BEVERLY ANN DAVENPORTDepartment of Anthropology, History and Social MedicineUniversity of California, San Francisco

Witnessing and the Medical Gaze: HowMedical Students Learn to See at a Free Clinicfor the Homeless

This article analyzes doctor-patient communication as it is taught tomedical students in a student-run free clinic for the homeless. Moving be-yond Foucault's concept of the medical gaze, it incorporates ByronGood's theorizing about the soteriological aspects of medicine and medi-cal education as well as aspects of practice theory as illuminated by An-thony Giddens. Ethnographic examples illustrate the necessary tensionbetween objectification and subject-making that exists in the specificpractices engaged in by both students and preceptors at the clinic site.[doctor-patient communication, medical education, homelessness, Fou-cault, practice theory]

I went to the clinic for the first time some time, like, about a year ago . . . towardsthe end of the first quarter. . . and um, it was a really intense experience... . It wasactually a very big day 'cause it was also the first day of my preceptorship1.. . andso I was just around the corner from [the site of the Wednesday night clinic], andthat raised all sorts of things in my mind. I came to really, really, really enjoy it[the required preceptorship] b u t . . . it paled in comparison to the clinic.

I was paired with a second-year student.. . and we saw . . . this one woman, Iremember her name, I remember everything about her. . . . She was about 19 yearsold. She had been a runaway at about 15 or so. She was using a lotta speed, and shewas suicidal and really depressed and um, she came in . . . why did she come in? Ithink she had a cold. She was also working as a sex worker, kind of. She had thisreally fucked up relationship with this older man who was basically her pimp andalso her drug supplier. . . .

I hardly said a thing. I just mostly witnessed the interaction between the sec-ond-year student and her, and it was really sensitive, like a really good encounterthat uncovered all of this unhappiness a n d . . . it really blew me away. I guess howI described it to myself at the time was that up until that moment in my life I hadconsidered myself to be somewhat experienced in the world . . . um, but I felt likethere was nothing in my life that had at all prepared myself for that moment, and Ireally didn't know what to think or say . . . . And I remember the post-clinic meeting,

Medical Anthropology Quarterly 14<3):310-327. Copyright © 2000, American Anthropological Association.

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you know, I just remember thinking, "I don't know what I'm thinking" (laughs). Iwas so transformed and moved and just blown away. . . .

And then I guess I volunteered a couple of other times that I don't rememberreally in any way, but at some point I was realizing that I was learning so muchmore in these encounters than I was in my classes. And I was becoming increas-ingly unhappy and marginally functional as a traditional medical student. . . . Imean other circumstances in my life were contributing to this, but I was feeling in-creasingly severed from whatever had initially motivated me to go through theawful nonsense of medical school. And also feeling overwhelmed by just all thisuniverse of facts and figures that I'm supposed to be competent in but have no wayof organizing . . . and yet, you know, I'd go to clinic and I would feel a sense oflearning that was more real and memorable and concrete to me and a sense of, Idunno, it wasn't always like I'd learn something, but that I would at least feel aliveabout this process that I was going through. [Extract from an interview with Ivan,a second-year medical student, fall 1997]

How and what do medical students leam to see in encounters with patients? Itis commonplace to read in the theoretical and popular literature how theprocess of medical education teaches students to "objectify" their patients,

that is, transform them into problematic body parts rather than view them as wholehuman beings in fully contextualized psychological and social environments.2 Thisarticle addresses this question in a unique context, clinics for homeless people runby medical students attending a university in a city in the United States, which Iwill refer to as Angel Bay.3 What happens when clinical teaching and learning takeplace in a site away from the formal center of medical education, and which has anideology that is explicit in its oppositional stance to the prevailing practices of thepatient-provider relationship?

Michel Foucault addressed the historical and epistemological roots of objecti-fication in The Birth of the Clinic (1994). He described how the emerging medicaldiscourse led to a way of viewing patients that he called the "medical gaze." Thechange Foucault described was fundamental. Over the course of the 18th century,the question the doctor asked the patient was transformed from "What is the matterwith you?" to "Where does it hurt?" (Foucault 1994:xviii). This notion of the gaze,of seeing a "case" or a "condition" rather than a human being, has become a domi-nant paradigm in critiques of modern medicine.

This article examines aspects of the medical gaze that I observed while con-ducting ethnographic fieldwork with the medical students' Campaign on Home-lessness. I found that among this group of students and their supervising faculty,there was a struggle to maintain a balance between gazing, as Foucault might termit, and witnessing, their indigenous term for acknowledging the whole lives of thepopulation they served. My research was driven by questions situated at the inter-section of the anthropology of medical education, professional socialization, andthe doctor-patient relationship. Although Foucauldian theory informed my field-work and my initial inquiry, it was necessary to move beyond Foucault in order totruly understand the processes I witnessed. Specifically, Byron Good's discussionof the mediation between the soteriological and the physiological practices ofmedicine and Anthony Giddens's concept of "social reflexivity" significantly en-riched my analysis.

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The aim of this article is to demonstrate how a synthesis of the theoretical po-sitions of Foucault, Good, and Giddens can illuminate the practice of medical edu-cation in the micro-settings of clinical encounters. I use extensive field data todemonstrate this and to ground the theoretical discussion.

Beyond the Medical Gaze

The Birth of the Clinic describes the discursive transformation that allowedlate 18th-century French physicians to justify their "educational" display of thepoor patients who came to the hospitals of Paris for treatment and help. The un-written and unspoken contract between the doctor and the impoverished patientwas that by presenting one's self for help, one was obliged to let one's body be-come an object for presentation. Foucault argued that through the practice ofautopsy, medical scientists learned to understand and treat disease better, as theysaw it mapped on to the dead bodies of their patients: "It is when death became theconcrete a priori of medical experience that death could detach itself from counter-nature and become embodied in the living bodies of individuals" (Foucault1994:196, emphasis in original). The changing discursive practices within the fieldof medicine reflected a changed relationship of man to himself—man allowedhimself, for the first time, to be constituted as an object of science (Foucault1994:197).

