Classic Ethnographies

Trisha Greenhalgh discusses classic ethnography texts and their applicability to health services research.

Ethnography is, traditionally, the remit of anthropologists. Think mud huts and pith helmets: months or years living among the ‘natives’, immersed in the strangeness of a distant culture and producing what Clifford Geertz called thick description [1]. More recently, ethnography has been appropriated by both management academics and health services researchers to study the culture of organisations [2-4].

In general, doctors are not trained in anthropology – or indeed in other interpretive methods. The methodology has become distorted and over-rationalized by medically trained researchers whose criteria for excellence have been appropriated from the randomized controlled trial. They may wrongly equate rigour with the use of structured checklists of what to observe, how, and for how long – or for two researchers to make independent observations of the same phenomenon on the assumption that they should both come out of the experience with the same set of ‘facts’. In reality, ethnography draws extensively on subjective methods and rigour is as much about reflexivity (self-questioning) and criticality (considering alternative explanations) as about accuracy or reproducibility of measurement [5].

A standard (and perfectly legitimate) ‘ethnographic’ assignment for medical students in training is to sit discretely on a hospital ward for an hour and count how many staff wash their hands between patients – a task whose findings can be used to both educate students and inform performance management. But such activities are not useful in generating richly theorized accounts of the routines, subcultures, social relations and prevailing norms and rituals of a hospital or ward – which would require more extended observation and interpretive analysis.

Even though a drawn-out period of fieldwork is now almost impossible for the health services researcher, it is still worth reading some book-length classic ethnographies to illustrate the genre and see first-hand how ‘richness’ is conveyed. Here are examples of the best in the genre, starting with some from outside the medical field. They include my own favourites and some suggestions from a crowdsource exercise on Twitter:

Paul Willis’s Learning to Labour: How working-class kids get working-class jobs [6] – based on a year shadowing a class of doomed-to-fail schoolboys from the wrong side of the tracks in the mid 1970s (including joining in their pranks). As  @DrWayneThexton pointed out, whilst Willis’s popular and gripping story is often cited as an outstanding example of the genre, it was not without its later critiques [7].

@KatieRobinsonOT nominated Rebekah Nathan’s My Freshman Year – an account by a professor of anthropology of a year-long spell under cover as a student in her own university[8].  Subtitled ‘what a professor learned by becoming a student’, the book’s power lies in Nathan’s ability to convey, from the perspective of an undergraduate, why it makes sense to (for example) miss classes, hold back from speaking up in class even when you know the answer, and even collude in minor forms of cheating.

Another of my own favorites is Van Maanen’s ethnographic study from the 1970s of the local police department in a rough downtown neighborhood. It is replete with earthy thick description that enables the reader to journey with the anthropologist and share his subjective reactions to the unfolding of events.  Take this list of the terms used by police to refer to alleged or potential criminals:

“The asshole – creep, bigmouth, bastard, animal, mope, rough, jerk-off, clown, scumbag, wise guy, phoney, idiot, shithead, bum, fool or any of a number of anatomical, oral or incestuous terms – is part of every policeman’s world.” [9]

This strong vernacular language, presumably reproduced from verbatim notes made during different periods of fieldwork and later collated under a theme such as ‘descriptors of alleged criminals’, conveys key elements of the culture of the police force studied. Their self-assigned role was not ‘community relations’ but ‘containment of assholes’. As Van Maanen’s account richly demonstrates, much was implied by this – and much followed from it.

One of the all-time classic ethnographies in medicine is Erving Goffman’s Asylums: Essays on the social situation of mental patients and other inmates [10],  first published in 1961 and nominated by @davemack. Here, for example, is the opening paragraph of the book, which describes the dehumanizing process of being admitted to a ‘total institution’:

“The admission procedure can be characterized as a leaving off and a taking on, with the midpoint marked by physical nakedness. Leaving off of course entails a dispossession of property, important because persons invest self-feelings in their possessions. Perhaps the most significant of these possessions is not physical at all, one’s full name; whatever one is thereafter called, loss of one’s name can be a great curtailment of the self.”

