis: the construction and management of double stigma

Mitigation of the tuberculosis (TB) and HIV syndemic is undermined by critical clinical, operational and social challenges of which the social aspects have been least explored. This paper examines the lived experience of TB disease and HIV from the perspective of affected individuals to analyze how they may think about their dual illness; how they understand their illness with TB in relation to HIV, and vice versa; and how they characterize their (stigmatized) experiences in the context of their perceptions and identities. From February-August 2009, qualitative, semi-structured interviews were conducted with 40 adults with HIV and TB disease at three ambulatory clinics in KwaZulu-Natal, South Africa. Subjective meanings of illness experience were analyzed using modified grounded-theory. Emergent themes on illness perception and disclosure revealed how patients constructed dichotomous identities associated with TB and HIV through social constructs of moral susceptibility and (im)permanence. Each identity was associated with relatively disparate degrees of stigma as a product of labeling, negative stereotyping and discrimination. HIV bore the least desirable identity and invoked the greatest stigma. However, the confluence of the two epidemics rendered TB symbolic and symptomatic of HIV, and enhanced the visibility of AIDS. Dual illness thus introduced a paradox to patients' identity constructions, and produced a unique, overlapping double stigma. This facilitated new forms of stigma against TB, and aggravated existing stigma against HIV. It also conferred visibility to some forms of extra-pulmonary TB. Patients managed their double stigmas through novel forms of information sharing that relied on segregating their dual illness identities. Patients deflected the dominant stigma of HIV through concurrent processes of HIV 'othering' - their symbolic distancing from persons affected by HIV, and 'covering' - their selective disclosure of illness (and identity associated) with TB over that of HIV. Findings call for greater consideration to the complex role of stigma in the delivery of TB/HIV healthcare.     

At the margins of biomedicine: the ambiguous position of ‘Registered Medical Practitioners’ in rural Indian healthcare

This analysis challenges a tendency in public health and the social sciences to associate India's medical pluralism with a distinction between biomedicine, as a homogeneous entity, and its non‐biomedical ‘others’. We argue that this overdrawn dichotomy obscures the important part played by ‘informal’ biomedical practice, an issue with salience well beyond India. Based on a qualitative study in rural Andhra Pradesh, South India, we focus on a figure little discussed in the academic literature – the Registered Medical Practitioner (RMP) – who occupies a niche in the medical market‐place as an informal exponent of biomedical treatment. We explore the significance of these practitioners by tracking diagnosis and treatment of one increasingly prominent medical ‘condition’, namely diabetes. The RMP, who despite the title is rarely registered, sheds light on the supposed formal‐informal sector divide in India's healthcare system, and its permeability in practice. We develop our analysis by contrasting two distinctive conceptualisations of ‘informality’ in relation to the state in India – one Sarah Pinto's, the other Ananya Roy's.     

‘Futureless persons’: shifting life expectancies and the vicissitudes of progressive illness

Medical technological advances can have profound effects on people's lives by extending the life course and creating uncertain futures. This is the case for a number of persons with ‘diseases of childhood’ who can now survive well into adulthood with technological support. This paper draws on a Canadian qualitative study of young men with Duchenne muscular dystrophy (DMD) which examined the effects of a shifting life expectancy on personal identities. Engaging with Pierre Bourdieu's central concept of habitus, we discuss the temporal dimensions of social exclusion and marginalised identities. Participants’ narrative accounts revealed how their dispositions were orientated to a shortened lifespan that exerted damaging effects regardless of actual lifespan. Compounding their material, social and symbolic isolation was a temporal isolation whereby the men had lived every day anticipating that it could be their last for as much as a decade. The findings suggest a need to re‐orient medical and social discourses to serve and include adults with DMD and other conditions previously limited to childhood in their communities.     