Led by medicine, the "human sciences," through their production of knowl-edge, developed increasingly refined "technologies of power." This interrelation iswhat Foucault refers to as "power/knowledge":

First the hospital, then the school, then, later, the workshop were not simply "reor-dered" by the disciplines; they became, thanks to them, apparatuses such that anymechanism of objectification could be used in them as an instrument of subjec-tion, and any growth of power could give rise in them to possible branches ofknowledge; it was this link, proper to the technological systems, that made possi-ble within the disciplinary element the formation of clinical medicine, psychiatry,child psychology, educational psychology and the rationalization of labour. It is adouble process, then: an epistemological "thaw" through a refinement of powerrelations; a multiplication of the effects of power through the formation and accu-mulation of new forms of knowledge. [ 1995:224, emphasis added]

The very language that is used in knowledge production is fraught with relations ofpower. However, because this language is cast as "objective," the fact of that poweris hidden from its users. This is the nature of discourse. It is this fact that is so fright-ful in the vision of the modern world that Foucault presents in Discipline and Pun-ish: we are all caught in the social webs created by the interplay of knowledge andpower. Even those who are aware of the objectifying aspects of the power-knowledgerelation are unable to develop effective ways of breaking free of its sticky strands.

Though this vision has been criticized because it leaves so little room foragency or resistance (see, for example, Turner 1994), many analyses of medicalpractice appear to support it. For example, Mizrahi notes:

Treating patients as absent when they are physically present denies the existenceof the human subject. By treating most patients as subjectless objects, the housestaff eliminated them as active participants in patient care. .. . Techniques of ob-jectification were applied in collegial and patient interaction and appeared to be

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grounded in the basic process and structure of graduate medical training, such asdoctors' behavior on rounds. They also seem basic to the professional orientationof medicine, for they help doctors to separate the patient from the disease; to denypain and suffering, especially if it is not in their estimate organically based; and todiscredit or dismiss commonplace or uncomplicated illness. [ 1986:99]

Similarly, Waitzkin (1979) points out that the macro power relations in capi-talist U.S. society are reproduced in miniature in doctors' examination rooms. Hisanalysis of taped conversations between doctors and patients reveals the multipleways physicians act as agents of social control. Even mainstream medical educa-tors have recognized the problem of objectification. One can pick up almost at ran-dom any copy of Academic Medicine published over the past five years and find atleast one study measuring the effectiveness of educational interventions designedto improve communications skills and/or editorial or philosophical essays callingfor renewed efforts to ensure that physicians-in-training receive sufficient trainingin the arts of compassion (see Coles 1998; Hafferty 1998; Hafferty and Franks1994; Regan-Smith 1998).4 These articles demonstrate the concern and awarenessmedical educators have regarding the widespread perception of physicians as lack-ing in the ability to treat their patients as whole persons.

But these examples ignore alternative evidence suggesting that the picture isnot so stark. Even in the examples cited above, the reader can see that some practi-tioners (at least some of those who publish in Academic Medicine) want to do morethan simply teach their students to objectify their patients. Byron Good's suggestion(1994:65-87) that medicine be seen as a symbolic form (a term he borrows fromthe philosopher Cassirer) offers a more nuanced analytical approach. For Good,one of the core activities of medicine as a symbolic form is the process of media-tion between its technical and soteriological aspects, that is, between human physi-ology and human salvation with all the moral connotations implied in the latter term.

Good acknowledges the medical gaze, and he sees it as a given of the scien-tific epistemology that informs medical practice. But he insists that notions of thesalvational aspects of medical practice are never far away. Objectification is thusmitigated because the medical culture is both shaped by and shapes the socialworld of which it is a part (this is the central purpose of symbolic forms). Studentsenter medicine with a passion to alleviate suffering, a motivation not sufficientlymeasured in terms of scientific curiosity. In his fieldwork Good shows that the dis-course between faculty and students "tacks back and forth between engagement inclinical practices and moral reflection" (1994:87).5

It is this aspect of Good's argument that is compelling in the present context.Good's analysis is important because as he looks at the processes of medical edu-cation, he reinserts the agency of individual students and professors. Also, he re-minds us that the desire to save people from suffering has been compelling would-be healers for a long time (compare Balint 1957, who uses the term apostolicfunction to express the same thing).

When Good mentions Foucault in this discussion, he points out that Fou-cauldian analysis is limited because it "excludes the centrality of experience and inlarge measure, the dialogical qualities of discourse" (1994:69). However, Good'swork seems less in opposition to Foucault than an enrichment of his framework.Many of the examples Good cites could easily be read as cases of how medical

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discourse, rather than changing them, shapes the object of practice and reproducespower relations. What Good emphasizes are the experiential/phenomenologicalaspects of individuals becoming doctors. Though the structure of medicine influ-ences these actors, it does not simply reproduce itself through them. Their actionscan also transform it.

Anthony Giddens's notion of social reflexivity supplies a conceptual tool forunderstanding how this process works. Williams and Calnan define social reflexiv-ity as "the susceptibility of most aspects of social activity, and material relationswith nature, to chronic revision in the light of new information and knowledge"(1996:1612). Social reflexivity is a condition of "later modernity" and leads to analmost continual examination, scrutiny, reappraisal, and revision of social beliefsand practices. In their article on how the lay and medical worlds interact, Williamsand Calnan argue that the objectified docile bodies found in current social sciencecritiques of medicine are not as passive as they are made out to be. They point to avariety of ways that practices are shaped by social reflexivity; the power flows arenot unidirectional. I believe this concept, which is compatible with both Fou-cauldian power/knowledge and the tension between physiology and soteriologyexamined by Good, is useful in understanding the world of learning embodied inthe Campaign on Homelessness. I turn now to the field data to elucidate these con-nections.

