“New technologies have extended the reach of our interactions beyond the geographical limitations of traditional communities, but the increase in flow of information does not obviate the need for community. In fact, it expands the possibilities for community and calls for new kinds of communities based on shared practice.”Etienne Wenger

Some days I yearn for that day 10 years ago when I opened my first AOL email account and heard that sensitive, yet robotic voice say, “you’ve got mail!” I would dial in once a day, be connected after 5 minutes and than sign off when I had finished, hearing again that same voice say, “goodbye.” It was simple and easy and the beginning of a commitment to a community of learning.

Times have changed however, as we all know. Yet social media like social networks, Facebook, twitter, and wikis haven’t exactly been welcomed with open arms by everyone. In fact, the emergence of such movements has produced a bit of resistance, fear, frustration, criticism and maybe too, a yearning for something different. Why? For one thing, it asks users to take a risk – a leap of faith into an environment that demands participation, collaboration and openness within and between others. This move can be uncomfortable, but also a move that can promote a more in-depth understanding of various organizational forms by encouraging the exploration of alternative, and more collaborative, communicative practices about health, medicine and clinical practice.

Because we are excited about such possibilities, we are headed to Toronto for the Medicine 2.0 Congress in a few weeks where we will be presenting a project titled, “Clinical Care in the ‘Spaces in Between’: Web 2.0 and the Communicative Reformation of Clinical Practice.” You are welcome to read the abstract here.

The conference is unique in its bringing together of participants from 18 countries including academics, software and Web 2.0 developers, biomedical researchers, consultants, business leaders, health professionals, consumers and payors. Together, we will look beyond the health 2.0 hype to identify the evidence of what works and what doesn’t in communicating effective care within and between communities. These discussions, interestingly are facilitated by the conference’s philosophy of openness, which is very conducive to discussions, networking and collaboration. The conference will begin with several noteworthy keynote speakers and then will cover topics ranging from virtual communities, personal health records, health information, clinical practice, medical education, medical learning and much more.

For those of you attending, we are looking forward to meeting you and generating some stimulating discussions together! And for those of you who aren’t attending, we’d love to hear from you as well about the conference, our abstract or your own commitments to a shared practice within these communities. After all, new conversations like new technologies can extend the reach of our interactions beyond the limitations of traditional communities thereby underscoring our shared concern and passion for improving clinical practice.

My AOL and “you’ve got mail” days have expanded and despite my own resistance, I have found much delight in the uniqueness of new technologies and new forms of organizing for, if nothing else, their commitment to a community of learning.

Hope to see you in Toronto!

Thanks to Dru Bloomfield and slowburn for the images.

Carey Candrian

Theories of the real…control the vocabularies of healing…if one could construct a map to negotiate a way through rival beliefs on health and healing, its baseline would be ontology, what counts as real. From this line a path would lead to the status of individuals in competing realities, then to different understandings of therapy that follow from competing descriptions of the human person. Finally, the moral and political languages of liberty, privacy, competence, and authority would appear. The first position, though, is reality. It fixes directions for the traveler journeying through the languages of health and healing, and provides the baseline references to justify beliefs about health acts and possibilities. –Frohock (1992, pp. 47-48)

What constitutes health is a question recently posed by H. Gilbert Welch, M.D., a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. One technique he discusses is simply narrowing the definition of what is health. Think to yourself for example, how many people you know who have high cholesterol, low blood pressure, low vitamin D, low iron, diabetes, osteoporosis and so on. These abnormalities are important however; and often are a difference that makes a difference in health care.

But, as Dr. Welch points out, this strategy has generated a host of other problems. As he states: “Doctors who are overwhelmed by the number of ailments their patients allegedly have (and who are often distracted from the most important ones); doctors in training who are increasingly confused about who is really sick and who is not; lawyers who increasingly have a field day with the charge of ‘failure to diagnose’; patients who get too much treatment or lose health insurance because they been given a new diagnosis; and a frazzled, fearful public adrift in a culture of disease. Oh, and did I mention that it has been a disaster for health-care costs?”

Thinking through definitions of what is normal can be explained communicatively. In so doing, we begin to ask what counts as normal and why this concern should matter. What counts as normal calls our attention to “abnormalities” and “health” not as natural categories but as products of social construction maintained through interaction as Berger & Luckmann (1966) explain in greater depth. In short, our interactions are filled with contests for meaning. But definitions like what is normal, or what it means to be healthy or ill, are used by individuals and groups to construct their own preferred versions of reality in place of alternatives that may be uncomfortable for them.  Clearly, we have come to a lot of agreement about these things which allows us to communicate more easily with each other, but often less creatively and productively.

Understood communicatively, the point is not to resolve what constitutes health but rather to reclaim productive tensions as a critical aspect of all life – including health. Even more, thinking about what is normal, brings some relief – as well as a reminder – that these are perspectives rather than attributes of individuals and groups. Therefore, it is impossible to understand what it means to be normal without examining the assumptions that lie below our understandings of health and illness. These assumptions, like the dominant focus on the disease cancer and not dying from cancer, in general terms become “common sense”. But do these commonsensical assumptions leave room for understandings not based only in standardization but also on what individuals experience and express? For example, one of the best cancer hospitals in the world proclaimed in public advertising and on every one of their computers, “The Best Cancer Care…Anywhere.” How would we rethink cancer if it read, “The Best Care of Patients with Cancer…Anywhere?”

Rethinking what is normal in light of the healthcare reform messages flooding every headline is no simple task. If health is understood as the absence of abnormality as Dr. Welch alludes to, the only way to know you are healthy is to become a customer. But a customer of what? Or a customer for whom? And a customer to what extent? Further, he elaborates that health is a state of mind that when viewed as the absence of abnormality, conflicts with the desire and hope for a healthier society. In other words, our definitions of health fix meanings through the languages of health and healing, justify beliefs about health, move people to act in certain ways, and hold spaces of possibilities.

How do your own definitions of what is normal influence the care you seek/receive?

How do our understandings of health and illness impact the work environments of the medical providers doing this work?

What challenges face you and your practice of bringing comfort and care to your patients with increased expectations and restrictions as well as an inherently narrow albeit contestable definition of normal?

Looking forward to your thoughts!

With thanks to zen and dmason for their images…

Carey Candrian

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