Grant Proposal Archive

Proposal Cover Sheet

Submitted to the NSF-DDRIG, Winter 2012

Tawni Tidwell, Anthropology

Transmitting Diagnostic Skills in Tibetan Medicine: Embodied Practices for Indigenous Categories of Cancer

Posted February 2013

NSF-SBE Cultural Anthropology DDRIG

Doctoral Dissertation Research:

Transmitting Diagnostic Skills in Tibetan Medicine: Embodied Practices for Indigenous Categories of Cancer

Project Investigator (PI): Dr. Carol Worthman Co-Project Investigator (CO-PI): Tawni Tidwell

IRB Approval: pending Tawni Tidwell ‧ NSF-SBE Cultural Anthropology DDRIG ‧ PROJECT SUMMARY ‧ January 15, 2012

PROJECT SUMMARY. Tibetan medical diagnostics for indigenous categories of cancer provide a lens for understanding embodied expertise among Tibetan physicians. This diagnostic repertoire is comprised of pulse diagnosis, urinalysis and other embodied practices of illness recognition that are trained in the tactile and sensory capacities of the physician him- or herself. This investigation of Tibetan medical diagnosis as it is formally transmitted, cultivated, and clinically deployed, will track the system in action and open a gateway to understanding the epistemological underpinnings of Tibetan conceptions of pathology and treatment. The focus on cancer is strategic, for cancers are the nosological categories in which the Tibetan medical and western biomedical systems most closely overlap. As such, this overlap opens a space in which to distinguish the distinctive features of the two systems of diagnosis and care. As the first western student in Men-Tsee-Khang, the premier Tibetan medical school, this investigator will work with Tibetan medical students, faculty and a group of expert physicians to document how diagnostic skills are transmitted, cultivated and applied, with particular regard to cancer. Intellectual Merit. The current project provides original and innovative research to anthropological theory and the discipline as a whole by contributing to two areas: 1) explication of cultural knowledge transmission processes of a tradition focused on effective transmission of practiced skills, and 2) biocultural understandings of how humans create and teach complex knowledge systems around health and well-being. With respect to how cultural knowledge is transmitted, particularly, knowledge of practice, or technologies, Tibetan physicians describe their tradition as a textually-based, orally-instructed, practically-implemented knowledge transmission system that extends at least 2,000 years. My originality would exist in investigating the learning processes and related sociocultural structure that support a system that self-identifies with the capacity to transmit cultural knowledge resiliently over thousands of years. This system provides an excellent case study in contributing to general understandings of how specialized medical epistemologies are conceptualized, transmitted and enacted in practical skill. Broader Impacts. This project is positioned to provide insight into medical education in a sophisticated, rigorous and systematic non-Western medical system. In doing so, it is situated to illuminate our own forms of medical teaching, training and learning, and look at the cultural health paradigms of a region, Tibet, that has gained greater interest among both medical professionals and the public, but remains little understood. It will further facilitate collaborations and partnerships between Western medical researchers and practitioners and Tibetan physicians through the institutional alliances that my position as a student at the Tibetan medical school has already begun generating. For example, in 2010, Tibetan Medical School vice principal and my teacher Dr. Khenrab Gyamtso came to Emory to co-teach a semester anthropology course on Mind, Religion and Healing introducing core concepts and practices of Tibetan medicine to fifty undergraduates. This past summer, Emory faculty taught courses on neuroscience, endocrinology, and medical anthropology at the Tibetan Medical School, and will do a longer workshop this coming summer. This year, Tibetan physician Dr. Tashi Dawa was brought to Emory for a year-long fellowship working with Emory researchers investigating Tibetan herbal preparations to treat hepatitis C. Tibetan medicine has gained greater collaborative appeal globally both in research and in clinical practice, yet few individuals have trained in both systems and can help facilitate these partnerships. My career is focused on this aim and the current project builds significantly toward that end. Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012

Doctoral Dissertation Research: Transmitting Diagnostic Skills in Tibetan Medicine: Embodied Practices for Indigenous Categories of Cancer

Statement of Research Problem The present study investigates the diagnostic skills and underlying transmission practices used by Tibetan medical physicians and students for diagnosing indigenous forms of cancer known as dre-ned (Tib. 'bras-nad)1. Tibetan medical diagnostics are embodied skills comprised of pulse diagnosis, urinalysis and other practices of illness recognition trained in the tactile and sensory capacities of the physician him- or herself. The central questions of this study are:

1) How do Tibetan physicians conceptualize and diagnose indigenous cancer (dre-ned)? 2) What are the learning processes implicated in developing embodied diagnostic skill? And 3) How does dre-ned reveal critical epistemological underpinnings of Tibetan conceptions of pathology and treatment in order to provide a foundation of comparison to Western biomedical conceptions of cancer?