Setting the Scene and Methodology

Angel Bay is a large city on the western coast of the United States. Lack of af-fordable housing, the increasing economic divide between the urban poor and thetechnocrat classes, a labor market with few opportunities for the unskilled and un-dereducated, and radically limited facilities to care for those with severe, chronicmental illness have all contributed to a substantial homeless problem there (Susser1996; Walker et al. 1990). In 1990, medical students at the local state university in-itiated the Campaign on Homelessness (the "Campaign"), which now operatesclinics four days a week at various sites throughout the city and which also has amission to educate the university community about the causes and conditions ofhomelessness.6 One way the Campaign meets this objective is through an electivecourse offered each fall that attempts to describe the historical, social-structural,and phenomenological worlds of homelessness. Participation in this elective is re-quired before any medical student is permitted to volunteer at the Clinic; thus, theelective is heavily subscribed by first-year students.

In the summer of 1997,1 began participant-observation research with the stu-dents and faculty preceptors who comprise the Campaign. The data presented hereare drawn primarily from my field notes of their interactions in the clinical milieubut are also informed by my observations in other settings.7 Besides going to theClinic, I enrolled in the quarter-long elective at ABC University Medical School,attending all lectures and participating in small group discussion sessions. I also satin on orientations to the Clinic at the School of Nursing and the Dental School,whose students also volunteer, though to a lesser degree than the medical students.In a nine-month period I went to seven of the nine monthly meetings of Soma (seeendnote 7); I also attended Soma's day-long retreat held in September.

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I observed at the Clinic on all four days of operation: Tuesday, Wednesday,Thursday, and Saturday. Clinics are held in two different locations and draw ondifferent elements of the homeless population of Angel Bay, depending on the dayof the week. On Tuesdays and Thursdays, the site is a large city-operated men'sshelter near the freeway in the warehouse district. People in cars speeding pastmight notice the colorful mural adorning one wall of the shelter, but will likelyhave no inkling of the building's function. On Wednesdays, the Clinic is located ina community organization storefront located in the skid row section of downtown,an area known for its concentration of single-room-occupancy (SRO) hotels and anextremely active drug trade. Exactly one city block away, a glittering shoppingmall draws tourists from all over the United States and the world, as well as theprosperous denizens of Angel Bay. The neighborhood is gentrifying, exacerbatingthe lack of affordable housing. A needle exchange takes place at this location onWednesday nights, and about half of the patients seen then are clients of this pro-gram. On Saturdays, this same site houses a women's clinic. Students arrive earlyon Saturday morning to hand out flyers to passersby and to the women leaving awomen's shelter not far away.

In addition to observation in the clinics, I interviewed two second-year medi-cal students and four clinic preceptors, all key informants. Based on the prelimi-nary findings emerging from my observations and these interviews, I constructedan open-ended interview schedule to use with four other second-year and sevenfirst-year students, who represented a stratified (by class rank) random sample ofCampaign volunteers. These additional interviews served to cross-check observa-tions and impressions. They helped me confirm or reject tentative findings and al-lowed for a more in-depth understanding of the learning experiences at the Clinic.

I also collected written material produced by the Campaign. This included theclinic coordinator's manual, the clinic handbook, and the referral guide. I printedout information about the Campaign from its website and subscribed to both theCampaign's and Soma's listservs, saving pertinent messages for analysis.

Iterative readings of this entire body of material led to the development of acoding scheme that focused on various categories of actors, actions, and attitudesassociated with the Campaign. "Good learning," "giving voice," and "quality, notquantity" were phrases repeatedly used by project participants. These phrases wereincorporated into my coding scheme as in vivo codes (Corbin and Strauss 1990).Analysis of the coded material led to the formation of code clusters; these clustersproduced themes that I expand upon below.

In this article, I focus mainly on the clinic observations, since these observa-tions allow me to demonstrate the practices of the Clinic's learning environment.In the 17 times I went to the Clinic, I participated in seven student-preceptor-pa-tient interactions from beginning to end, that is, from the moment the student(s)and a patient walked into the examination room for the initial history and physical,through the presentation of the patient's history to the preceptor, to the preceptor'sfollow-up examination of the patient in the presence of the student. By hanging outat the work table where the clinic coordinator (generally, a more experienced sec-ond-year student) directed the activities of the Clinic, and around which studentsand preceptors gathered during slow times or while writing up their S.O.A.P.notes,8 I was able to observe dozens of other formal and informal teaching mo-ments, from which I built this analysis.

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Gazing and Witnessing: Practices of Social Reflexivity

It is by entering the asylums where poverty and sickness languish together that he[the medical student] will feel those painful emotions, that active commiseration,that burning desire to bring comfort and consolation.... It is there that he willlearn to be religious, humane, compassionate. [Menuret, Essai sur les moyens deformer de bons medecins, Paris, 1791; quoted in Foucault 1994:84]

The Ideology of Witnessing

Witnessing is the indigenous term Clinic volunteers use to describe the actionof attentive listening to the people who go there for help. It entails respectful focuson the entirety of a person's life situation, not merely on their ailment. It impliestreating each person who walks into the clinic as an individual, not a representativeof a class. Witnessing expresses the central value of the Clinic's ideology. In thesettings where discourse dominates—the annual Fall Retreat, the monthly Somameetings, and the Homeless elective lectures—witnessing is advocated in directopposition to the values that prevail in other medical education settings.

