Session 8b: Defining Parameters & the Contexts of Practice

Jarmilla Mildorf - Narratives of Domestic Violence Cases: GP's Defining their Professional Role
Department of English, University of Stuttgart, Germany

General practitioners today face a wide array of psychosocial problems in their practice work, which potentially threaten the "ceremonial order" (Strong, 1979) of the consultation. Domestic violence is an issue that GPs feel overwhelmed by and consequently their response may not always be as adequate and helpful as victims of abuse expect (Williamson, 2000). Questions that therefore arise are: How do GPs perceive their own role as health care professionals who have to deal with this problem, and to what extent do their views and attitudes inform and influence their practice work?

This study investigates twenty GPs' narratives about their experiences with abuse victims with a view to identifying the discursive strategies by which the doctors set up defining parameters and explanatory frameworks and thus also create their professional identity (Schiffrin, 1996). More specifically, reinstantiations of the discourse of the social (Goffman, 1974) and the biomedical model (Annandale, 1998) as well as spatio-temporal mappings (Herman, 2001) in the GPs' narratives are shown to reflect underlying assumptions and cognitive processes which further widen the gap between doctors and patients and provide GPs with a legitimate excuse to relegate responsibility to the women or to other service providers.

Since the GPs' narratives constitute an "institutional memory" (Linde, 1999; Trinch, 2001) for the primary care sector, they indirectly inform further policy and practice. The study thus also reveals how the GPs' narratives impede rather than initiate paradigm shifts, which would be necessary to improve service provision in the context of psychosocial issues such as domestic violence. Finally, it is demonstrated that sociolinguistic narrative analysis not only proves to be a useful tool for unravelling underlying problems but also offers solutions from within the "narrative paradigm" (Sarbin, 1986).

Peter Twohig - Evidence, Identity and Family Practice; A Qualitative Inquiry
Delhousie University, Department of Family Medicine, Halifax, Nova Scotia, Canada B3H 2E2

Over the course of the twentieth century, general practice underwent a decline in many settings, followed by a period of renewal, around mid-century. In Canada, renewal followed the usual steps, including creating a professional association (1954) and assuming a place both in undergraduate and postgraduate medical education. Indeed, McMaster University's residency in family medicine was the first in North America (1967). These were important building blocks in the creation of family practice's (as it was called in Canada) professional identity. Other elements, such as family practice research, remain more contentious. More broadly still, the relationship between science, medical research, clinical practice and professional identity remains poorly understood.

"Evidence" is an important constituent element of contemporary family practice in countries such as Canada, the United States and Great Britain, and elsewhere. Evidence-based medicine (EBM) has been defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" (Sackett, et al. 1996). Viewed in the broadest sense, EBM seems to re-cast the language and culture of medicine. But while the role of evidence is significant, family practice, as a patient-centered discipline that deals with the "whole person" in specific community contexts, must continually weigh "evidence" against patient preferences and values. This paper seeks to explore the ways in which family physicians employ and deploy evidence in day to day practice. Data were collected through nine focus groups, held in eight different settings to explore a recent Canadian guideline for cardiovascular disease. Family physicians in our study endorsed the ideal that clinical practice should include considerations of evidence, but recounted various other factors that shaped their ability to make use of evidence, including clinical issues (such as whether a patient was symptomatic), patient preferences, socio-economic concerns, and a wide range of other factors.