I hypothesize that the Tibetan medical texts, oral instructions and praxis learning for physicians provide a unique form of medical training in sensory and tactile data that systematically link information about the body to provide specific, trackable knowledge sets about the patient physiology for a given expert Tibetan physician. Tibetan medicine provides a highly specified, culturally and textually propagated system of diagnosis for its physicians, particularly in pulse diagnosis and urinalysis. Through physician- embodied diagnostics, patient-oriented medication, and subtly nuanced therapeutic practices and behavioral interventions, the Tibetan medical system engages a precise conceptualization of ways to identify, recognize, and treat disease. This project looks at how Tibetan medicine relies on the physician as diagnostic tool and interpreter to see, feel, and conceptualize indigenous categories of cancer through embodied modalities. In the interest of objectivity, Western medicine has missed much of the information processing capacities of embodied expertise (Csikszentmihalyi 1997; Ericsson, Krampe, and Tesch-Römer 1993; Greenfield 2004; Lantieri and Goleman 2008): the physician as a diagnostic instrument. Recent inclusions in Western medicine have occurred in the fields of psychiatry and psychology whereby specialists monitor their own subjective reactions to patients as an aid to diagnosis (Betan et al., 890). By contrast in Tibetan medicine, tactile and observational skill has provided the primary means for physicians to recognize illness historically to present-day. The focus of the current project is to illuminate the sensory modalities comprising such expertise and how it is cultivated. Most research in Tibetan medicine and other non-Western medical systems has focused on mental illness (Jacobson 2000; Millard 2002; Kleinman 1989; Fadiman 1998; Kleinman, Das, and Lock 1997; Silva 2006; Kitanaka 2011). This project takes up cancer because it is literally something you can put your finger on. Cancer is a life-threatening physical condition where practices matter for its recognition, treatment and experience. Tibetan medicine incorporates conceptions of health and healing that integrate mind, nutrition, environment, social connections, an extensive materia medica and therapeutic modalities – areas all shown to impact cancer treatment. A system that integrates these areas systematically may 1 Tibetan transliterations in parentheses follow the standardized system established by Turrell Wylie in 1959 (Wylie 1959; Jacobson 2000). The romanized form here is pronounced “dré-néd” with a long “-ay” for each syllable.

1 Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012 prove beneficial in contributing approaches to addressing cancer. Diagnosis provides a place to start. As a gateway to treatment and to the patient's illness experience trajectory, diagnosis invokes the epistemological paradigm of a given medical system (Good 1994), and in Tibetan medical diagnostics, does so through embodied practice. In investigating the diagnostic techniques and learning processes that undergird Tibetan medical diagnosis of Tibetan indigenous cancer, my inquiry will look at three areas of analysis: 1) the medical epistemology, pedagogy and praxis of training and the development of expertise, 2) the dialectic of text-based conceptual and praxis-based perceptual experience in learning and practicing Tibetan medical diagnostics, and 3) the role of the physician-patient relationship in understanding the whole patient, specifically, the multifold causes and conditions affecting illness trajectories and health outcomes. The investigation will look at the individual roles of the three areas as well as synergistic interactions in the context of indigenous cancer. Data Collection & Analysis I. Through participant-observation as a student at Men Tsee Khang, the premier Tibetan medical school, and through interviews with faculty and fellow classmates, I aim to examine how Tibetan medical epistemology and diagnostic skill through embodied practice are taught, with specific regard to indigenous forms of cancer (dre-ned). For data collection, I will record and transcribe all interviews and significant class and mentoring sessions. My first area of analysis will investigate pedagogies engaged by faculty, modes of praxis learning transmitted through mentorships, and learning processes undertaken by fellow classmates and myself. Tibetan medical diagnostic skill acquisition and transmission engages text memorization, theoretical foundations, patient case experience, fostering patient relationship quality, mindfulness and sensitization practices, and understanding of causal and conditional influences on illness trajectories such as environmental, social, nutritional, behavioral and mental conditions. I will look at these processes, influences and methods of how situated knowledge of the body interacts with knowledge practice systems to develop skill development and further such skills toward expertise. Analysis II & III. In the second area of analysis, I will look specifically at how the dialectic of text-based and orally-instructed conceptual and praxis-based experience mutually inform one another to ground the theoretical framework in embodied practice. I will locate constructions of authority between what texts say and distinctions in oral and experiential instruction and praxis, and the relative constitutive roles for the transmission of a tradition's knowledge skill. Finally, in the third area of analysis, I will investigate how the physician-patient relationship is taught and clinically applied, and how it may facilitate access to specific knowledge sets of Tibetan understandings of patient health and the complex matrix of conditions motivating pathologic processes, healing conditions, specific diagnoses and treatment pathways from the Tibetan perspective. I propose that better understanding of these Tibetan medical tracking systems for Tibetan indigenous cancer will provide: 1) Detailed insight and systematic evidence for how complex etiological systems are applied to specific conditions, such as Tibetan indigenous cancer; 2) A comprehensive account of an embodied knowledge form, how it works and the transmission processes implicated for its learning and development of expertise; 3) A way to understand diagnosis in a non-biomedical tradition using systematic application of embodied and subjective practice; 4) Embodied practice knowledge of the body; and 5) On a broader scale, what constitutes knowledge and how it is produced.