First-year students who took the fall Homeless elective heard this ideologyexpressed early on. The very first lecturer, a specialist in health care for homelesspeople, spoke of the importance of "meeting people where they are," of withhold-ing judgment and focusing on the quality of the attention students provided to thepatients. She used a vivid image to remind the class of the need to see beyond ap-pearances: "Can you see the spark in the eyes of the homeless person covered withlice?" That same day, the next lecturer, himself a frequent clinic preceptor, pickedup the refrain. Referring to the failing social system that contributes to clinic pa-tients' miseries, he exclaimed, "We're not gonna fix it, but we're gonna bear witnesss."

The notion of witnessing resonates at multiple levels. Notice Ivan's languagein the extended quote that begins this article: "I hardly said a thing. I just mostlywitnessed the interaction between the second-year student and her" (referring tothe patient whose life story affected him so profoundly). Here, witnessing means toquietly observe. But, as used by the volunteers at the Clinic, witness implies an en-gagement with the event that observe lacks. Witness also means to testify, to speakout on someone's behalf. This is implicit in the language of the second lecturerquoted above, who spoke of "a clinic that you run that bears witness to these sto-ries." Here, bearing witness has a very clear moral/religious connotation, exactlyas Good (1994) has suggested. One bears witness for one's convictions, even whenthey may be unpopular or when the act of witnessing may be personally dangerous.Discipleship is also implicit in the notions of witnessing—a powerful metaphor forthe relationship between preceptors and students (as well as between more and lessexperienced students) at the Clinic. Within the local world of the Campaign onHomelessness, witnessing encompassed all of these meanings.9

Ann Swidler argues that ideology plays a crucial role in periods of socialtransformation. She writes, "when people are learning new ways of organizing in-dividual and collective action, practicing unfamiliar habits until they become fa-miliar, then doctrine, symbol and ritual directly shape action" (1986:278). The wit-nessing ideology is the Campaign's conscious attempt to change the way medicineconstructs its objects. The activities of the Clinic are structured along the lines ofclassic clinical training—learning how to get a history and conduct a physical

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exam under the supervision of an experienced senior physician—but the forms be-lie the Campaign's challenge to medical education as usual.

This opposition was explicit in the discussions at the Fall Retreat. For exam-ple, one faculty preceptor responded to a second-year student who expressed hisconcern that he didn't know enough medicine to really help the Clinic's patients bysaying, "At your level you're more in touch with the whole person. Focus on or-gans later. Tap into what it means to be a healer and hold on; many of us feel like itwas squished out of us during our education." Another second-year student re-flected on how different the experience of working at the Clinic was from what hethought would be his likely experience as a third year on the wards. A preceptor in-troduced himself to a large group of first-year students assembled for a lecture inthe Homeless elective class as a "recovering family practice resident." The com-ments of these students and teachers demonstrate a stance toward their own medi-cal education and residency training that is consistent with Giddens's concept ofsocial reflexivity.

Witnessing is also seen as a way to counter the symbolic violence of the medi-cal gaze (Bourdieu 1991). At the retreat and in interviews, medical students ex-pressed their fear of exploiting the Clinic's patient population, given its vulnerabil-ity and their own lack of clinical expertise.10 At the retreat, Jean, a second year,described her intense feelings on this point, particularly in her early days of volun-teering. She wondered if there were a way to ease such feelings for the incomingfirst years. Dr. Rudnytsky asked her why she felt such feelings needed fixing. Heinsisted that they were a screening test: the fact that one had such concerns aboutexploitation and abuse was evidence of suitability for working with this population.

The value of witnessing was sometimes applied as a salve for the helplessnessthat volunteers felt in the face of the overwhelming social problems the clinic's pa-tients forced them to confront; other times, it eased the feelings of inadequacy thatstudents expressed over their lack of knowledge. But it was more than that—it wasan ideological attempt to alter the balance of power between patients and practi-tioners in favor of patients. How this played out in the actual activities of the Clinicdemonstrates the tensions between witnessing and gazing, as well as between thepoles of physiology and soteriology that are the motive forces behind the Clinic'sexistence. Though preceptors consciously questioned and offered resistance to thekind of training they knew the students were getting in their required classes, theyalso knew that their students needed to be able to function effectively in that otherenvironment; they themselves had come through the same system. At the retreat,the preceptor did not say, "Forget about organs"; he said, "Focus on organs later."In the ideology of the Clinic, the emphasis was on witnessing. In the micro-prac-tices of teaching and learning in the actual clinical encounters, the actors' actionsalternated: now gazing, now witnessing, now gazing again.

Ideology in Action: Quality, Not Quantity

The students and preceptors hold staff meetings at the beginning and end ofeach clinic session. In the pre-clinic meeting the more experienced students andpreceptors inculcate the practice of witnessing into their less experienced peers.One way this is expressed is through the repetition of the phrase "quality, not quan-tity," which I heard at almost every pre-clinic meeting I attended. In the context of

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the Clinic, "quality, not quantity" means taking time to gather a full history on eachpatient, not simply the medical aspects of the patient's complaint, but also his orher social and psychological environment. The Women's Clinic coordinator'schecklist exhorts the coordinator to "remind everyone of the philosophy of theclinic: we emphasize quality interactions, providing this population with a sensi-tive entry into the health care system and a setting where women can feel safe, aswell as a non-judgmental learning environment for students." Similar language canbe found in the Men's Clinic and Wednesday Night coordinators' checklists.When the pre-clinic meeting must be brief because of the number of patients wait-ing to be seen, the mantra of "quality, not quantity" becomes shorthand for witnessing.

