The individual, “characters” and social roles

Recently I read Alasdair MacIntyre’s “After Virtue.” On my other blog I have posted a range of quotes from that I found stimulating and provocative. One chapter, “Emotivism: Social Content and Social Context”, draws heavily on the work of Erving Goffman and also Philip Rieff’s work on therapeutic culture. In this chapter, which I found possibly the least convincing of the book (though perhaps for my own reason), MacIntyre discusses the notion of moral “characters” – the Therapist, the Rich Aesthete, the Manager. Most of his argument is around the Manager as character, in what is an assault on the idea of managerial culture and expertise.  Characters are not the same as social roles:

Characters specified thus must not be confused with social roles in general. For they are a very special type of social role which places a certain kind of moral constraint on the personality of those who inhabit them in a way in which many other social roles do not. I choose the word ‘character’ for them precisely because of the way it links dramatic and moral associations. Many modern occupational roles – that of a dentist or a garbage collector, for example – are not characters in the way that a modern bureaucratic manager is.

For MacIntyre, the Therapist is one of those characters with dramatic and moral associations, although with a caveat you don’t always find in this kind of discourse:

It is of course important that in our culture the concept of the therapeutic has been given application far beyond the sphere of psychological medicine in which it obviously has its legitimate place… Philip Rieff has documented with devastating effect a number of the ways in which truth has been displaced as a value and replaced by psychological effectiveness.

This specific point is not one I am going to discuss at length now. The passage from MacIntyre I have found most helpful in this chapter – and one which perhaps offers a resolution of the somewhat uncomfortable air of “being a Character” is the following:

Contrast the quite different way in which a certain type of social role may embody beliefs so that the ideas, theories and doctrines expressed in and presupposed by the role may at least on some occasions be quite other than the ideas, theories and doctrines believed by the individual who inhabits the role. A Catholic priest in virtue of his role officiates at the mass, performs other rites and ceremonies and takes part in a variety of activities which embody or presuppose, implicitly or explictly, the beliefs of Catholic Christianity. Yet a particular ordained individual who does all these things may have lost his faith and his own beliefs may be quite other than and at variance with those expressed in the actions presented by his role. The same type of distinction between role and individual can be drawn in many other cases. [MacIntyre describes a trade union official who in his role acts in a way that “generally and characteristically presupposes that trade union goals … are legitimate goals” but who “may believe that trade unions are merely instruments for domesticating and corrupting the working class by diverting them from any interest in revolution.

As a psychiatrist, one is very often confronted with a certain response; in practice, in daily life, even in literature and the media. recently I read Patrick Leigh Fermor’s book on monasticism, A Time to Keep Silence.

In it he suddenly imagines a discourse between “a psychiatrist” and the monks, in which the psychiatrist seems keen to dismiss their lives as an expression of various neuroses etc. I can’t imagine, as a psychiatrist, ever doing such a thing; partly Leigh Fermor is reflecting the norms of his time (the 1950s). I have found it helpful, since reading MacIntyre’s passage, to reflect on the distinction between myself as the individual people encounter, and the social role and character they expect to encounter.

#irishmed, Telemedicine and “Technodoctors”

This evening (all going well) I will participate in the Twitter #irishmed discussion, which is on telemedicine.

On one level, telemedicine does not apply all that much to me in the clinical area of psychiatry. It seems most appropriate for more data-driven specialties, or ones which have a much greater role for interpreting (and conveying the results of!) lab tests. Having said that, in the full sense of the term telemedicine does not just refer to video consultations but to any remote medical interaction. I spend a lot of time on the phone.

I do have a nagging worry about the loss of the richness of the clinical encounter in telemedicine. I am looking forward to having some interesting discussions on this this evening. I do worry that this is an area in which the technology can drive the process to a degree that may crowd out the clinical need.

The following quotes are ones I don’t necessarily agree with at all, but are worth pondering. The late GP/anthropologist Cecil Helman wrote quite scathingly of the “technodoctor.” In his posthumously published “An Amazing Murmur of the Heart”, he wrote:

 

Young Dr A, keen and intelligent, is an example of a new breed of doctor – the ones I call ‘techno-doctors’. He is an avid computer fan, as well as a physician. He likes nothing better than to sit in front of his computer screen, hour after hour, peering at it through his horn-rimmed spectacles, tap-tapping away at his keyboard. It’s a magic machine, for it contains within itself its own small, finite, rectangular world, a brightly coloured abstract landscape of signs and symbols. It seems to be a world that is much easier for Dr A to understand , and much easier for him to control, than the real world –  one largely without ambiguity and emotion.

Later in the same chapter he writes:

 

Like may other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.

