Culture, Medicine, and Psychiatry

, Volume 35, Issue 2, pp 163–182 | Cite as

En-case-ing the Patient: Disciplining Uncertainty in Medical Student Patient Presentations

  • Seth M. Holmes
  • Maya Ponte


The problem-oriented medical record is the widespread, standardized format for presenting and recording information about patients, which is taught to future physicians early in their medical training. Based on our participant observation of medical training, we analyze the ways in which the patient presentation operates in medical training as a disciplinary technology that manages uncertainty in the clinical decision-making process. We uncover various mechanisms at work including the construction of a coherent narrative structure in which chaotic experiences are re-organized and re-interpreted to fit neatly in a linear plot with a predictable ending, the atomization of the patient as a whole into separable “problems,” the attempt to solve these “problems” as though they are independent of one another, and the mystification of translations in scale, which give rise to much of the uncertainty in medicine. Operating at the boundary of the chaotic and often ungraspable world of the suffering experience of the patient and the highly structured realm of the medical record, a patient presentation is one medium through which both a disciplined record of experience and disciplined medical practitioners are produced. This process functions to transform the human subject patient into a recognizable, generic clinical case, and the medical student into an identifiable, professional future physician.


Clinical training Medical education Physician-patient relationship Patient presentation Case presentation 



We are grateful to the participants in the Society for Medical Anthropology panel on the anthropology of clinical training, the anonymous reviewers and the editors of Culture, Medicine and Psychiatry, Renee Fox, Mary Jo DelVecchio Good, Vincanne Adams and Sharon Kaufman for their helpful feedback. The first author would like to thank the Robert Wood Johnson Foundation Health & Society Scholars Program at Columbia University and the Program in Health and Social Behavior at UC Berkeley for the time to analyze and write this manuscript.