Micro-Practices 1: History Taking. The practice of witnessing is evident inthe way patient histories are taken. In six of the seven student-patient interactionsI observed, this meant a gentle, thorough probing of the patient's history, beginningwith what brought him or her to the clinic that day, but encompassing a far broaderdomain. The following vignette is typical:

Adam began the history taking, eliciting immediately a story about Mr. Wil-liams's problems with getting on SSI, losing hisjob of 37 years working at a print-ing press/publishing house—initially, a really depressing presentation. Jeanjumped in. She was masterful. She kept saying "sounds like" and either summa-rizing or rephrasing things that he [Mr. Williams] had said or made reference to ina way that would bring out more information. For example, she said, "Sounds likeyou had a different kind of life up until about a year ago. What changed?" . . .thereby bringing out this work history, plus the fact that he had severe vision prob-lems that needed to be addressed (that's why he's seeking SSI). She was sensitiveand gentle both with him and with Adam, the first-year medical student (this beinghis first time at the clinic). I kept wondering how she had learned this. [Field notes,fall 1997]

This selection also demonstrates how, in general, a more experienced and a less ex-perienced student pair up to work together at the Clinic. They usually negotiatehow tasks will be accomplished, with the less experienced student expressing trepi-dation about his or her ability to do what is required. The second-year student's en-couragement and modeling of appropriate behavior are important elements in theteaching practices of the Campaign. Jean's questioning brought out a fascinatinglife story and gave all of us who witnessed the exchange a richer understanding ofMr. Williams than would have been possible had she (and Adam) focused solely onthe medical issue that brought him to the Men's Clinic—blisters on his feet. Jean'scommentary on this exchange afterward was revealing:

Jean and Adam discussed the way the interview went immediately after Mr. Wil-liams left. Adam was concerned about how long he should let Mr. Williams "ram-ble on" about his life and social history before he jumped "to the importantmedical stuff.". .. Jean pointed out that the real medical problem is some-times/often revealed in the stories—she brought up the guy with the severe ingui-nal hernia who showed up complaining of a cough, but who, upon feeling morecomfortable with her, let his real concern come out. She said, "Patients never tellus their history in the order specified in our H&PE [history and physical examina-tion] handbook." She said this in a joking way—making the important point thatthe history-taker needs to attend to what the patient is saying, even if it isn't the

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first thing that the history-taker needs in order to be able to write up the history inthe proper, medically approved order. [Field notes, fall 1997]

In this exchange, Jean told Adam that allowing a patient to "ramble on" was a pow-erful interview technique, not evidence of inefficiency or inexperience. But shecouched this message in terms of "gazing"—"Patients never tell us their history inthe order specified in our H&PE handbook"—that is, she was asserting that what is"medically important" would be revealed in the "witnessing" process.11 Historytaking then, is an important context for students to put the witnessing ideology ofthe Campaign on Homelessness into practice. But as this example illustrates, his-tory taking is also a locus of struggle between gazing and witnessing.

Micro-Practices 2: Patient Presentations. A conflict exists between the goalof understanding a fully rendered human being and the need to accomplish a"medical" task. Students at the Clinic know that they must be able to shape the longand complex stories their patients tell them into a (re)presentation for their precep-tors. The Clinic policy is for this presentation to take place in the examination room,with the patient present, active as a witness while his or her story is being told. Thispractice differs dramatically from what occurs more typically in clinical training,where the student and supervisor confer out of earshot of the patient or, if in frontof her, speak as though she were not there (Anspach 1997). For example, in aWednesday Night pre-clinic meeting, Dr. Stanley, one of the preceptors who hasbeen with the clinic since its founding and who is viewed by students and preceptorsalike as an "elder statesman" of the Campaign, underlined the clinic coordinator's"quality, not quantity" remarks by emphasizing the importance of presenting infront of patients and by explicitly contrasting this to the bad experiences the patientshave had in other health care settings.12 Often in these presentations, however,students receive more messages about gazing than they do about witnessing, as thefollowing example illustrates:

Tina [Dr. Swenson, the preceptor] emerged from the other examination room andcame in. Jordan [first-year medical student] presented to her. Again, Peaches [thepatient] was sitting on the examination table. Jordan and I were together on theleft, Tina on the right. The discussion was between Tina and Jordan. Peaches at-tempted to engage, include herself in the discussion of symptoms. She was inter-ested, asking her own questions, interrupting the flow of highly technicallanguage, looking for the reasons why heroin use might cause irregular periods.More history came out, including the fact that she now remembered that some-times she was regular when she was using, sometimes she was irregular when shewas using. . .. She also remembered that she had been on the pill between her firstand second child (a period of about six years), and that might explain her regular-ity. Tina decided that BC pills would be the solution for her irregularity and of-fered her a three-month supply. She wanted to do a pregnancy test first, because ofthe danger of giving the pill to someone who is pregnant. She asked Peaches abouther history of high blood pressure; Peaches stated that there was no problem there.The pregnancy test came out negative, as expected; Tina gathered three packs ofBC pills, opened one to show Peaches how to use them and after the explanationwas complete, noticed the pack of Newport cigarettes near her (Peaches's girl-friend had given them to her when she left for work) and asked about her smoking.Peaches said she didn't smoke that much, about one pack per day, but Tina became

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reluctant to give her the pills because of the danger of a thromboembolism, whichcan come on suddenly and without warning. She apologized, urged her to quitsmoking, supported her decision to check in with [a local heroin-kicking pro-gram] to see about getting clean again, and wished her well. [Field notes, winter1998]

Here, the patient is mostly "talked over," despite her attempts to participate in Jor-dan's presentation of what is, after all, her story. The issues of her drug use, her de-cision to move to Angel Bay City from the East Coast, all become secondary to thestated objective of her visit to the Women's Clinic, her irregular periods. The ulti-mate irony, of course, is that a heroin-user is advised to quit smoking in order totake birth control pills to relieve the symptom of irregular periods, which is causedby her heroin addiction in the first place. I do not use this example to belittle thegood intentions of the preceptor, nor to question her medical judgment but, rather,to show how easily witnessing turns into gazing.

