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Building a Culture of Research in Clinical Medicine: An ethnography of professional aspiration, privilege and crisis at the intersection of hospital and university in South Africa

This thesis is an ethnography of a group of medical doctors in South Africa who produce clinical research based on their patient practice. These clinician-researchers are scarce around the globe but praised as contributing indispensable clinical insights to research in an aim to improve healthcare. In South Africa government and professional bodies recently took action to expand and racially transform this elite of knowledge producers with the aim of remedying the country’s healthcare, perceived as being in crisis. My ethnography centres on the University of the Witwatersrand (Wits), specifically its School of Clinical Medicine, its associated teaching hospitals, and its attempts to grow a so-called culture of research among doctors. It is a reflection on the relationship between clinical practice and knowledge production at the intersection of resource-insecure public hospital and research-intensive university — both powerful state institutions with competing demands for doctors. Drawing on interviews and participant-observation I describe and analyse the aspiration, contestation, contingency, and actual work of research production among local clinicians. Overall this thesis indicates that the resource-insecure context in which clinicians produce knowledge creates the opportunity for and the value of their research. But this context simultaneously limits the scale, translation, and social good of their research, undermines the valour and expertise of clinician-researchers, and in cases bifurcates their knowledge production from their clinical experiences. This undercuts the pervasive imaginary of doctors’ clinical insights as fundamentally valuable to clinical research; and the potential of their research to improve healthcare for a population with a unique demographic and epidemiology by providing locally-embedded evidence for best practice, rather than relying on research from the global north. My evidence also indicates that publicly claimed professional aspiration to create a more inclusive democratic scientific community of doctors sits in tension with the often unacknowledged professional privilege many doctors have in the dispersed labour of research and does not fully reflect the unequal professional experiences and engagement that research doctors have in relation to gender, race, language, and locality. I argue that attempts to build a culture of research in clinical medicine sit uneasily within its larger institutional structures and historical context. My ethnography of “studying up” is relatively uncommon in South African anthropology. But I demonstrate that profession is a useful lens through which to study the relationship between power, knowledge, and human suffering, including the brutalisation of professionals, in post-apartheid institutional life. The thesis also highlights the personal and epistemological challenges of doing interpretivist research among a professionallyprivileged, research-literate community that places great value on instrumental knowledge production. Keywords: Biomedicine, clinical research, clinician-researcher, ethnography, hospital, knowledge production, medical anthropology, profession, South Africa, University of the Witwatersrand.

Full Name
Dr Renée van der Wiel