2 Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012

Literature Review and Significance The present investigation engages transmission processes, embodied knowledge, and medical epistemologies invoked vis-à-vis diagnostic praxis. It builds on existing scholarship in anthropology, history of medicine, sociology, and the development of expertise. In the realm of medical anthropology and history of medicine, it builds on the work done viewing medical systems as ideologies (B. J. Good 1994; Kleinman 1989; Lock and Farquhar 2007; Scheper-Hughes and Wacquant 2002; Mol 2002), and furthers this approach to show that a cultivated language of the body leads to novel knowledge sets about the body that implicate health outcomes and illness trajectories in how those knowledge sets are tracked (Kleinman 1989; Kuriyama 2002; Luhrmann 1991; Luhrmann 2000; Mol 2002). Knowledge sets are constructed by epistemically embedded ways of understanding, diagnosing, tracking and treating. For example, heart health was historically tracked exclusively for signatures of cardiovascular pathologies that then inhibited inquiry into its connection to a host of other immune, neural, gastrointestinal and mental effects for health which are now investigated through the heart's vagal tone (Kok and Fredrickson 2010) . The current project significantly furthers the work done on the production of new knowledge sets about the body based on distinct tracking systems by showing that they can specifically implicate our understanding of major physiologic diseases of our time such as cancer. Kuriyama (2002) set a solid foundation for the inquiry of the current project by pursuing the question of how do specific ways of using our senses affect distinct ways of thinking, and thus affect specific ways of seeing the body? His analysis focuses on the divergence of thinking in Greek and Chinese medicine regarding the pulse: the Greek, a view of pulse connected strictly to heart function and an assumed homogenous pressure and character throughout the body, and the Chinese, a view of pulse that stretches beyond pulsating blood vessels to influences that cross other physiologic systems and may be read through the mediator of the pulse. I seek to trace similar knowledge sets in the Tibetan system through pulse and urine around the diagnosis and pathways understood to be connected with indigenous forms of cancer (Tib. 'bras-nad). The current project also furthers the anthropological work done on bodies proper versus bodies lived (Scheper! Hughes and Lock 1987; M. Lock and Farquhar 2007) by expanding the discourse around “bodies proper” as constructed by Western biomedical perspectives on the body through historio-cultural epistemes which emerge from and by simultaneously conditioning discourses (Foucault 2007). The current project looks at the collusion and tension bodies proper have with bodies lived – and the medical epistemologies that construct and are constructed by the illness experience through the lens of physician in contact with patient (Kleinman 1989, 108; Harrington 2008). The current project contributes to our understanding of the lived, contextualized body, by investigating the situated knowledge of the body, knowledge that is accumulated through perceptual praxis knowledge of the particularism of individuals and the myriad of factors that affect a pulse – environmentally, socially, mentally, physiologically. Each factor with knowledge practice systems to provide tracking systems of health and dis-ease that integrate these influences into one system. Such multifold factor integration works toward a novel mode of health knowledge. The current project builds on Mauss's early conceptions of habitus (Mauss 1973) and work done on the sociology of the body. Similar to Mahmood's (2005), I will use Pierre Bordieu's, and Aristotle's more proactive version of habitus, as “acquired excellence at either a moral or a practical craft, learned through repeated practice until that practice leaves a permanent mark on the character of the person” (136). I will draw upon Tanya Luhrmann's work (1991; 2000) to further this notion of habitus and connect it to Mauss's earlier conceptions (1973) by using the theoretical framework of habituated and enculturated conceptualizations of mind-body processes that result from specific professional training.

3 Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012

The project will bring a ritual performance theory lens to the medical clinic looking at how text-based bodies of knowledge discourse with experts in the field that draw from those texts to enact the ritual- practices of performance. Ritual performance theory has only minimally been introduced to anthropological work (Briggs 1988; Flueckiger 2006), and thus, such an approach contributes a dialectic of context, specificity of each practice, and the role of meaning making in healing modalities (Harrington 2008). Finally, the project builds on medicine in practice to investigate how large complex knowledge systems get operationalized. Medical anthropology has long looked at medical system epistemologies (Charles 1980; M. Lock and Nichter 2002; Foster 1976; Arthur 1978; Farquhar 1987; Kuriyama 2002), and the patient-centered experience (Kleinman 1989; Biehl 2005; M.-J. D. Good et al. 2008), but has rarely looked at the practitioner training with diagnostic praxis. Because of the lack of works focused on the the training and practices of practitioners (existent include, Konner 1993; Flueckiger 2006), and – much less – Tibetan medical practitioners (Millard 2002; Jacobson 2000), my work will contribute new inquiry into the cultivated embodied knowledge of the clinician in practice and the tools which lend themselves to developing models of knowing that can be applied to both the systems biomedicine has developed as well as those that Tibetan medicine has fostered. Additionally, in focusing on the practitioner in a modality of difficult embodied skill, such as pulse diagnosis, my research will focus on the expert physician and how such expertise is cultivated. Initial work has begun in this area (Ericsson, Krampe, and Tesch-Römer 1993; Csikszentmihalyi 2008; Csikszentmihalyi 1997), but minimal research has been rigorously conducted on the learning processes involved in cultivating such expertise (Greenfield 2004).

Preliminary Studies by the Student As the first Westerner to be admitted to the Dharamsala Tibetan Medical School, Men-Tsee- Khang, and thus, as a student immersed in the complexity of the conceptual and praxis-learning of Tibetan medical cancer diagnostics, I am particularly well-positioned to carry out this project. I have the privilege to be a student, educated in the traditional pedagogy, including the practicum training of pulse diagnosis and urinalysis and their applications to the various forms of Tibetan medical forms of cancer (Tib. 'bras-nad). I also have extensive access to the practitioners, including some of the best Tibetan physicians in the world, renowned for their work with cancer patients. As a Tibetan medical student, I have the opportunity to gain the necessary advanced theoretical, disciplinary and medical training from the Tibetan side to apply my theoretical grounding in anthropology. My training in the fields of cultural and biological anthropology provide unique contributions to the understanding of Tibetan medical diagnostics of cancer – both critical in unraveling the multifold implications of the learning processes as well as the applications involved. My experience in ethnographic methods, having done a cumulative three years of work, research and study in the Dharamsala community, as well as in Tibetan communities in central and eastern Tibet, Ladakh, and Himalayan border regions, allows me to access current incarnations of Tibetan medicine's centuries of detailed, experientially-accumulated knowledge of physical ailments, including social and medical treatments. With over ten years of training in both colloquial and classical Tibetan – at Stanford University, Tibet University, among communities in central Tibet, Amdo eastern Tibet, Kham southeastern Tibet, and refugee communities through India and the U.S., as well as serving as translator for numerous Tibetan physicians during these times – I have developed the language skills that allow me to function as interpreter and translator for all conversations, interactions and text analyses.