Micro-Practices 3: The Physical Exam. The Clinic is a teaching environment,and technical communication between the student and preceptor that sometimesexcludes the patient is to be expected. The following excerpt from an interviewwith a preceptor reveals how he believed he managed to balance the teaching ofthe technical and pathophysiologic aspects of medicine with the interpersonal:

. .. and so sometimes with really fascinating stuff, that's why we spend a littlemore time on just the physiology, like that guy with liver failure.. .. But. .. whileyou're teaching the technical you're also teaching the interpersonal... . [For ex-ample, I might say to a student] "This is how you examine a thyroid gland," andthen I'll demonstrate here as I'm talking to patients (miming an examination tech-nique)—"OK, ma'am this is blah-de-blah. My name is Dr. Rittenhouse, this ishow I'm gonna do it, please sit here, now let me feel on your neck here, let meknow if I'm choking you too much," and I'm demonstrating interpersonal skillswhile I'm showing the technical skills and at the same time I'm saying now [to thestudent], "Sometimes this lobe of the thyroid may be a little hyperactive, so you'llnotice it down here." .. . We're doing ALL this stuff. [Interview excerpt, fall 1997]

In the interactions I observed, preceptors varied in the extent to which thisideal typical behavior was practiced. In one case, for example, a preceptor skill-fully conducted a history and physical exam on a woman who was complaining ofshoulder pain that she attributed to an abscess. He moved very close into her physi-cal space, smoothly bantering with her about her heroin addiction and her attemptto get into a buprenorphine study.13 All the while, he was instructing the second-year medical student who had initially examined her, both explaining and model-ing techniques for conducting a physical and eliciting more aspects of a patient'shistory simultaneously. When he left the room briefly, Ellie, the patient, ex-claimed, "He's good, he knows what he's talking about."

At almost the opposite extreme, a preceptor at the Men's Clinic made almostno attempt to engage his male patient as he conducted a neurological exam on him,despite the patient's passing remark that he had spent time in San Quentin prison,"where the doctors are like vets [i.e., veterinarians]."14 Despite the stylistic range,however, what was consistent in these encounters was the simplification of a

WITNESSING AND THE MEDICAL GAZE 321

complicated set of physical, psychological, and social problems uncovered by thestudent into something you could see, and therefore address medically.

Micro-Practices 4: Charting. Another context where "the gaze" predominatedin teaching messages was in filling out patient charts, commonly referred to as"S.O.A.P. notes." Making choices about what got written on the form and what wasexcluded occupied an extraordinary amount of clinic time. I estimated that studentsspent at least as much time composing S.O.A.P. notes as they did examining andtreating patients. Three central observations are important here. First, students wererepeatedly told to put the definite and specific on these forms, that which they feltconfident about, that which was treatable. This often meant that they were com-pelled to reduce the social histories they had gathered into at most a sentence ortwo, focusing the bulk of their time, energy, and writing on their patients' mostconcrete and immediate physical problems. Second, students received explicitinstructions from preceptors with regard to the medico-legal aspects of recordkeeping, as the following example demonstrates:

When I got back to the clinic, Jordan [first-year medical student], Fifi [first-year,advanced-practice nursing student], and Tina [MD preceptor] were charting.There was back and forth about what should be put on a chart. .. . Jordan was con-cerned because she didn't know all the proper abbreviations. Tina pointed out thatit was more important that she get the general idea of organizing information in aS.O.A.P. format, that she would learn the abbreviations during her third year. Dur-ing the charting, Tina wrote little addenda or urged that the students write addendato various elements of the chart to make sure that the records were complete froma legal standpoint. For example, Adelaide's. .. complaint of chest pain generateda teaching point about writing "atypical, not consistent with heart disease" in themedical records. Similarly, Ginger's frequent sweats generated the phrase "afe-brile" to be added to the record. Again, Adelaide's depression (which was definedas "life-threatening") required careful charting to make sure it was appropriatelydealt with. [Field notes, winter 1998]

This type of instruction was very common across all of the clinics.A third important aspect of S.O.A.P. note writing is that it was an occasion

where a lot of student-to-student teaching took place. I frequently heard more ex-perienced students give less experienced students advice on terminology andphrasing in S.O.A.P. notes, usually introduced by the expression, "I would say . . ."Occasionally, I saw some critical examination of the process. For example, whenJean and Adam began writing up the record on Mr. Williams, Jean prefaced her re-marks by observing "how snotty" she thought it was that in common medical prac-tice what the patients report is "subjective" and what the doctor sees is "objective."Her remarks revealed a critical awareness of the power dynamic at play in medicalpractice, and one that, at least in this arena, she thought it important to resist.

Though S.O.A.P. note writing tended to be an occasion where "gazing" pre-vailed, sometimes a preceptor's comments about the note revealed a shift back towitnessing. The form used by the Clinic required that one primary diagnosis bechecked off from a list of ICD-9 codes grouped mostly by organ system. Providerscould also check off as many secondary diagnoses as they wished. In one case, astudent seeking guidance from a preceptor asked, "Secondary diagnosis of chemical

322 MEDICAL ANTHROPOLOGY QUARTERLY

dependence?" The preceptor responded, "Yeah, that and loneliness." She went on,"Loss of housing is on the form as a secondary diagnosis, too."

