Critical Dialogues and Reflections
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CRITICAL DIALOGUES AND REFLECTIONS Morhaf Al Achkar Submitted to the faculty of the University Graduate School in partial fulfillment of the requirements for the degree Doctor of Philosophy in the School of Education, Indiana University August, 2018 Accepted by the Graduate Faculty, Indiana University, in partial fulfillment of the requirements for the degree of Doctor of Philosophy. Doctoral Committee _____________________________________ Phil Carspecken, PhD _____________________________________ Barbara Dennis, PhD _____________________________________ David Estell, PhD _____________________________________ Chad Lochmiller, PhD Date of Defense: April 23, 2018 ii I dedicate this work to those among us who suffer and find in their pain a wealth of meaning they tap into to generously give others. I also dedicate it to my parents, Souad & Ahmad. iii Acknowledgements I would like to acknowledge the generous giving of my advisors Phil Carspecken, Barbara Dennis, Dave Estell, and Chad Lochmiller. I also want to acknowledge the love and care my dad, Ahmad; my siblings, Bassem, Wafa, Hana, Nada, Amal, Malack, Houda and Mustafa have all given me. This work could not have been possible without the care, kindness and support of: Crystal Shen, Ahmad Borazan, Laura Chow, Gregory Sadler, Debra Revere, Shaun Grannis, Kevin Gebke, Paul James, Sumedha Gupta, Palmer MacKie, Dan Evans, Laura-Mae Baldwin, Yasin Haj Saleh, Matthew Thompson, Kelly Davies, Kim Bauer, and many other friends, colleagues and mentors. iv Morhaf Al Achkar CRITICAL DIALOGUES AND REFLECTIONS Medicine and medical education have become technicized. Aspects of the subjective and normative worlds are shoved to the side or annulled. Doctors and medical students are reduced to “specialists without spirits.” Patients are objectified and dehumanized. “Critical dialogue and reflections” is an attempt to call out the inadequacies of our current framework of thinking about medicine and medical education, written by someone who is a patient, a doctor, an educator, and a researcher. This is a two-paper dissertation. The first paper is a conversation in critical theories. In the first part, I present dialogues and reflections on Foucault’s Power/Knowledge and Habermas’s Theory of Communicative Action. In the second part, I advance the conversation on Habermas’s distinction between communicative and strategic actions, leveraging Hegel’s early writings on morality. This paper develops a methodological framework that gives the theory of communicative rationality a central position. It is a methodological framework in three interrelated senses: methodological foundations for conducting research on the social aspects of medical education and medical practice; methodological framework to guide pedagogy in medical education; and methodological framework for doctor-patient relations. In the second paper, I use the communicative rationality framework to propose a developed method of learning for doctors in training. The theoretical features of this method are articulated through qualitative data analysis of video-taped doctor-patient interactions. It argues for general principles as they are implicitly embedded within the interactions that I analyze through the framework presented in the first paper. In this method, resident physicians review videos of their work through dialogues with their peers. Attending physicians also review the videos and dialogue with one another as they reflect on resident performance. In this work, I restore the normative evaluative and let the subjects speak. It is my belief that medical education and medicine are in desperate need of an alternative theoretical framework. My work here comes to provide just that. v _____________________________________ Phil Carspecken, PhD _____________________________________ Barbara Dennis, PhD _____________________________________ David Estell, PhD _____________________________________ Chad Lochmiller, PhD vi Table of Contents Acknowledgements ................................................................................................................................... iv Introduction to the two-papers dissertation ............................................................................................ 1 The First Paper: Critical Dialogues and Reflections in The Philosophy of Social Sciences ......... 16 Part 1. The Possibility of Social Order: Hobbes, Foucault, then Habermas ............................... 16 Introduction ........................................................................................................................................ 16 Hobbes: The Social Contract.......................................................................................................... 16 First reflection ................................................................................................................................... 17 Foucault: Power and Knowledge ................................................................................................... 19 Second reflection .............................................................................................................................. 25 Habermas: The Theory of Communicative Action ...................................................................... 27 Final reflection ................................................................................................................................... 39 References ........................................................................................................................................ 43 Part 2. Conscience. Communicative and Strategic Actions. ......................................................... 44 Habermas: The Theory of Communicative Action ...................................................................... 44 First Reflection .................................................................................................................................. 51 Hegel: The Beautiful Soul, Evil and its Forgiveness ................................................................... 54 Second reflection .............................................................................................................................. 66 Final reflection ................................................................................................................................... 72 References ........................................................................................................................................ 80 The Second Paper: Critical Dialogues and Reflections in Medicine and Medical Education ....... 81 Introduction ............................................................................................................................................ 81 Literature review ................................................................................................................................... 84 Theoretical and Metatheoretical Discussion ................................................................................ 85 The history of video reviews and working models....................................................................... 94 Video Reviews: Feasibility, Acceptability, and Effectiveness .................................................. 105 Comparative Evaluation ................................................................................................................ 125 Reflection and aims ....................................................................................................................... 133 Methodology ........................................................................................................................................ 134 Theoretical framework. .................................................................................................................. 134 Research Methods: Critical Qualitative Methods ...................................................................... 140 Findings ............................................................................................................................................... 150 Primary reconstruction of the visit aspects ................................................................................. 150 Secondary reconstruction of the visit aspects ........................................................................... 161 Discussion ........................................................................................................................................... 172 vii References .......................................................................................................................................... 181 Reflections on the experience of being the patient ........................................................................... 188 Supplementary Material ........................................................................................................................ 193 Appendix 1. Exploring perceptions and experiences of patients who have chronic pain as state prescription-opioid policies change: A qualitative study in Indiana State ........................ 194 Appendix 2. Video review guide ....................................................................................................... 215 Curriculum Vitae ........................................................................................................................................... viii Introduction to the