Ethnotale: Up Close and Personal

A few years ago we were hired to observe doctors and nurses inserting central venous catheters in hospitals and clinics in order to identify opportunities for reducing the possibility of infection.  We had been working on the project for a few months and had observed in several areas within hospitals and clinics, but were really needing to understand how things might be different in the pre-surgery area of hospitals.  We had worked hard to go through all of the proper channels and had finally secured permission to observe in the pre-surgery area.  We had institutional review board permission and had spoken to the nurse in charge of the pre-surgery area several times and thought we were ready to go.

We arrived at the hospital bright and early, excited for our first day of fieldwork.   After meeting the head nurse and being given a tour of the area, I asked who actually did the catheter insertions in the pre-surgery area and was told that the department of anesthesiology did the insertions.  I asked if they had been informed about what we were doing and was told ‘I don’t think so.’  Years of experience washed over me as I realized this was NOT GOOD, so I headed for an impromptu meeting with the chair of the anesthesiology department.  He was cordial and listened intently about the goals of our project and the process we had gone through to obtain permission.  When I was finished, he exploded.  He let me know that this was just the latest in a long line of events that proved how little his department was valued by the hospital.  He assured me that he didn’t hold me responsible and told me that I seemed like a very nice lady.  BUT he could not allow us to observe any catheter insertions on that day because he needed to do some research, see who had dropped the ball and inform the other doctors about what was going on.  He promised to touch base with me later to update me.  That afternoon, I received a call from the department chair’s assistant telling me we were cleared to observe insertions the next day. She said a memo had been sent out and everyone would be expecting us.  I was thankful to only have lost one day of fieldwork.

The next morning, we arrived at the hospital early and when the first catheter insertion hit the floor we were ready. We had asked permission of the patient and the resident who was doing the insertion.  We were in the middle of the insertion when the attending physician walked in and motioned for us to step into the hall.  He asked what we were doing and I told him it was fine, we had permission from the chair of the department and that there had been a memo circulated about the matter.  He informed me that he had read the memo and asked me if I had (I had not).  He pointed out that the memo clearly stated we were not allowed to observe residents.  My heart sank.  I walked outside and called the chair of the department who was working off-site on that day.  It was then that I discovered the value of inserting someone’s name during a reprimand.  Dr. X said ‘I hold you responsible, Melinda.’  ‘You should have read the memo, Melinda’ (I hadn’t been given a copy of the memo). ‘I will call you later to discuss whether we can work this out.’  We left the hospital completely deflated.  We had now lost two full days of insertion observation, approximately 24 hours of data collection.  That afternoon, the department chair called me and told me we could return the next day.  His assistant had forwarded me the memo and we reviewed the perimeters and rules of our observation.  I took some Advil and tried to refocus my thoughts.

On the third day, we arrive at the hospital earlier than before, we wanted to get settled in and be ready for any and all opportunities for insertion observation.  On that day, because the caseload was low, there was only one doctor performing insertions.  It just so happened this was the same doctor who had exposed us on the second day and he was NOT interested in participating in our study. We again spent the entire day observing the comings and goings of the pre-surgery area, but no catheter insertions.

On the fourth day, we returned, hoping against hope that things would be better.  The first few doctors doing insertions declined to participate in our study, so we had another couple of hours to make general observations.  I was beginning to panic.  What if we didn’t get to see any insertions.  How was I going to explain THAT to the client.  Just before noon, one of the doctors came and sat down next to me and asked me to explain exactly what we were doing.  I gave him my 3-minute elevator pitch on our work, the project, etc.  He seemed to relax a little bit and asked me if I had ever read the book ‘Three Cups of Tea’.  I told him I had not and he gave me a quick overview of the book.  He explained that it was written by a guy who got sick while mountain climbing and was forced to remain in a village with strangers until he recovered.  The title of the book came from the Balti proverb that explains how tea rituals move you from stranger status (first cup) to honored guest (second cup), and then to family member (third cup).  The doctor patted me on the back and said he had just wanted to share that idea with me and then invited me to watch him do an insertion.  For the rest of the afternoon and into the next day, my partner and I couldn’t keep up with the insertions that we were invited to observe.  We were invited to watch virtually all of the insertions that were happening on the floor and were also invited to watch insertions that occurred in other departments and in patients’ rooms.  We were invited into the break room and asked to have lunch with a few doctors.  We ended up with more instances of observation and interviews than we had originally planned.

As I left the hospital on the last day, I was relieved and excited to begin the process of breaking my observations down and figuring out the patterns that separated catheter insertion in the pre-surgery area from the other areas that we had observed.  But it wasn’t until a few days later as I was reviewing my fieldnotes from the first three days that that I realized what a wonderful gift I had been given by things not going according to plan.  I had been given the opportunity to observe the context of the pre-surgery area for hours without having to focus on the technical aspects of catheter insertion.  I had noted a lot about the patterns of interaction and the flow and movement of patients and staff within the pre-surgery area.  This allowed me to really place my specific observations about the challenges that doctors faced in inserting catheters in the pre-surgery area into a more understandable context.

When I reached the point in my fieldnotes where I had written about the doctor telling me about ‘Three Cups of Tea’, I realized that there had been a hidden message.  At the time, I thought he was telling me about the book because I was a sociologist and he thought I would appreciate the story.  It was only later that I realized that by telling me the story, he was inviting me to my second cup of tea.  While sitting in the pre-surgery area for days, we had become a fixture and had transcended the ‘stranger’ status and became if not an honored guest, at least an ‘okay observer’ (as evidenced by the number of invitations we received for observation and interviews).

This experience taught me two things:  1) Never forget to look for the opportunities that are presented when things go wrong.   2)  Remember how different your access and perspective is when you are having the first cup of tea versus the second cup of tea.  And always try to get to the second cup of tea before leaving the field.

I’m often asked if it is really possible to do ‘real’ ethnography while working within the kinds of timelines that working in business contexts require.   That conversation will be saved for another blog post, but for now I will say that it is often possible to get to the second cup of tea pretty quickly if you are a skilled ethnographer.  In fact, I’m often at two cups of tea within the first few hours of spending time with someone.  You would be really surprised how much rapport and intimacy can be built when someone realizes that you really ARE interested in their story.