Micro-Practices 5: Post-Clinic Meetings. The post-clinic meetings were alsoarenas of "gazing" discourse. These meetings were similar to rounds, where eachpatient seen during the session was presented to the group by the student or studentswho had treated him or her. Again, the nature of the Clinic as a site for learningmedicine meant that discussions of pathophysiology in the day's most "interesting"case often predominated. Even the most fervent advocates of witnessing couldswitch easily into an objectified analysis of a patient. For example, at the end of aclinic one rainy February night, Rich (the preceptor) asked Wilson (a first-yearmedical student) to discuss the patient he'd seen who had come in complaining ofscabies. Wilson began by referring to "the patient" and was immediately stoppedby Rich, who insisted that he use the patient's name, George. He asked Wilson totell the group as much as he could about George's life and what he knew about howhe lived from day to day:

Rich emphasized the importance of knowing what people do all day long, saying,"You need to know this." They then returned to the medical presentation. Richpointed out that the patient's skin was a mess. Wilson began describing the skin,Rich corrected his word choice, substituting excoriations. Rich also pointed outthat he had gynecomastia from liver disease, palmar erythema, and capet medusa(i.e., a spidery pattern of veins around the belly button). He also had ascites (fluidin the belly). Rich described these patients as "Seagram's Coolers" (they're wetand they're dry—i.e., ascites plus dry skin). Rich also said he looked cirrhotic andpointed out that a symptom of liver failure is "itchiness." [Field notes, February1998]

Notice how easily Rich slipped back into the language of his city hospital resi-dency: George became a "Seagram's Cooler," that is, a case, a disease merelymapped on to this particular human body. And then, a few turns later in the conver-sation, Rich returned to witnessing by reminding the students sitting around the ta-ble that social issues below the surface (of the presenting medical problem) are sorich and so important to explore. I followed up on this point with him in an inter-view a week later, asking him to reflect on his interaction with Wilson that night,and specifically asking about his insistence on Wilson referring to his patient by hisgiven name:

. . . though there isn't any set curriculum I've set aside for homeless that I want thestudents to get when they're there, one thing I want them to get is that their senseof humanity and caring for others is as developed in their first and second years asit ever will be. And perhaps may get eroded as time goes on. So that's their great-est strength, and I want them to feel confident and good about their experience....The other thing that happens in medicine is we deeply depersonalize our patientsextensively over time, and that gets more and more specialized until you're a spe-cialist in the second and fourth cranial nerves, that's all you do is look at thosenerves, and nothing else matters and this, you know, you forget the part that's thehuman around it. And a homeless person, it's much more important to recognizethat those cranial nerves don't have a lot to do with the person's day-to-day exis-tence and it's important to recognize the whole person. So I try to go against thetrend of depersonalizing patients by using third person singular: "This is a 46-

WITNESSING AND THE MEDICAL GAZE 323

year-old white man who comes in with a history of blah blah blah." I want them tomake it more, I guess this is still the same, grammatical form, but make it more ofa person. And I want them to interject their own selves, make it more of a first-per-son dialog: "So I met Bill. And Bill was disheveled. .. ." It's very different than"This is a 46-year-old disheveled man." And the differences between those twosentences to me are huge. They're both describing the same person and both usingthe same words, but you say, "I met Bill and he looked disheveled to me" gives,enters into a subjectivity and questioning as opposed to this is what he is, this is hislabel. [Interview excerpt, February 1998]

Rich wanted his students at the Clinic to think of their patients as subjects; this isthe essence of witnessing. His dialogue with Wilson demonstrated one of the cen-tral theoretical arguments of this article: "the irruption of the fundamentally moraldimension of illness into this rational-technical sphere" (Good 1994:85). His insis-tence on the ideology of witnessing altered his practice, even though it was filteredthrough the forms of gazing discourse. That rainy night, Rich taught Wilson a les-son on how to see both the disease and the man who was suffering from it.

Conclusion

In this article, I have argued that Foucauldian theory provides only partial in-sight into the processes taking place in the clinics of the Campaign on Homeless-ness. I have asked the reader to consider both Byron Good's analysis of how medi-cine constructs its objects and Calnan and Williams's use of Giddens's term socialreflexivity in order to better understand these activities. I have shown how in themicro-settings of the Clinic, the physical-technical and the soteriological sides ofmedicine were in constant and necessary tension with each other.

The preceptors and the students manifested social reflexivity—scrutiny andrevision of social beliefs and practices—in their efforts to teach and learn tech-niques of medicine by caring for the Clinic's patients. Espousing the ideology ofwitnessing was a way to alter the substance of clinical practice, even as the practiceitself retained many aspects of its classic form.

Within the setting of this clinic for the homeless we have seen how discourseaffected actual practices within medical culture, even if only at the outskirts. Butthe Campaign on Homelessness in Angel Bay is not isolated. There is a widespreadinterest in service and student-run clinics in U.S. medical schools (Cohen 1995;Collins 1995; Everedetal. 1996; Fiore 1995; Pi 1995; Poulsen 1995; Ratner 1995;Sanderson 1996; Seifer 1998; Yap and Thornton 1995), and there is evidence thatthese activities feed back into the formal educational arenas as well (Eckenfels1997). Foucault's analysis helps us to penetrate the micro-physics of power/knowledge as a feature within medical education, but the practices of social reflex-ivity demonstrated by the Campaign's use of the witnessing ideology serve asdemonstrations of resistance within the structure that can transform it, even as theagents are transformed by it.

Within the Clinic's setting, students learned an alternative behavioral vocabu-lary for interacting with patients. Preceptors were well aware that their teachingwas going against the grain of convention, and they made every effort to bolster theirstudents' beliefs in the importance of the practice of witnessing—considering thewhole person when looking at a patient—because it was not likely to be a messagethey heard anywhere else. This is the meaning in Rich's remarks: "One thing I

324 MEDICAL ANTHROPOLOGY QUARTERLY

want them to get is that their sense of humanity and caring for others is as devel-oped in their first and second years as it will ever be. And perhaps may get erodedas time goes on" (emphasis added). For the volunteers of the Clinic, having an al-ternative vocabulary to take with them into their formal clinical training may serveas a defense against such erosion.

