Final structure of the collaborative clinical case conference (CCCC) model
From 2015 to 2018, we held 7 sessions at the undergraduate level, and 10 trials in postgraduate and CPD settings for family physicians. Summaries are shown in Tables 1 and 2, respectively.
The final procedures of the conference model, what we call the collaborative clinical case conference (CCCC) model, and the role of clinical faculties, anthropologists, and case presenters are summarized in Figure 1, which is divided into two phases: preparation and implementation. An illustrative example of how the case conference proceeded is shown in Appendix 1.
In the preparation phase of the CCCC, clinical faculties first recruited a prospective presenter, and anthropologists recruited anthropologists who wished to participate in the conference. The clinical faculties, prospective case presenter, and anthropologists formed a team to hold the conference. Next, the prospective presenter was asked to list several patient cases. To retrieve a wide range of suitable cases for analysis with an anthropological perspective, several topics were used by the case presenters (Figure 1). They were also asked to consider including “probing questions” that they would like to discuss at the conference. Based on the request, the prospective presenters gave summaries of their patients’ cases.
Second, the anthropologists assessed and selected one or two cases. The criteria used to select potentially suitable cases for the conference are shown in Figure 1.
Third, after choosing the cases for inclusion in the conference, the medical anthropologists and case presenters collaboratively constructed and elaborated the case presentation. This co-constructive interaction is a unique feature in the case conference model. Here, the anthropologists analyzed the preliminary written case and requested that the presenter retrieve additional contextual information deemed necessary for discussion and anthropological understanding. In some instances, the anthropologists suggested modifying or changing the “probing questions” formulated by the case presenters when they found that the questions might not promote an understanding of the case. Based on these comments, the case presenters rewrote and elaborated on the case. During this phase, the case presenters reviewed the chart, reflected on the cases and their performance, and sometimes conducted an additional interview of the healthcare professionals involved.
Finally, the anthropologists prepared their comments based on the elaborated cases. The anthropologists described several lessons that they learned after reflecting on the project. First, the comments are informative when they provide a theory that helps participants make sense of the conundrum, or form a question which can potentially reframe the clinicians’ perspectives on the case. In other words, the comments do not always have to answer the “probing question.” Second, the comments help clinicians follow the analysis of the anthropologists when they are explicit about the way they connect anthropological theories with the cases. For example, it is effective to quote particular phrases in the written cases since clinicians tend to regard the written case as authentic. Similarly, clinicians can better understand the case when anthropologists clarify the kind of phenomena they elicit from the quoted data before providing theoretical accounts. While introducing the technical terms or concepts from SBS, it is often imperative to identify which are technical to avoid confusing the clinicians, since some technical SBS terms mimic lay terms (e.g., symbol, culture, exchange). Finally, preparing distinct comments from two or more anthropologists is preferred, if possible. This is because having a variety of perspectives on the cases exemplifies the multifaceted way in which social scientists analyze daily phenomena.
The implementation phase is approximately a 2-3-hour session during which one case is discussed. First, the goal of the conference, which is to experience the clinical relevance of SBS through a discussion of real clinical cases, is explained. Next, a brief introduction of social and medical anthropology (e.g., ethnography and participant observation) is given, before the case presenter describes the elaborated case with “probing questions.” This is followed by a small group discussion by the participants and comments on the cases by medical anthropologists. If time permits, a floor discussion is again encouraged, based on the anthropologists’ comments. Finally, the case presenter reflects on the entire process to conclude the conference.
Development of the collaborative clinical case conference
The process of developing the CCCC can be summarized in three phases: quasi-CPC, interactive, and constructive phase. Each phase represents a distinct model and its features. The differences between the three phases, and the processes by which we developed them are summarized in Figure 2. Here, we simplified the gradual process of the development into three distinct phases to clarify the differences.
Quasi-CPC phase
We initiated the conference with a structure almost identical to that of the conventional CPC. One significant modification to the structure was assigning two anthropologists as commentators, a decision aimed at demonstrating a variety of perspectives to understand the case, whereas medical diagnosis is usually a process to find one definitive answer.