4 Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012

My formal training in Tibetan medicine began three years ago when I met Dr. Khenrab Gyamtso, the Vice Principal of the Tibetan Medical School and my primary teacher in the medical texts for the last three years. Our interactions have provided the foundation for my understanding of Tibetan medicine as a system, in theory and practice, and, more specifically, its diagnostics and applications in cancer. This time has also afforded me the familiarization with dozens of case studies related to Tibetan medical approaches to cancer. For a three-month period, the summer of 2011, in Dharamsala, I conducted pilot research with students, faculty and practitioners for the following areas of exploration:

! Textual explication of the proper training of a doctor, specifically regarding diagnosis; ! Modes of defining the constitutional energetic systems (Tib. nyes-pas) foundational to Tibetan medical epistemology called rlung, mkhrispa and badkan2, in general, and laying the foundation for their role in indigenous forms of cancer (Tib. 'bras-nad) types; ! Ways of identifying function in the constitutional energetic systems (Tib. nyes-pas) through diagnostic techniques; ! Exploratory interviews on medical training techniques, experiences and views on developing expertise in diagnosis; and ! Conducting related test questionnaires for a handful of physicians and medical students at Men- Tsee-Khang and privately practicing physicians. The five surveys comprised: demographics, medical training experiences; medical practice experience and perspective on expertise; physician-related Buddhist practice and perspective on function of this practice; and lifetime life events that may contribute to developing qualities identified for expert physicians.

I found that the physicians' patients, colleagues and community members identify experts as those physicians who tend to have at least two decades of experience and who have been selected to be personal physicians to the Dalai Lama or other high lamas. These physicians are also known to treat extensive patient populations. Because the elimination of variation in diagnostic skill is impossible, even with expert physicians, and revealing this variability is culturally prohibitive at this time, I have chosen not to incorporate targeted inquiry into the variation, but will address this indirectly as part of my study through the methodology of learning the diagnostic procedure and explanations for indigenous forms of cancer. I began the textual foundations for dre-ned, looking specifically at the three major categories of differentiation: a rlung form, a mkhrispa form, and a badkan form. I also began learning pulse diagnosis and urinalysis through practicum mentorship – and the nuance involved in each distinct pulse signature, and tongue, eye, complexion and urine characteristics. There are extensive subcategories of Tibetan forms of cancer within each of these three major categories, with subtle pulse and constitutional characteristics related to these distinctions. I also distributed questionnaires and conducted semi-structured interviews with most of the identified expert physicians, as well as twelve other physicians regarding their education experiences and training methods, current practices and patient variety, major influential life events and experiences, and demographics.

Research Plan: Design, Site & Data Analysis The current project will be conducted in three data collection phases: 1) scholastic participant- observation of textual basis, oral instruction, and practical learning of diagnosis for cancer, 2) clinical

2 Pronounced “lüng,” “tree-pah,” and “bay-gan,” respectively.

5 Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012 participant-observations and interviews for dre-ned diagnosis in praxis, and 3) analysis of Tibetan and Western past medical diagnostic and treatment records of patients observed in the clinical encounters. There will be a fourth phase for final data analysis, though transcription and limited data analysis will occur throughout all phases. These three data collection phases will be administered over two years with the second and third clinical ethnographic and analytical parts phasing in nine months after the first pedagogy ethnographic phase initiates, and the final analysis phase over the last six months. Thus far, no other funds have been secured for the current project, and the budget provided in the main application details how the NSF grant would cover all required expenses for the project. Phase I. In phase one, as an official student at Men-Tsee-Khang Tibetan medical school, I will engage in scholastic participant-observation looking specifically at the transmission modalities of how dre-ned and diagnosis are taught in the classroom as both theory and praxis knowledge of embodied skills and how they are characterized as part of Tibetan medical epistemology through textual foundations, oral explications and practical skill mentorships. As a student, I will be conducting textual analysis of the Tibetan medical locus classicus, rGyud bZhi, and its associated commentaries. This will allow me to specifically investigate the Tibetan medical epistemology underpinning dre-ned, indigenous cancer types, with the faculty mentorship. In this phase, my data will consist of the root and commentarial textual passages and oral instructions that explicate foundational causes, facilitating conditions, proper diagnostic recognition and treatment modalities of dre-ned, and the associated practicum learning as a medical student myself and observation of my fellow classmates. Analysis will highlight both the metaphorical and corporeal cues of diagnostic criterion and conceptual frames articulated for dre-ned in the texts, classroom, and instructive conversations. Phase II. In phase two, I will look at how diagnostics and theory translate and transform into clinical practice vis-à-vis dre-ned. Tibetan medicine, and, specifically, several expert doctors in the community, have become destination treatment resources for cancer3. Thus, Dharamsala attracts a number of cancer patients from throughout India, as well as Russia, Mongolia, China, Nepal and Bhutan. My clinical participant-observation will focus on five such doctors in the area whom I have highlighted in my pilot study during the summer of 2011 as expert physicians identified by patients, colleagues and the general community for cancer treatment. I will conduct clinical participant- observations of the diagnostic moments for at least twelve cancer patients per expert physician regarding how such diagnoses are described and conducted. Preliminary surveys administered to each physician before I conduct any clinical encounters will also give me background data regarding each physician's educational and professional experiences and practices for diagnosis and dre-ned, specifically. I will also conduct a cognitive interview with physicians after the clinical encounter to gain further description and reflections on the diagnostic experience that may not have been articulated during the time with the patient and may provide richer recollections of the information accessed during the diagnosis (Fisher, Geiselman, and Amador 1989; Fisher 1992; Memon, Meissner, and Fraser 2010). My data for this phase will consist of rich descriptions of the metaphorical and corporeal cues, actions and interactions conducted by the physician – both in the physician's own articulation of the experience and my observations of it. I will also observe and describe the physician-patient dynamic and rapport using descriptions by Tibetan medicine of key features of the physician-patient relationship to understand it as a critical pathway for diagnostic information access and successful treatment in Tibetan medicine. Analysis will assess what descriptions and observations say about medicine as an ideology, and the types of cultivated languages of the body being employed to diagnose and 3 Of important note is that the diagnostic categories of biomedical cancer and Tibetan cancer, dre-ned (Tib. 'bras-nad), often coincide, though my project will focus on the Tibetan form irrespective of the biomedical diagnosis.