In Historical Metaphors and Mythical Realities, Marshall Sahlins chargedthat structuralism operated from the premise of the old French saying, 'The morethings change, the more they remain the same" (1981:6-7). In the Clinic, manythings "remain the same": many of the practices are not all that different from whathappens in more conventional contexts. But the witnessing ideology evinces a cul-tural transformation that inverts that famous saying. The preceptors and studentsare not "technicians of the micro-physics of power" (Foucault 1995); they are ac-tive agents, pushing back against and transforming the structure, even as they oper-ate within its constraints.

NOTES

Acknowledgments. I would like to thank the patients, students, and faculty of the Cam-paign on Homelessness who graciously consented to my requests to witness their work. Ivery much appreciated the comments of all three anonymous MAQ reviewers; they helpedme to make this a better article, as did Abigail Kohn and Philippa Strelitz, critical readers ex-traordinaire. I received support while writing this article from the National Institute of Gen-eral Medical Sciences, Grant Number R25 GM56847.

Correspondence may be addressed to the author at Department of Anthropology, His-tory and Social Medicine, University of California, San Francisco, Box 0850, San Fran-cisco, CA 94143-0850; badaven@uclink4.berkeley.edu.

1. Preceptors are clinical faculty who supervise medical students. Preceptorship is aterm widely used in medical education to characterize the relationship between cliniciansand students in the first two years of instruction. In the third year, the terms shift to the vo-cabulary of the hospital, where supervising physicians are called interns, residents, and at-tendings. In this article, the term preceptor is used mainly to refer to the volunteer doctorsand nurse-practitioners who worked with the students at the clinic for the homeless; the pre-ceptorship that Ivan mentions here is an element in his required medical school course on pa-tient interviewing, where students are placed with community-based primary carephysicians, whose practices they observe approximately once a month over the course of theschool year.

2. See, for example, three excellent memoirs of medical school—Melvin Konner'sBecoming A Doctor (1987), Toni Martin's How To Survive Medical School (1983), andPerry Klass's A Not Entirely Benign Procedure (1987)—for first-hand accounts of the edu-cational process. Frederic Hafferty (1991), Terry Mizrahi (1986), Daniel Segal (1984), andHoward Waitzkin (1979) describe this process from the perspective of academic social science.

3. All geographic, group, and individual names associated with this field project havebeen changed.

4. Academic Medicine is the premier peer-reviewed journal of medical education inthe United States and is published by the Association of American Medical Colleges.

5. Interestingly, the examples he cites often demonstrate how efforts are made to con-tain the soteriological aspects of medical discourse. For example, in an interview with athird-year student who describes a troubling incident on the wards with an AIDS patientexperiencing steroid-induced psychosis, what is remarkable for the student relating the storyis that "the resident who presented .. . [the patient's history]... never described the details,never opened the issue of how frightening it was" (Good 1994:85). The teaching practice fo-cused on the technical, despite the obvious soteriological elements in the event.

WITNESSING AND THE MEDICAL GAZE 325

6. I use the term Campaign to refer to the entire set of activities—both the education ofthe university community and the medical care for the homeless. Clinic refers only to themedical care activities provided by the Campaign. In this article, I refer to the Tuesday andThursday clinics as "the Men's Clinic," to the Wednesday clinic as "Wednesday Night," andto the Saturday clinic as "the Women's Clinic."

7. The 17 clinic observations on which this article draws occurred over a six-monthperiod from August 1997 to February 1998, with the bulk of observations (13) taking placein October and November 1997. These clinic observations are nestled in the center of thestudy, which itself began in early July 1997 and was completed in April 1998. Being able toobserve the Campaign on Homelessness over this length of time allowed me to comprehendits yearly cycle, which is largely a function of the academic calendar of the second-yearmedical students. During the spring quarter of each year, the second-year students begin toturn over the management of the Clinic to the first-year students. By this point the first yearshave sufficiently adjusted to the pace of medical school, have participated in the electiveduring the fall quarter, and have volunteered at one or more clinic sites a few times. Thesestudents are the pool from which the governing body of the Campaign on Homelessness,Soma, derives its membership. By the end of June, the former first-year students, now sec-ond years, are fully in charge, staffing the clinic over the summer and planning the next fall'selective for the newly entering first-year students. It was at this point in the annual cycle thatI first began my research.

8. S.O.A.P. stands for Subjective, Objective, Assessment, Plan, the standard format fordescribing patients' problems on medical records.

9. In the 1960s, members of the Religious Society of Friends, colloquially known asQuakers, "witnessed for peace" in protest against the Vietnam War. Witnessing can thus alsobe defined as a political activity, a point made by one of the clinic preceptors who read anearlier draft of this article.

10. In my attempts to gain entry at the beginning of this field project, members ofSoma expressed their concerns about the potentially exploitative nature of my proposed ac-tivities.

11. This exchange contrasts with an example in Scheper-Hughes and Lock's seminalessay, "The Mindful Body" (1987:8). In that example, medical students failed to make theconnection between the distressing social context of a woman's life and her debilitatingheadaches.

12. My research proposal focused on medical students and preceptors, and human sub-ject constraints prevented my interviewing of patients, though I did have informal conversa-tions with them at the Clinic. I did interview a community volunteer at the WednesdayClinic. He had been homeless but was currently managing an SRO hotel in the area. Hethought that the Clinic's students and doctors treated the clientele "so politely that they putthem into shock . .. they're not used to being treated courteously . . . someone [who] treatsyou like you was a human being" (Field notes, 11/5/97).

13. Buprenorphine is a drug that is currently being tested as a possible replacement formethadone.

14. The patient did not make the "vet" comment to disparage the preceptor; he said hehad chosen to come to the Clinic over the city-run neighborhood health center and the emer-gency room of the city hospital specifically because he preferred the way he was treated atthe Men's Clinic.

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Accepted for publication April 5, 2000