From the evaluation of the “quasi-CPC” phase, the questionnaire found that most participants acknowledged the significance of learning SBS from their clinical cases. They generally perceived the anthropologists' comments as valuable as they comprehensibly described the implicit aspects of the practice or patients' situation. Notably, some participants appreciated the legitimate opportunity to discuss sociocultural issues that rarely become central in their workplace. However, some areas for improvement were suggested. First, the anthropologists pointed out that the case presentation was not always enough to promote a sociocultural understanding of the case. This is not only because participants did not have the information required for the analysis, but also because their limited understanding of the sociocultural aspect made it difficult to judge and contextualize information that was significant. Second, some participants found it difficult to start the case discussion without any suggested discussion points. This would be because clinicians are used to conventional biomedical conferences in which questions such as, “What is the diagnosis?” or “What is your management?” are apparent. Thus, we posit the following two points: 1) the interaction between anthropologists and clinicians while preparing cases is necessary to ensure that appropriate information is included in the presentation; and 2) some “probing questions” might be useful to initiate the case discussion.
Interactive phase
To ensure interaction before the conference, we modified the case preparation from an isolated process by the case presenters to a collaborative one with anthropologists. First, we changed the method of asking prospective presenters to list the cases for the conference after initially suggesting that they select cases with perceived “sociocultural” difficulties. We added three topics based on the reflection that their understanding of “sociocultural” would be limited and lead to a narrow selection of cases being brought into the conference (Figure 2). We also asked them to add “probing questions” that they wanted to discuss to the case summary. Second, after the case was presented to the anthropologists, they requested additional information, such as contextual aspects and perception of other health professions, to ensure that adequate contextual information is included in the case presentation.
The modifications done to ensure interaction before the conference had several effects. The anthropologists’ requests urged the clinicians to review their chart or talk to their colleagues about the case. This led them to become more cognizant of the difference between their perspectives and that of others’, and rewrite the case presentation. Second, comments from anthropologists did not always provide a straightforward answer to the “probing questions” from the case presenters. Instead, anthropologists sometimes pointed out certain characteristics of the medical perspective by analyzing the way that the “probing questions” were formed, and proposed an alternative question through their anthropological analysis. For example, regarding a case involving a depressive elderly woman who “refused” care from physicians and other professionals such as, pharmaceutical therapy and home visits to her husband with dementia, the participating health professionals discussed how to overcome her rejection, whereas an anthropologist posed the question: “What was the lady protecting from the healthcare professionals?” Participants and clinicians in our team were impressed by the reformed questions of the anthropologists, since it led participants to shift their perspectives on the case, and the case presenters to remember otherwise forgotten information. A participant described the physicians' perspectives as “interventionist,” which makes it challenging to understand patients’ worldviews. During the discussion, some participants noticed that physicians tend to assume that they are being neutral and exclude themselves from the case presentation and discussion. In the evaluative questionnaire after the trial of the interactive structure, one participant noted that, “since medical professionals cannot be objective no matter how they strive to be, they should be sensitive to their own filter.” This recognition of the unattainable nature of objectivity and the significance of being cognizant of the uniqueness of physicians' perspectives shows an awareness of epistemology. This seems to be partly inspired by the explanation of participatory observation in the introductory lecture, but mainly by anthropologists' attitudes towards discussing the positionality and perspective of case presenters during the conference.
Two points were drawn based on the observation. First, anthropologists’ comments do not always have to be conclusive. Instead, their essential role in the conference is to reframe the questions. We hypothesized that the conference is focused not only on the process of looking for an answer to the predefined problem, but also on that of posing a useful question which leads to a subsequent exploration of appropriate management. Second, allowing the case presenter to respond to the anthropologists’ comments might be useful, since it would highlight how the anthropologists’ reframing could influence the clinicians understanding of the case and possibly lead to alternative actions within the case. To achieve this, we attempted to focus more on posing questions and exploring methods to secure the iterative process as much as possible between the case presenters and anthropologists in the preparation phase.