Other classics in the medical genre, written by anthropologists or sociologists who chose to study the behavior and social relations of the ‘natives’ (that is, health professionals) on hospital wards (and, in one case, community based clinics) include:

• Howard Becker’s Boys in White: Student Culture in Medical School [11], also published in 1961. An early account of what we would now call the ‘hidden curriculum – the subliminal messages conveyed to students about what is important and what is required, nominated by @kmcconville21;
• Charles Bosk’s Forgive and Remember: Managing Medical Failure [12] (first published in 1979 and described at the time as “the definitive study of the training and lives of young surgeons”), nominated by @adamHedgecoe;
• John Gabbay and Andrée Le May’s Evidence based guidelines or collectively constructed “mindlines?” [13], a detailed study of how knowledge is generated, exchanged and used in UK general practice, nominated by @drmarionlynch;
• Cheryl Mattingly’s Healing Dramas and Clinical Plots [14], a study of the work of occupational therapists working with people who have sustained life-changing injuries, which surfaces how these professionals help profoundly damaged individuals rebuild an identity and purpose in life through the ‘therapeutic drama’ of physical therapy;
• Samantha Solimeo’s With Shaking Hands: Aging with Parkinson’s Disease in America’s Heartland [15], nominated by Grant Gibson @DrGrantGibson
• Gelya Franks’ Venus on Wheels [16], a classic study of a woman living with profound disability (congenital absence of all four limbs) and encountering the transition from adolescence to adulthood, nominated by Katie Robinson @KatieRobinsonOT;
• Anne Fadiman’s The Spirit Catches You and You Fall Down [17], a meticulous ethnography of the experience of severe epilepsy in the young child of an immigrant Hmong family. She uses thick description to ‘make the familiar strange’ – that is, to depict the strangeness of the American hospital system as seen through the eyes of low-literacy parents from a very different cultural background.

As the above examples illustrate, ethnography that is oriented to producing a rich picture of actions in context and to ‘making the familiar strange’ can complement conventional health services research methods (such as surveys or semi-structured interviews).  I find I am using ethnography increasingly in my own research – see these papers, for example, on the family lives of toddlers with (and without) obesity [18], people living with diabetes [19], use of assisted living technologies by older people with multi-morbidity [20], use of computer technologies by primary care practitioners [21] and decision-making by healthcare commissioning groups [22].

Have you tried ethnography? Or been inspired by some classic texts that are not listed here? Add a comment to this blog!

1. Geertz C: Thick description: Toward an interpretive theory of cultures. In: The interpretation of cultures. edn. New York: Basic Books; 1973.

2. Reeves S, Kuper A, Hodges BD: Qualitative research methodologies: ethnography. BMJ (Clinical research ed) 2008, 337(aug07_3):a1020-a1020.

3. Dixon-Woods M: What can ethnography do for quality and safety in health care? Quality and Safety in Health Care 2003, 12(5):326-327.

4. Greenhalgh T, Swinglehurst D: Studying technology use as social practice: the untapped potential of ethnography. BMC medicine 2011, 9:45.

5. Golden-Biddle K, Locke K: Appealing work: An investigation of how ethnographic texts convince. Organization Science 1993, 4(4):595-616.

6. Willis PE: Learning to labor: How working class kids get working class jobs: Columbia University Press; 1977.

7. Walker JC: Rebels with our applause? A critique of resistance theory in Paul Willis’s ethnography of schooling. 1985.

8. Nathan R: My freshman year: What a professor learned by becoming a student: Penguin; 2006.

9. Van Maanen J: ‘The asshole’. In: Policing Key Readings edn. Edited by Newburn T. Cullompton: Willan; 2005.

10. Goffman E: Asylums: Essays on the social situation of mental patients and other inmates: Aldine Transaction; 1968.

11. Becker HS: Boys in white: Student culture in medical school: Transaction publishers; 1961.

12. Bosk CL: Forgive and remember: managing medical failure: University of Chicago Press; 2003.

13. Gabbay J, le May A: Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ (Clinical research ed) 2004, 329(7473):1013.

14. Mattingly C: Healing dramas and clinical plots: the narrative structure of experience. New York: Cambridge University Press; 1998.

15. Solimeo S: With Shaking Hands: Aging with Parkinson’s Disease in America’s Heartland: Rutgers University Press; 2009.

16. Frank G: Venus on wheels: Two decades of dialogue on disability, biography, and being female in America: Univ of California Press; 2000.

17. Fadiman A: The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures: Macmillan; 2012.

18. Chan C, Deave T, Greenhalgh T: Childhood obesity in transition zones: an analysis using structuration theory. Sociol Health Illn 2010, 32(5):711-729.

19. Hinder S, Greenhalgh T: “This does my head in”. Ethnographic study of self-management by people with diabetes. BMC health services research 2012, 12(1):83.

20. Greenhalgh T, Wherton J, Sugarhood P, Hinder S, Procter R, Stones R: What matters to older people with assisted living needs? A phenomenological analysis of the use and non-use of telehealth and telecare. Social Science & Medicine 2013, 93:86-94.

21. Swinglehurst D, Greenhalgh T, Myall M, Russell J: Ethnographic study of ICT-supported collaborative work routines in general practice. BMC health services research 2010, 10:348.

22. Russell J, Greenhalgh T: Affordability as a discursive accomplishment in a changing National Health Service. Social science & medicine (1982) 2012, 75(12):2463–2471.