6 Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012 conceptualize dre-ned. I will evaluate the extent of habitus, field and doxa physicians take as given, and the types of naturalized truths understood in their diagnostics and understanding of dre-ned. Phase III. For phase three I will follow-up with patients post-clinic for a semi-structured interview. In this interview, I will review past Tibetan and/or Western biomedical diagnoses and treatments, as well as obtain any medical records such as CT scans and laboratory blood work that patients consent I may copy for analysis. The interviews and/or medical records will allow me to look at diagnostic and treatment history to understand how the diagnosis I observed is informed by the patient's past medical interactions. Data in this phase will comprise: 1) notes from the patient semi- structured interviews, 2) available medical records of past diagnosis and treatment, and 3) notes from the diagnostic moment of phase two. I will analyze the data in phase three by identifying if the dre-ned discussed in the diagnosis correlates with cancer as understood by a Western biomedical audience. I will focus on a simple correlation analysis of the following: existence and location of a cancer or tumor; existence, degree and location of metastasis; and any other organ malfunction or health. The correlation is important in understanding to what degree dre-ned can be understood as the Western biomedical category of cancer and any other correlation in functional systems between the two medical systems. Phase three also allows me to bring the data together from all three phases and look at what metaphorical and corporeal language and practice is being brought together to transmit and recognize 1) the ideologies underpinning Tibetan medical dre-ned diagnostics, 2) the ways in which pulse, urine and other Tibetan medical diagnostics can form a cultivated language of the body that organizes distinct knowledge sets around dre-ned, 3) the modes that Tibetan physicians inhabit a habitus of embodied knowledge enacted by Tibetan medical epistemology and related learning processes, and 4) the most influential factors for the transmission of embodied skills vis-à-vis the conceptual-perceptual dialectic of Tibetan medical pedagogy in diagnosis and dre-ned and any implications in the way the physician-patient relationship is engaged. These areas of analysis will facilitate looking at discrepancies among textual sources, transmission practices and clinical implementation of cancer diagnostics, how such instruction and ideology is put into practice, as well as how it relates to what we know as cancer. Phase IV. Although I will conduct transcription and limited data analysis throughout the data collection process, the final phase will comprise the primary data analysis period. Qualitative data will be analyzed using MAXQDA software that will aid in transcription, and allow thematic coding, and the ability to group, filter and hierarchize codes. Codes will include factors previously mentioned (i.e. corporeal and metaphorical cues, dre-ned subcategories, constitutional energetic system impairments, Buddhist conceptual frameworks, biomedical correlations, and so forth) as well as using the “grounded theory” approach. Grounded theory allows the generation of theory from data in qualitative research by (1) coding concepts from the raw data that is used to develop the theory, and (2) creating analytical categories which systematize the theory (Bernard and Ryan 2009; Patton 2002) . Through these analytic tools, I will identify the most significant diagnostic criterion using emic categories and concepts that inform a dre-ned diagnosis. Additionally, grounded theory will allow me to employ indigenous categories of diagnosis to illuminate the role each diagnostic criterion plays in recognizing dre-ned and its levels of severity and types. Placing coded classroom, clinical, and interview data and indigenous categories from these contexts alongside each other will (1) reveal the influence of textual authority, oral instruction, various learning processes on developed embodied diagnostic skill, (2) demonstrate the relationship of sensory and tactile observations and other clinical experiences of the patient, as well as knowledge of past biomedical diagnoses on a given dre-ned diagnosis, (3) locate the epistemological underpinnings of dre-ned pathology and treatment, (4) suggest conceptual and/or

7 Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012 physiological foundations of comparison to Western biomedical conceptions of cancer, and (5) clarify the the types of naturalized truths understood in Tibetan medical epistemology that provides for specific diagnostics and understandings of dre-ned. By supplementing these analyses with observational data and my own experiences of learning processes in the Tibetan medical system, I will extract how these conceptualizations and indigenous categories are enacted in the educational and clinical setting to develop embodied expertise in diagnosing Tibetan indigenous forms of cancer, dre- ned.

Research schedule The following provides a chart of the current project's research schedule divided by research activity, including scholastic participant-observation, interviews and surveys administration, clinical observations, interview transcription, and data analysis.