Now, as I have previously written:

One suspects that Dr A is something of a straw man, and by putting listening to the patient in opposition to other aspects of practice, I fear that Dr Helman may have been stretching things to make a rhetorical point (surely one can make use of technology in practice, even be something of a “techno-doctor”, and nevertheless put the patient’s story at the heart of practice?) Furthermore, in its own way a recourse to anthropology or literature to “explain” a patient’s story can be as distancing, as intellectualizing, as invoking physiology, biochemistry or the genome. At times the anthropological explanations seem pat, all too convenient – even reductionist.

… and re-reading this passage from Helman today, involved as I am with the CCIO , Dr A seems even more of a straw man (“horned rimmed spectacles” indeed!) – I haven’t seen much evidence that the CCIO, which is fair to say includes a fair few “technodoctors” as well as technonurses, technophysios and technoAHPs in general, is devoted to reducing the human to pure information. Indeed, the aim is to put the person at the centre of care.

 

And yet… Helman’s critique is an important one. The essential point he makes is valid and reminds us of a besetting temptation when it comes to introducing technology into care. It is very easy for the technology to drive the process, rather than clinical need. Building robust ways of preventing this is one of the challenges of the eHealth agenda. And at the core, keeping the richness of human experience at the centre of the interaction is key. Telemedicine is a tool which has some fairly strong advantages, especially in bringing specialty expertise to remoter areas. However there would be a considerable loss if it became the dominant mode of clinical interaction.  Again from my review of An Amazing Murmur of the Heart:

 

In increasingly overloaded medical curricula, where an ever-expanding amount of physiological knowledge vies for attention with fields such as health economics and statistics, the fact that medicine is ultimately an enterprise about a single relationship with one other person – the patient – can get lost. Helman discusses the wounded healer archetype, relating it to the shamanic tradition. He is eloquent on the accumulated impact of so many experiences, even at a professional remove, of disease and death: “as a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment”.

Psychiatry and Society blog – 2008-2011

This is far from my first effort at blogging. There was a blog about classical music concerts in Dublin which may still exist out there. There has been a now defunct blog on the University of Warwick site entitled “Philosophy as a Way of Life.” There was a blog called “Taytoman Agonistes” which still exists – it was basically a commonplace book. There has been Scarface Project, , which I tried to get people interested in There has been Alarm Logos of Dublin, which I also have tried to get people interested in

And there was Psychiatry and Society , which was linked with a series of lectures of the same name I organised for UCD undergraduate medical students. The blog was the subject of academic research as you can read here. To quote that abstract in full:

Blogs have achieved immense popularity in recent years. The interactive nature of blogs and other web-based tools seem consonant with contemporary pedagogical theories regarding student engagement, learner-centred teaching and deep learning. The literature on the use of blogs in education and in particular medical education has focused largely on their potential use rather than the practical experience of medical educators.

We designed a series of teaching sessions designed to explore the interface between psychiatry, mental health, and wider social issues.  To complement this course, a blog specifically designed to provide extra information on the material covered was produced, and to act as a forum for discussion. A widely available, free-to-access web based tool was used to create and design the blog. One of the course tutors was the administrator, and invited the other tutors and lecturers from the course to write on the blog. The blog was publicised at the students’ lectures, at which all the students were present, and via the students’ eLearning platform.

To fully assess the effectiveness of the blog in helping students achieve the learning objectives, quantitative measurements are required. A focus group of students was formed to explore medical students’ use of blogs for educational purposes in general, and the use of this blog in particular. These findings, and reflections on the use of the blog from the lecturer’s point of view, are presented

And that’s more or less what we did. The main “reflection” that has stuck with me in the years since was a comment from a participant that she preferred books as they were more interactive than online resources; you can simply underline, highlight and generally write on a book. This has stayed with me as an example of the paradox that “interactive” technology is “interactive” in very specific, designed ways.

The blog is still there in all its Blogspot glory. There isn’t all that much evidence of student interactivity, except here, predictably enough in a post about faith and delusion. I didn’t realise that there have been comments left in more recent years. I am not sure if any make all that much sense, even the ones which aren’t spam (and which are written in the patented Mr Angry YOU ARE JUST WRONG style so common in internet discourse)

Looking through the blog overall, I don’t find much that deserves to survive the inevitable disappearance of blogspot in a few years. I did come across this  amusing story again which reminds me of something else entirely I will (probably) post here. Looking back ,there is a tension between the blog as a sort of electronic notice board (ie lecture A will be on date B) and my attempts to post contact that would evoke comment. This never really panned out. I deliberately kept a lid on prolixity and looked for topics that I thought would be interesting for a diverse group of medical students. Of course, in retrospect, it would have been best to enlist a group of medical students to actually blog themselves. Those days have come and gone, and Web 2.0 is rather old hat now, but it was an interesting experiment.