‘Nowadays you don’t even see your neighbours’: loneliness in the everyday lives of older Australians

Loneliness is a pressing social issue for older people globally. Despite this, there is a paucity of studies on how older people themselves perceive loneliness and how service providers can support them. This study sought to address the gap using in‐depth and semi‐structured interviews with 60 older people and eight focus groups with aged care service providers in Australia in 2007. A purposive sampling strategy was employed to incorporate maximum participant variation. People 65 years and over were recruited from four large service providers in two Australian states. Our findings show that loneliness is influenced by private, relational and temporal dimensions and whether older people feel that they have, or are seen by others as having, a sense of connectedness with the wider community. Participants expressed the importance of maintaining social contact and having a sense of connection and belonging to the community. Our study highlights both the significance of gathering the views of older people to generate an understanding about loneliness and the need to recognise loneliness as a diverse and complex experience, bound to the context in which it is understood and perceived and not synonymous with social isolation. Such an understanding can be used to both evaluate and improve upon programmes that address loneliness and to help maintain an integration of older people in the community.     

What constitutes ‘good care’ and ‘good carers’? The normative implications of introducing reablement in Danish home care

As populations worldwide are ageing, Western welfare states are currently implementing welfare reforms aimed at curbing the rising need for social and healthcare services for ageing populations. A central element in home‐care reforms in several welfare countries is reablement: short‐term home‐based training programmes aimed at re‐enabling older people to live in their own homes independently of care. In this paper, we explore how transitioning from compensatory care to reablement care is not merely a practical process, but also a deeply normative one. Drawing on Annemarie Mol's concept of ‘ontonorms’ we analyse the normative dynamics involved in transitioning from one form of care to another as reflected in reablement professionals' practices and discourses. The paper draws on 10 months of multisited ethnographic fieldwork carried out from April 2015 to February 2016 in a Danish municipality, including participant observations of reablement practices as well as qualitative interviews with 13 professionals working with reablement. We demonstrate that professionals generally consider reablement to represent a desirable shift in home care from ‘bad care’ practices of making people passive through compensatory care, towards ‘good care’ practices of ‘keeping people going’ despite their limitations. Moreover, we demonstrate that while therapists are valued as ‘good carers’ due to their ability to focus on development and training, nurses and in particular home helpers are devalued as ‘bad carers’ due to their ‘caring genes’ and lack of technical and theoretical skills necessary for documentation work. Finally, we discuss the implications of these normative dynamics, which may risk stigmatising compensating care practices, although this form of care to a large extent continues to coexist with reablement practices. In conclusion, we argue for a more nuanced approach to care, recognising compensatory care and reablement as complementary forms of care, each doing good under different circumstances.     

‘If I can walk that far’: space and embodiment in stories of illness and recovery

Illness and recovery transform embodied experience, and transform the experience of space. Space, in turn, is a valuable resource in the telling of an illness narrative. Starting from a phenomenological perspective that takes the body to be the centre of experience, and hence of selfhood and storytelling, this article offers an argument for and an approach to analysing space as a narrative resource in stories about illness and recovery. Using a case study of one woman's stories about her amputation, it demonstrates how both narrated space and narrating space can be used as devices to structure the narrative and position its characters and interlocutors to construct the narrator's embodied experiences and identities. The article reveals intersections between embodied experience, space, and narrative identity construction, offering a new way of attending to illness narratives and a new way of engaging with narrative space.     

‘I'm not just a number on a sheet,I’m a person’: Domiciliary care,self and getting older

Social care funding is reducing in spite of a growing older population. Within this context, domiciliary services are increasingly failing to deliver care that respects the individuality and heterogeneity of older people. To date, there has been limited research in the U.K. that explores, from the older person's perspective, how care practices interact with self. Using biographical‐narrative methodology, this study takes a constructionist approach to understand the individual's lived experience of care and how it interacts with sense of self. A three‐stage model of data collection was used, beginning with a narrative biographic enquiry, exploring with participants (65 yrs +, n = 17) their journeys into care and any possible relationship to personal identity. Stage 2 involved a two‐week period of diary completion, with participants recording daily reflections on their care experiences. In stage 3, a semi‐structured interview explored the diary entries, linking back to the narrative biographic enquiry to reveal ways in which specific care practices interacted with the sense of self. The findings reveal that a strong relationship between older person and formal carer, forged through familiarity, regularity and consistency, plays a significant role in promoting feelings of autonomy. Furthermore, such relationship mediates against the loss of executional autonomy that often accompanies increasing disability. Maintaining autonomy and control was a recurring theme, including in relation to home, privacy and dignity. Feelings of autonomy are also promoted when formal carers understand the unique ways in which individuals experience ageing and being in the cared‐for relationship. This paper suggests that a care approach should be based on two tenets. First, a knowledge and insight into the importance of understanding and respecting the older person's continuing development of self, and second applying this knowledge to care through a positive, stable and consistent relationship between the older person and the carer.     