Co-constructive phase
Given the reflection, we modified the structure in three ways. First, in the preparation phase, anthropologists guide the case presenter on what additional information to gather, and how to frame questions. Second, clinicians asked the anthropologists to clarify how they reframe the clinician’s questions when they comment on the case in the implementation phase. This is achieved by one anthropologist directly commenting on the case, and another explaining the premise and underlying perspective of the comment. Finally, we gave case presenters a chance to reflect on the discussion process after the anthropologists’ comments, to share the impact of the conference on their understanding.
Throughout the trials of the co-constructive structure, which is identical to the final structure of the CCCC, one notable finding was that the case preparation process provided a unique learning opportunity for the case presenters. Based on the influence of the anthropologists, case presenters were urged to review their charts, interview their colleagues with questions that clinicians rarely ask during work, and re-examine their perspectives on the clinical situation. Through this experience, some clinicians noticed that the understanding of particular clinical phenomena is not monolithic, but differs among the involved healthcare professions (as an example of a case presenter’s learning, see Appendix 1). The anthropologists’ expertise in ethnography helped facilitate this process, since they were able to notice which contextual information was missing and the kind of requests or questions that would be informative for the case writers to further their analysis. Therefore, the case preparation in this phase could be understood as a process of collaborative clinical case writing by case presenters and anthropologists, in which the former can perform a brief quasi-ethnographic exploration and experience a method of how social scientists explore “clinical” phenomena, and the latter can participate in the process of constructing the clinical reality. Here, anthropologists played the role of the collaborative explorer of clinical phenomena by (re)framing clinicians’ questions and guiding the exploration.
The iterative structure of the implementation phase (Figure 2) enables a growing understanding of the clinical case through interactions among participants, case presenters, and anthropologists. Here, the case conference is not a deductive act for testing a hypothesis, but rather an explorative act to co-construct the understanding of the case. The co-constructive relationship between anthropologists and case presenters is a strength of this structure, and could lead to clinically relevant SBS learning experiences.
Role stratification and learning of faculty clinicians and anthropologists: The case conference model as faculty development
In addition to the gradual change in the anthropologists’ role throughout the conference, the interaction of clinicians and anthropologists was gradually stratified during the model development, as schematically illustrated in Figure 3. At the beginning of the project, clinicians described their clinical contexts to the anthropologists, and anthropologists explained the characteristics of their disciplines in the preparation and implementation of the conference. The conference became a place where a group of clinicians and anthropologists could gather and explicitly express their reasoning processes. As a result, some mutual understanding between faculty clinicians and anthropologists emerged. Participants’ reactions to the anthropologists’ comments allowed the latter to know which particular theories and findings were complementary to the physicians’ perspectives and easy for them to understand. The anthropologists found it interesting that some scholarly “obsolete” theories were very relevant to the physicians, whereas other cutting-edge articles were not. This understanding of the academic-clinical gap was a significant lesson for the anthropologists who participated in our project.
In the latter phase of the project, some clinicians and anthropologists came to play a “translator” role (Figure 3). For example, experienced anthropologists in the conference guided more novice colleagues by giving tips such as, “take care of the academic-clinical gap.” These translational attempts were particularly influential for “novice” anthropologists who were entirely alien to medical education, since such attempts functioned as the “scaffolding” to promote their participation in and learning of medical education.
The clinicians in the research team (JM and HN) learned how the stances of the anthropologists were different from those of the clinicians. While clinicians tend to assume the cases are patients and their diseases, anthropologists tend to recognize that they are sediments of the process between the presenting clinicians and their contexts. This gap led to different targets of analysis during the case conference. In particular, clinicians try to know the patients and their health problems, whereas anthropologists go beyond these and include the relationship between case presenters, patients, other stakeholders, and even the perspectives of the case presenters, as well as the conference participants. Thus, while the task for clinicians during the conference is an analysis of the case, the task for anthropologists is an analysis through the case. The presented cases function as an epistemology for anthropologists to understand the clinicians and their perspectives, and clinical practice. Such comparative understanding helped the clinicians explain how their perspectives differ from those of the anthropologists during the conference. This growing mutual understanding was an additional, but significant process accompanying our research project.