8 Tawni Tidwell ‧ NSF-SBE Cultural Anthropology DDRIG ‧ Data Management Plan ‧ January 15, 2012

DATA MANAGEMENT PLAN

Introduction. This Data Management Plan (DMP) addresses the data that will be collected under the proposed project entitled “Transmitting Diagnostic Skills in Tibetan Medicine: Embodied Practices for Indigenous Categories of Cancer,” and is designed to be consistent with the NSF Policy on Dissemination and Sharing of Research Results. In accordance with this policy, this plan does not include preliminary analyses (including raw data), drafts of scientific papers, plans for future research, peer reviews, or communications with colleagues. Furthermore, data to enable peer review and publication/dissemination and/or to protect intellectual property may be temporarily withheld from distribution and other proposed data management. This plan will ensure that the data produced during the period in which project research data is engaged is appropriately managed for its usability, access and preservation.

Data, software and materials produced. The data produced by the current project will include demographic information of Tibetan physicians and patients seen in Tibetan medical clinics, transcripts from interviews and classroom contexts, and Tibetan medical and biomedical records voluntarily shared by patient under signed confidentiality agreement. The demographic data and Tibetan medical and biomedical records are needed for published reports to characterize characteristics of the subject population.

Data management. Data collection will be accompanied with appropriate documentation and associated metadata for preservation and long-term access. Final dataset will be stripped of identifiers. Files will include the data itself saved as audio files (.mp3), transcription word documents (.doc and .nb), and scanned medical record data (.jpb). The additional NoteBook (.nb) format links audio, text and image files for easy access to linked data variables and provides an ease of organization, formatting, and access.

Data access & archival. Researchers associated with this project are not aware of reasons that would prohibit the sharing of data generated under this project for public and/or potential secondary uses once in its final form stripped of identifiers. The right for first use of the data is retained by the principal investigators, whom will work with the appropriate NSF Program Officer in identifying public databases which would provide an appropriate public database for the de-identified data. Summary forms of the data will be provided to journal publications and published in tables, appendices, or online supplementary materials. De-identified raw data will be made available for access and sharing as soon as reasonably possible, likely one year after initial publication of the data. Project researchers will archive the raw data locally on regularly backed-up computers and will be preserved at least three years beyond the award period, as required by NSF guidelines.

Data confidentiality. All research records will be kept confidential, and access will be restricted to the Project Investigator and primary research team members only. Identifying information will be removed at completion of field research period and such identifiers will be replaced with project code numbers. A database linking study code numbers to consent forms and identifying

1 Tawni Tidwell ‧ NSF-SBE Cultural Anthropology DDRIG ‧ Data Management Plan ‧ January 15, 2012 information will be stored separately on password-protected computers in a secure, locked office. The secure computers are located in the Anthropology Building at Emory University in Atlanta, Georgia. Researchers will maintain participant privacy such that any report of individual data will only comprise interview, medical record, and demographic content without identifying information.

Intellectual property and data sharing. Data and intellectual property generated under the project will be addressed in accordance with both Emory University and NSF policies. Ownership of sole or joint inventions developed under the project will be owned by the institution(s) employing the inventor(s). Inventors shall be determined by U.S. Patent law. University and participating investigators/institutions will disclose any inventions developed via project activities and such inventions will be reported and managed as provided by NIH policies. Similar procedures will be followed for copyrights.

Materials generated in association with the project will be shared in accordance with Emory University, participating institution(s) and NSF policies. Any materials transferred will be administered under a material transfer agreement.

Database access (of de-identified data) and any associated software tools generated under the project will be made available for education, research and non-profit purposes. Web-based applications will provide access, as appropriate.

Data publication will occur during or at completion of the project, as appropriate, consistent with standard scientific practices. Project researchers will make available research data that documents, supports and validates research findings after the main findings of the project have been accepted for publication. Available research data will be redacted to prevent disclosure of personal identifiers.

2 Tawni Tidwell ‧ NSF-DDRIG SBE Cultural Anthropology DDRIG ‧ Budget & Justification ‧ January 15, 2012

Project Budget

Budget Exchange Rate: US$1 = INR43

FOREIGN & DOMESTIC TRAVEL 1. Atlanta, GA to New Delhi, India (roundtrip) = $2,000 2. New Delhi to Gaggal airport, domestic travel (roundtrip) = $400 3. Local travel Gaggal airport to Tibetan Medical School (roundtrip) = INR1,000 = $25 4. Local travel visiting Tibetan physicians in Dharamsala area INR160 roundtrip x 2x per week for 100 wks = INR32,000 = $745 Travel Sub-total =$3,170

OTHER DIRECT COSTS LODGING 5. Lodging $300 per month x 12 months for 2 years = $7,200 Lodging Sub-total = $7,200 LIVING EXPENSES 6. Food at Tibetan Medical School INR9000 per month x 12 mo for 2 years = INR216,000 = $5,023.26 Living Expenses Sub-total = $5,023.26

COMMUNICATION, PHOTOS & COPIES 7. Digital voice recorder with microSD card for recording clinical encounters and interviews = $171.18 8. Software for qualitative data (interview) analysis (MAXQDA Single-User Educational Lic) = $585 9. Data backup drive (4 TB) for all project data (audio, visual and documents) = $383.35 10. Internet INR1,000 per month x 12 months for 2 years = INR2,400 = $558.14 11. Cell phone for physician visit coordination INR500 x 12 months for 2 years = INR1,200 = $27.91 12. Questionnaire copies $20 per copy x 5 physicians = $100 13. Patient medical record copies INR10 per pg, 6 pp per patient x 120 patients = INR7,200 = $167.44 14. Patient medical record scans/faxes, INR100 expenses for 100 patients = INR10,000 = $232.56 15. Photographs of urine and pulse interactions, INR50 per photo, 2 photos per patient x 120 patients = INR12,000 = $279.07 Communication, Photos and Copies Sub-total = $2,504.65 HONORARIUMS (for physicians and patients) 16. Honorariums in gratitude for study participation INR1000 per physician x 5 physicians, INR200 per patient x 120 patients = INR29,000 = $674.42 17. Honorariums in gratitude for additional interviews,