Stories of change in drug treatment: a narrative analysis of ‘whats’ and ‘hows’ in institutional storytelling

Addiction research has demonstrated how recovering individuals need narratives that make sense of past drug use and enable constructions of future, non‐addict identities. However, there has not been much investigation into how these recovery narratives actually develop moment‐to‐moment in drug treatment. Building on the sociology of storytelling and ethnographic fieldwork conducted at two drug treatment institutions for young people in Denmark, this article argues that studying stories in the context of their telling brings forth novel insights. Through a narrative analysis of both ‘the whats’ (story content) and ‘the hows’ (storying process) the article presents four findings: (1) stories of change function locally as an institutional requirement; (2) professional drug treatment providers edit young people's storytelling through different techniques; (3) the narrative environment of the drug treatment institution shapes how particular stories make sense of the past, present and future; and (4) storytelling in drug treatment is an interactive achievement. A fine‐grained analysis illuminates in particular how some stories on gender and drug use are silenced, while others are encouraged. The demonstration of how local narrative environments shape stories contributes to the general understanding of interactive storytelling in encounters between professionals and clients in treatment settings.     

‘The world has changed’: pharmaceutical citizenship and the reimagining of serodiscordant sexuality among couples with mixed HIV status in Australia

In this article, I revisit the question of whether HIV can ever be reimagined and re‐embodied as a potentially non‐infectious condition, drawing on a current qualitative study of couples with mixed HIV status (serodiscordance) in Australia. Recent clinical trials have consolidated a shift in scientific understandings of HIV infectiousness by showing that antiretroviral treatment effectively prevents the sexual transmission of HIV. Contrary to common critiques, I explore how the increasing biomedicalisation of public health and the allied discourse of ‘normalisation’ can in fact de‐marginalise stigmatised relationships and sexualities. Invoking Ecks's concept of ‘pharmaceutical citizenship’, I consider whether the emerging global strategy of HIV ‘treatment‐as‐prevention’ (TasP) can open up new trajectories that release serodiscordant sexuality from its historical moorings in discourses of risk and stigma, and whether these processes might re‐inscribe serodiscordant sexuality as ‘normal’ and safe, potentially shifting the emphasis in HIV prevention discourses away from sexual practice toward treatment uptake and adherence.     

‘She's usually quicker than the calculator’: financial management and decision‐making in couples living with dementia

This article explores how married couples managed their finances and made financial decisions when one spouse had dementia, drawing comparisons with the approaches used prior to the illness. More specifically, the article examines the role of social factors in influencing the involvement of people with dementia in financial management and decision‐making, particularly whether a gender dynamic adopted earlier in a marriage similarly influenced a gendered approach following dementia. The research formed part of a larger study of everyday decision‐making by couples living with dementia which explored the role of non‐cognitive factors in influencing whether people with dementia were involved in decision‐making processes. Twenty‐one married couples living at home took part; the recently‐diagnosed were excluded. Qualitative methods ‐including participant observation and interviews ‐ were used to examine the couples’ fiscal management and decision‐making‐processes, the perceptions of people with dementia and their spouses about their current financial abilities and whether any support provided by spouse‐carers influenced their partners’ financial capacity. The fieldwork was undertaken in the North of England between June 2010 and May 2011. Thematic analysis of the data showed that social factors influenced the perceived capacity of people with dementia and the financial practices adopted by the couples. In particular, gender influenced whether people with dementia were involved in financial decisions. The research demonstrated that non‐cognitive factors need to be taken into account when assessing and facilitating the capacity of people with dementia. In addition, as people with dementia were somewhat marginalised in decisions about designating financial authority (Lasting Power of Attorney), spouse‐carers may need guidance on how to undertake advance care planning and how to support their relatives with dementia in major decision‐making, particularly when there are communication difficulties.     