  1. Adams, Vincanne.2002. “Randomized Controlled Violence.” Social Studies of Science. 32 (5-6) 659-690.Google Scholar
  2. Anspach, Renee R.1988. “Notes on the Sociology of Medical Discourse: The Language of the Case Presentation.” The Journal of Health and Social Behavior. 29: 357-375.CrossRefGoogle Scholar
  3. Aronowitz, R. 1998. Making Sense of Illness: Science, Society, and Disease. Cambridge University Press.Google Scholar
  4. Becker, Gay. 1997. Disrupted Lives: How people create meaning in a chaotic world. Berkeley and Los Angeles: University of California Press.Google Scholar
  5. Bosk, Charles. 1981. Forgive and Remember: Managing Medical Error. Chicago: University of Chicago Press.Google Scholar
  6. Briggs, Charles, ed. 1996. Disorderly discourse: Narrative, conflict and inequality. New York: Oxford University Press.Google Scholar
  7. Butler, Judith. 2009. Frames of War, When is Life Grievable? New York. Verso.Google Scholar
  8. Castel R. 1991. From Dangerousness to Risk. In: Gordon C, Burchill G, Miller P, eds. The Foucault effect : studies in governmentality : with two lectures and an interview with Michel Foucault. London: Harvester Wheatsheaf; 281-198.Google Scholar
  9. Charon, Rita. 2004. “Narrative and Medicine.” In New England Journal of Medicine. 350: 9-10.CrossRefGoogle Scholar
  10. Charon, Rita 2006. Narrative Medicine. Oxford University Press.Google Scholar
  11. Charon, Rita 2007. “What to do with stories: The sciences of narrative medicine.” In Canadian Family Physician. 53: 1265-1266.Google Scholar
  12. Cicourel, Aaron. 1983. Hearing is not Believing: Language and the Structures of Belief in Medical Communication. In Sue Fisher and Alexandra Dundes Todd (eds) The Social Organization of Doctor-Patient Communication. Washington DC: Center for Applied Linguistics, pp 221–239Google Scholar
  13. Conrad, Peter. 1988. “Learning to Doctor: Reflections on Recent Accounts of the Medical School Years.” In Journal of Health and Social Behavior. 29(4): 323-332.CrossRefGoogle Scholar
  14. Crenner, Christopher. 2005. Private Practice in the early twentieth-century medical office of Dr. Richard Cabot. Baltimore: The Johns Hopkins University Press.Google Scholar
  15. Das, Veena. 1996. Language and Body: Transactions in the Construction of Pain. Daedalus 125:67–91Google Scholar
  16. Dehnel, Tim. 2010. Reacting to antibiotic resistance. The Lancet Infectious Diseases 10(11):746CrossRefGoogle Scholar
  17. Dumit, J. 2000 When Explanations Rest: ‘Good Enough’ Brain Science and the New Socio-Medical Disorders. In Living and Working with the New Medical Technologies: Intersections of Inquiry. New York: Cambridge University Press.Google Scholar
  18. Dunea, G. 1978. Confusion Oriented Medical Records. BMJ. : 1: 1686-1687.CrossRefGoogle Scholar
  19. Evans-Pritchard, E. E. 1937. Witchcraft, Oracles and Magic among the Azande. Clarendon Press, Oxford.Google Scholar
  20. Fadiman A (1998) The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Noonday Press. 341.Google Scholar
  21. Foucault, Michel 1972[1969] The Archeology of Knowledge and The Discourse on Language. Alan Sheridan Smith, trans. New York: Pantheon.Google Scholar
  22. Foucault, Michel. 1973[1963] Birth of the Clinic. Alan Sheridan Smith, trans. New York: Vintage.Google Scholar
  23. Fox, Renee C. 1957. “Training for Uncertainty.” In Merton, R.K., Reader, G. and Kendall, P.L. eds. The Student Physician: Introductory Studies in the Sociology of Medical Education. Cambridge, MA: Harvard University Press.Google Scholar
  24. Fox, Renee C. 1980. “The Evolution of Medical Uncertainty.” Millbank Memorial Fund Quarterly/Health and Society. 58(1): 1-49.CrossRefGoogle Scholar
  25. Fox, Renee C. 1988. The Autopsy: Its Place in the Attitude-Learning of Second-Year Medical Students. In Essays in Medical Sociology: Journeys into the Field. New Brunswick: Transaction Books.Google Scholar
  26. Fox, Renee C. 2000. Medical Uncertainty Revisited. In: Albrecht GL, Fitzpatrick R, Scrimshaw S, eds. Handbook of social studies in health and medicine. London; Thousand Oaks, Calif.: Sage Publications;:409-425.Google Scholar
  27. Freeman, Sarah H. 1986 Rounds Talk: A Source of Miscommunication in Physicians’ Explanatory Ac-counts. Paper Delivered at the 85th Annual Meetings of the American Anthropological Association, Philadelphia, PA.Google Scholar
  28. Good, B and MJ DelVecchio Good. 1993. “Learning Medicine.” In S Lindenmbaum and M Lock, eds. Knowledge, Power, and Practice. Berkeley: University of California Press.Google Scholar
  29. Good, B and MJ DelVecchio Good. 2000. “‘Fiction’ and ‘Historicity’ in Doctor’s Stories: Social and Narrative Dimensions of Learning Medicine. In Narrative and the Cultural Construction of Illness and Healing. Ed. C Mattingly and LC Garro. Berkeley: University of California Press.Google Scholar
  30. Good, Byron. 1994. Medicine, Rationality and Experience: An Anthropological Perspective. Cambridge University Press.Google Scholar
  31. Gordon, Deborah R. 1988. “Tenacious Assumptions of Western Medicine.” In Margaret Lock and Deborah R. Gordon, eds. Biomedicine Reexamined. Dordrecht, The Netherlands: Kluwer Academic Publishers. pp. 19-56.Google Scholar
  32. Hurst JW. 1971.Ten reasons why Lawrence Weed is right. N Engl J Med Jan;284(1):51-2.CrossRefGoogle Scholar
  33. Kaufman, Sharon. 1988. “Illness, biography and the interpretation of self following a stroke.” In Journal of Aging Studies. 2: 217-27.CrossRefGoogle Scholar
  34. Kleinman, Arthur. 1989. Illness Narratives: Suffering, Healing and the Human Condition. Basic Books.Google Scholar
  35. Konner, Melvin. 1987. Becoming a Doctor: A Journey of Initiation in Medical School. Penguin Books.Google Scholar
  36. Kuipers, J.C. 1989. “Medical Discourse” in Anthropological Context: Views of Language and Power. Medical Anthropology Quarterly 3(2):99–123CrossRefGoogle Scholar
  37. Kuriyama, Shigeshisa. 1999.The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine. New York, NY: Zone Books.Google Scholar
  38. Lock, Margaret. 2009. “Local Biologies.” In David Cayley ed., Ideas on the Nature of Science. Canadian Broadcasting Corporation. New Brunswick: Goose Lane Editions.Google Scholar
  39. Lupton D 1999. Risk. London; New York: RoutledgeGoogle Scholar
  40. Mattingly, Cheryl and Linda C. Garro, eds. 2000. Narrative and the Cultural Construction of Illness and Healing. University of California Press.Google Scholar
  41. Pettinari, Catherine J. 1988 Task, Talk and Text in the OperatingRoom: A Study in Medical Discourse. Norwood, NJ: Ablex.Google Scholar
  42. Rabinow, Paul. 1992 Artificiality and Enlightenment: From Sociobiology to Biosociality. In Incorporations. Jonathan Crary and Sanford Kwinter, eds. Pp. 234–252. New York: Zone.Google Scholar
  43. Rosenberg, Charles. 2002. The Tyranny of Diagnosis: Specific Entities and Individual Experience. The Milbank Quarterly 80(2): 237–260CrossRefGoogle Scholar
  44. Scarry, Elaine. 1987. The Body in Pain: The Making and Unmaking of the World. Oxford University Press.Google Scholar
  45. Scheper-Hughes, Nancy and Margaret Lock. 1987. “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology.” Medical Anthropology Quarterly. 1:1: 6-41.CrossRefGoogle Scholar
  46. Taussig, Michael. 1980. “Reification and the Consciousness of the Patient.” Social Science & Medicine. 14: 3-30.Google Scholar
  47. Velpry, L. 2008. “The Patient’s View: Issues of Theory and Practice.” Culture, Medicine and Psychiatry. 32(2): 238-258.CrossRefGoogle Scholar
  48. Weed LL. 1968. Medical records that guide and teach. N Engl J Med Mar 14;278(11):593-600.CrossRefGoogle Scholar
  49. Young, Allan. 1995. The harmony of illusions. Princeton: Princeton University Press.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Program in Health and Social BehaviorUniversity of CaliforniaBerkeleyUSA
  2. 2.Department of DermatologyUniversity of CaliforniaSan FranciscoUSA

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