1 Tawni Tidwell ‧ NSF-DDRIG SBE Cultural Anthropology DDRIG ‧ Budget & Justification ‧ January 15, 2012

INR500 per physician x 5 physicians = INR2,500 = $58.14 Honorariums Sub-total = $732.56

SUMMARY Travel Sub-total = $3,170 Lodging Sub-total = $7,200 Living Expenses Sub-total = $5,023.26 Communication, Internet, Photos and Copies Sub-total = $2,504.65 Honorariums Sub-total = $732.56 TOTAL BUDGET REQUESTED FROM WENNER-GREN = $18,630.47

Budget Justification 1. This rate on cheapest fares provided by Orbitz.com. 2. This rate is based on Kingfisher’s standard seasonal prices to Gaggal Airport. With baggage loads at this time, I will not be able to take the bus from New Delhi to Gaggal. 3. This is the standard taxi price from Gaggal airport to Men-Tsee-Khang Tibetan Medical Institute, secured by known taxi drivers. 4. My main lodging will be in the girls dormitory at Men-Tsee-Khang Tibetan Medical Institute. This is the cost of the school’s lodging. 5. Many physicians, including Dr. Yeshi Dhonden, will be up in McLeod, an INR80 one way ride. Given time constraints as a medical student, at times I will not be able to make the 40 minute one-way walk. I have put this category in to assist in this cost. 6. My food will come from the Men-Tsee-Khang Tibetan Medical School. This is the monthly cost. 7. Digital recorder required for clinical participant-observation, physician/patient interviews, and teachings. Price is mid-range Sony ($117.69), voice-activated recording, 4,000 hours recording with microSD card (16GB at $53.49). Mac compatible for use with MacBook Pro. 8. MAXQDA data analysis software for evaluating text recorded in interviews and clinical encounters. Cost for educational package most suited to the project’s analytical goals. 9. External hard drive for storage of all data (audio, visual, and textual) obtained for the project. Galaxy 4TB Firewire 800 for Mac is a standard hard drive for this size. Space required particularly for large amount of audio recordings throughout project. 10. In order to maintain contact with my advisors at Emory University in directing my research, I will need to have a personal internet source (USB stick from Reliance, and well-established India-based internet company for the area). Cybercafes are unpredictable and often full of Tibetan youth. This provides an unreliable source of fundamental communication. 11. I will need a cell phone for physician and patient visit coordination. This is the primary mode of communication in the area and critical for making contact in crowded developed areas. 12. This is the standard rate for printing and copying such questionnaires used during my 2011 pilot study.

2 Tawni Tidwell ‧ NSF-DDRIG SBE Cultural Anthropology DDRIG ‧ Budget & Justification ‧ January 15, 2012

13. This rate applies as above for printing and copying costs. I assume that patients with appropriate medical records will likely have approximately six pages of medical records to copy comprising CT scan results and laboratory blood work. 14. As above for copies of medical records, this item would provide for reimbursement to those patients who send or scan copies of their medical records. 15. Costs associated with photograph prints of urine sample and pulse-taking. Such image data will help in analysis when doctors describe characteristic differences particularly of urine, but also the patient themselves during diagnosis. 16. It is customary to offer a monetary, food or functional gift in thanks for a physician’s time, and likewise for patients with whom I will be spending time in interviews after clinical observations. This item covers such honorarium costs. 17. Similar to the above item, some physicians will be providing extra time in interviews and teachings. This item covers honorariums and gifts of gratitude for their additional time.