Disrupted faces,disrupted identities? Embodiment,life stories and acquired facial ‘disfigurement’

Questions about the relationship between faces, ‘disfigurement’ and identity intensified following the first facial transplant (2005). Over a decade later, empirical research exploring the influence of acquired facial ‘disfigurement’ on embodied identity disruption and re‐formation remains limited. A common strand of thinking assumes identities are contained within faces. Commentators have suggested that identities can be diminished through ‘disfigurement’ and restored or replaced through reconstruction or transplantation. The authors question this claim and provide a conceptually informed, empirical alternative drawing on the results of a phenomenologically located, narrative study exploring identity shift in British adults following acquired ‘disfigurement’. Findings suggest that faces are important to humans and that identities can be disrupted in the aftermath of facial ‘disfigurement’. Though, the relationship is not simple and cannot be predicted by the degree of corporeal change. Disrupted, liminal and contradictory strands of identity emerged; pre‐existing identities were strengthened, new ones emerged, and other non‐related experiences were also influential. Nuanced relationality was at the heart of participant sense‐making. Consequently, the authors reject the idea that identities are contained within faces and call for the development of a wider social and relational facial phenomenology to more comprehensively explore this fascinating, multifaceted relationship.     

Topographies of ‘care pathways’ and ‘healthscapes’: reconsidering the multiple journeys of people with a brain tumour

People diagnosed with brain tumours enter new and unfamiliar worlds in which they must make complex and previously unimaginable decisions about care, treatment and how to live their lives. While decisions are increasingly based around care pathways, these are embedded in values that often fail to accord with those of patients. In this article, we examine the cases of people with a brain tumour and how they, their families and healthcare professionals navigate and intervene in the course of life‐threatening disease. We use ethnographic data (2014–16) and modified social theory to highlight: (1) patients’ interpretations of disease and care and how they might differ from dominant biomedical logics; (2) complexity and contingency in care decisions; (3) rapid and unanticipated change owing to disease and bodily change; and (4) how people find ways through a world that is continually in motion and which comes into being through the combined action of human and non‐human agencies. Our modified ‘healthscapes’ approach provides an analytic that emphasises the constant precariousness of life with a brain tumour. It helps to explain the times when patients’ feel bumped off the pathway and moments when they themselves step away to make new spaces for choice.     

Masculinities, ‘guy talk’ and ‘manning up’: a discourse analysis of how young men talk about sexual health

Sexually transmitted infection testing rates among young men remain low, and their disengagement from sexual health services has been linked to enactments of masculinity that prohibit or truncate discussions of sexual health. Understanding how men align with multiple masculinities is therefore important for tailoring interventions that appropriately respond to their needs. We draw on 32 in‐depth interviews with 15–24‐year‐old men to explore the discourses that facilitate or shut down sexual health communication with peers and sex partners. We employ a critical discourse analysis to explore how men’s conversations about sexual health are constituted by masculine hierarchies (such as the ways in which masculinities influence men’s ability to construct or challenge and contest dominant discourses about sexual health). Men’s conversations about sexual health focused primarily around their sexual encounters – something frequently referred to as ‘guy talk’. Also described were situations whereby participants employed a discourse of ‘manning up’ to (i) exert power over others with disregard for potential repercussions and (ii) deploy power to affirm and reify their own hyper‐masculine identities, while using their personal (masculine) power to help others (who are subordinate in the social ordering of men). By better understanding how masculine discourses are employed by men, their sexual health needs can be advanced.     

‘Fat girls’ and ‘big guys’: gendered meanings of weight loss surgery

Over 80% of weight loss surgery (WLS) patients are women, yet gender is overwhelmingly absent in WLS research. This article discusses the findings of 54 interviews with twenty‐one women and six men waiting for WLS in Newfoundland and Labrador, Canada. We critically examine the ways that gender shapes the meaning of WLS in these narratives. We explore gendered meanings in participants’ perspectives on their embodied experiences before surgery, social support as they decided to undergo the procedure, and their expectations for their lives after WLS. We draw on feminist theory to explain how these findings counter the dominant gender‐neutral medical model of obesity.