Editor’s Note: In this second of a two-part series on difficult learning situations, John Langlois, MD, and Sarah Thach, MPH, of the Mountain Area Health Education Center (MAHEC) Division of Family Medicine in Asheville, NC, provide us with information and tips on managing difficult learning situations. The content of the column is based on materials developed as a part of the Preceptor Development Program (PDP), a comprehensive program of preceptor development materials supported by a Health Resources and Services Administration Family Medicine Training Grant (1D15PE50119-01). Detailed information on this project can be obtained from the PDP Web site at www.mtn.ncahec.org/pdp.

I welcome your comments about this feature, which is also published on the STFM Web site at www.stfm.org. I also encourage all predoctoral directors to make copies of this feature and distribute it to their preceptors (with the appropriate Family Medicine citation). Send your submissions to Paul Paulman, MD, University of Nebraska Medical Center, Department of Family Medicine, 983075 Nebraska Medical Center, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501. E-mail: ppaulman@unmc.edu. Submissions should be no longer than 3–4 double-spaced pages. References can be used but are not required. Count each table or figure as one page of text.

Mini-ethnography: Meaningful Exploration Made Easy
Jamie Weinstein, MD; William Ventres, MD

Students in their third year of medical school spend the majority of their time on hospital services mired in the minutiae of problem lists, differential diagnoses, and inpatient management. They are often completely out of touch not only with ambulatory practice but also with community life outside the hospital. Family medicine clerkships can remediate this situation by offering both exposure to outpatient medicine and a unique opportunity for broader educational experiences.

Many authors have suggested population-based projects, chart reviews, or independent learning modules as possibilities for enhancing a family medicine rotation.1 In this article, we present an alternative for actively engaging students in learning about the intersection of community and individual health: the mini-ethnography. Ethnography is a process of learning from people about various aspects of their lives. As such, it fits nicely with the view of family medicine as a “human science.” The core principles of ethnography involve defining a question, interviewing informants, becoming a participant observer in a community, analyzing one’s observations, and presenting results.2 The term mini suggests that it is doable in 6 weeks, allowing 1 day per week for the project.

To demonstrate the use of mini-ethnography, we present the following example in which a student investigated attitudes and communication about breast-feeding during a family medicine clerkship at a busy urban clinic (Table 1). After conducting a brief literature review—including three articles that illustrate the use of ethnography within medical contexts2-4—the student developed a general question and then identified and interviewed key informants. The audiotaped interviews followed a specific format. They began with a general statement about the project and an open-ended question to prompt the informant’s story. For approximately 30 minutes, the student actively listened to the narrative, using appropriate open-ended prompts (ie, “Tell me more about that”). Themes that emerged were identified. In the next half hour, the student asked increasingly specific questions about three or four of the most interesting themes. Immediately afterward, the student spent 1 hour reviewing the audiotape to recall information and quotations supporting the themes. The most interesting themes were listed and compared, and areas for further discussion were developed.

Limited participant observation occurred during a hospital-based lactation clinic. Weekly meetings provided a venue for the student to discuss data and progress with the preceptor; at the end, the student gave a lunchtime presentation to interested clinic personnel. The project fit comfortably into a 6-week rotation, with preceptor time commitment no more than 1 hour per week (Table 2). There are potential limitations to the use of mini-ethnography as a viable investigative methodology for medical students. Some students may be inherently uncomfortable with its qualitative nature. Others may have yet to gain confidence in their active listening skills. As well, the project’s success relies to a degree on the availability of interested and talkative informants.

Doing mini-ethnography has many benefits. Because ethnography is not hypothesis driven but, rather, observational and interactive, it is an engaging format for a student to explore the process of learning about a community. It allows students to develop their communication skills and introduces them to process-oriented, reflective medical practice. Because ethnography is qualitative and not based on surveys or statistical analyses, a fulfilling project can be completed in a reasonable time frame. For clinicians, it can foster their own reflective practice and further their insight into their communities. Having a student participate in activities outside the office frees up the preceptor’s schedule and helps balance the impact of having a student in a busy clinic.

Mini-ethnography can be used to explore a variety of topics. Projects can be tailored to student interests (as our example was) or be more generic in scope. Possibilities include studying people’s knowledge, attitudes, and practices regarding preventive services, phone triage, or nursing home care. Projects can be focused, such as examining how a certain ethnic group understands a specific disease state or how the local emergency services work (incorporating Saturday night ambulance rides for participant observation). They can be general, as in simply having a student use the process to get a sense about the community.

Regardless of the specific project, mini-ethnography can be tremendously worthwhile and enriching for both medical student and community-based teacher. We invite you to explore its use.

Corresponding Author: Address correspondence to Dr Ventres, Providence-Southeast Family Medicine, 4104 SE 82nd Avenue, Suite 250, Portland, OR 97266. 503-215-9850. Fax: 503-215-9855. E-mail: bventres@providence.org.

References
1. DaRosa DA, Dunningham GL, Stearns J, Ferenchick G, Bowen J, Simpson D. Ambulatory teaching “lite:” less clinic time, more educationally fulfilling. Acad Med 1997;72: 358-61.
2. Ventres WB, Frankel RM. Ethnography: a stepwise approach for primary care researchers. Fam Med 1996;28:52-6.
3. Miller W. Routine, ceremony, or drama: an exploratory field study of the primary care clinical encounter. J Fam Pract 1992;34:289-95.
4. Greenhalgh T, Hurwitz B. Narrative-based medicine: why study narrative? BMJ 1999; 318(7175):48-50.