3 Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012

References

Arthur, Kleinman. 1978. “Concepts and a model for the comparison of medical systems as cultural systems.” Social Science & Medicine. Part B: Medical Anthropology 12 (0): 85-93. doi:10.1016/0160-7987(78)90014-5. Bernard, H. Russell, and Gery W. Ryan. 2009. Analyzing Qualitative Data: Systematic Approaches. Sage Publications, Inc, September 30. Betan, Ephi, Amy Kegley Heim, Carolyn Zittel Conklin, and Drew Westen. 2005. “Countertransference Phenomena and Personality Pathology in Clinical Practice: An Empirical Investigation.” American Journal of Psychiatry 162 (5): 890-898. Biehl, João. 2005. Vita: Life in a Zone of Social Abandonment. 1st ed. University of California Press, June 27. Briggs, Charles L. 1988. Competence in Performance: The Creativity of Tradition in Mexicano Verbal Art. Univ of Pennsylvania Pr, December. Charles, Leslie. 1980. “Medical pluralism in world perspective [1].” Social Science & Medicine. Part B: Medical Anthropology 14 (4) (November): 191-195. doi:10.1016/0160-7987(80)90044-7. Csikszentmihalyi, Mihaly. 1997. Creativity: Flow and the Psychology of Discovery and Invention. Harper Perennial, May 9. ———. 2008. Flow: The Psychology of Optimal Experience. 1st ed. Harper Perennial Modern Classics, July 1. Ericsson, K.A., R.T. Krampe, and C. Tesch-Römer. 1993. “The role of deliberate practice in the acquisition of expert performance.” Psychological review 100 (3): 363. Fadiman, Anne. 1998. The Spirit Catches You and You Fall Down. 1st ed. Farrar, Straus and Giroux, September 28. Farquhar, Judith. 1987. “Problems of knowledge in contemporary Chinese medical discourse.” Social Science & Medicine 24 (12): 1013-1021. doi:10.1016/0277-9536(87)90017-7. Fisher, Ronald P. 1992. Memory-Enhancing Techniques for Investigative Interviewing: The Cognitive Interview. Charles C Thomas Pub Ltd, August. Fisher, Ronald P., R. Edward Geiselman, and Michael Amador. 1989. “Field test of the cognitive interview: Enhancing the recollection of the actual victims and witnesses of crime.” Journal of Applied Psychology 74 (5): 722-727. doi:10.1037/0021-9010.74.5.722. Flueckiger, Joyce Burkhalter. 2006. In Amma’s Healing Room: Gender and Vernacular Islam in South India. Indiana University Press, April 26. Foster, George M. 1976. “Disease Etiologies in Non! Western Medical Systems.” American Anthropologist 78 (4) (December 1): 773-782. doi:10.1525/aa.1976.78.4.02a00030. Foucault, Michel. 2007. Archaeology of knowledge. Routledge. Good, Byron J. 1994. Medicine, Rationality and Experience: An Anthropological Perspective. Boston, MA: Cambridge University Press, January 28. Good, Mary-Jo DelVecchio, Sandra Teresa Hyde, Sarah Pinto, and Byron J. Good. 2008. Postcolonial Disorders. 1st ed. University of California Press, February 4. Greenfield, Patricia Marks. 2004. Weaving Generations Together: Evolving Creativity in the Maya of Chiapas. illustrated edition. School of American Research Press, September 1. Harrington, Anne. 2008. The Cure Within: A History of Mind-Body Medicine. 1st ed. W. W. Norton & Company, January 17. Jacobson, Eric. 2000. Situated Knowledge in Classical Tibetan Medicine: Psychiatric Aspects

9 Tawni Tidwell ! NSF-SBE Cultural Anthropology DDRIG ! Project Description ! January 15, 2012

(Dissertation). Harvard Dissertation. Cambridge, MA. Kitanaka, Junko. 2011. Depression in Japan: Psychiatric Cures for a Society in Distress. Princeton University Press, October 16. Kleinman, Arthur. 1989. The Illness Narratives: Suffering, Healing, And The Human Condition. Basic Books, October 2. Kleinman, Arthur, Veena Das, and Margaret Lock. 1997. Social Suffering. 1st ed. University of California Press, December 30. Kok, Bethany E., and Barbara L. Fredrickson. 2010. “Upward spirals of the heart: Autonomic flexibility, as indexed by vagal tone, reciprocally and prospectively predicts positive emotions and social connectedness.” Biological Psychology 85 (3) (December): 432-436. doi:10.1016/j.biopsycho.2010.09.005. Konner, Melvin. 1993. Medicine at the Crossroads: The Crisis in Health Care. 1st ed. Pantheon. Kuriyama, Shigehisa. 2002. The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine. Zone Books, March 15. Lantieri, Linda, and Daniel Goleman. 2008. Building Emotional Intelligence: Techniques to Cultivate Inner Strength in Children. Sounds True, Incorporated, April 1. Lock, Margaret, and Judith Farquhar. 2007. Beyond the Body Proper: Reading the Anthropology of Material Life. Duke University Press Books, March 23. Lock, Margaret, and Mark Nichter. 2002. New Horizons in Medical Anthropology: Essays in Honour of Charles Leslie. 1st ed. Routledge, May 31. Luhrmann, Tanya M. 1991. Persuasions of the Witch’s Craft: Ritual Magic in Contemporary England. Reprint. Harvard University Press, April 4. ———. 2000. Of Two Minds: The Growing Disorder in American Psychiatry. 1st ed. Knopf, April 4. Mahmood, Saba. 2005. Politics of Piety: The Islamic Revival and the Feminist Subject. Princeton University Press, October 25. Mauss, Marcel. 1973. “Techniques of the body.” Economy and Society 2 (1) (February): 70-88. Memon, Christian A Meissner, and Joanne Fraser. 2010. “The Cognitive Interview: A meta-analytic review and study space analysis of the past 25 years.” Psychology Public Policy and Law 16 (4): 340-372. doi:10.1037/a0020518. Millard, Colin. 2002. Learning Processes in a Tibetan Medical School (Dissertation). University of Edinburgh Dissertation. Edinburgh. Mol, Annemarie. 2002. The Body Multiple: Ontology in Medical Practice. Duke University Press Books, December 27. Patton, Michael Quinn. 2002. Qualitative research and evaluation methods. SAGE. Scheper - Hughes, Nancy, and Loïc Wacquant. 2002. Commodifying Bodies. 1st ed. Sage Publications Ltd, October 18. Scheper! Hughes, Nancy, and Margaret M Lock. 1987. “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology.” Medical Anthropology Quarterly 1 (1) (March 1): 6- 41. doi:10.1525/maq.1987.1.1.02a00020. Silva, Chikako Ozawa-de. 2006. Psychotherapy and Religion in Japan: The Japanese Introspection Practice of Naikan. 1st ed. Routledge, September 27. Wylie, Turrell. 1959. “A Standard System of Tibetan Transcription.” Harvard Journal of Asiatic Studies 22 (December 1): 261-267. doi:10.2307/2718544.

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