La adaptación como acto comunicativo Los papeles de las instancias adaptadora

practice and organisation of TCM in the cultural context of this clinic.

3. Componential analysis involved a search for attributes that characterised the assessment and diagnostic structure found in traditional Chinese medicine and the meaning attached to these attributes by practitioners of TCM referred to in Chapter Six.

4. Cultural themes were revealed through the recognition of recurrent patterns in the domains and served to identify the subsystems of cultural meaning assigned to TCM in the clinical encounter of Kanbing.

4.6.1 Construction of a domain

The construction of a domain is the first step of the ethnographic analysis with the search for patterns that relate to the cultural behaviour of the clinic and the cultural knowledge embedded within the clinical practice. Domains were found through the DRS method in a search for terminology and patterns of meaning. Each included term was then examined for semantic relationships, similarities and variations to determine the inclusiveness to a domain.

In the construction of domain analysis I have used illustrations that portray specific domains constructed from the different categories of TCM practice observed within the clinic. Shank (2002, p. 142) points out, “… there has been a growing trend in qualitative research to move beyond a strict dependence on the written and spoken word as the primary source of data”. A visual portrayal through these figures provides a clear illustration of domains that depict an accurate representation of the structural process of TCM assessment.

Domains related to a specific understanding of how TCM is organised, and explored from the information contained in the field notes of cover terms. This included terms such as, the kind of relationship that was intrinsic to the roles undertaken by the practitioner, the form this took, and examples of the diagnostic roles attributed to the work of the practitioner. This informed the study of the difference between concepts of expectation of the cultural role applied to the clinical practice of TCM and in that found within the interaction that formed the social

exchange (Spradley, 2000, p. 86). Notions of how the practitioner conducted a TCM practice are discussed more fully in Chapter Six and client notions in Chapter Seven.

In this example of a single semantic relationship, the ‘clinic’, was selected to uncover the relationship between the practitioner’s role and clinical practice (Table 4.1).

Table 4.1 The clinic

Relationship Form Example

A TCM practitioner Functional Practice ability Is a kind of doctor Authority on TCM Clinical expertise Has clinic people visit Advice and treatment Assessment procedures Clients discuss illness Assessment on information Diagnosis made on client Advises on treatment Administration Initiates treatment

Single semantic relationships are described, to identify different functions that the practitioner is involved with (Fig 4.6, 4.7, 4.8). Examples of domains that identify semantic relationships are:

1. Practitioners in the clinic (Fig. 4.3). 2. People in the clinic (Fig. 4.4).

3. Categories of activities in the clinic (Fig. 4.5).

4. Semantic relationships involved in the explanation of differential diagnosis, (Fig. 4.6; Fig. 4.7; Fig. 4.8).

Data was used to describe the patterns of behaviour and the circumstances under which particular interactions between client and practitioners occurred (Aarmondt, 1989; Geertz, 1978; Morse & Field, 1995). Following this a preliminary analysis and interpretation of data produced information and led to further observation requiring detailed taxonomies of specific domains of clinic activities (Hammersley & Atkinson, 1995).

Data was used to form taxonomies from domains found in this social setting until data saturation was attained. This helped me to verify the consistency and the authenticity of patterns that emerged from the data and from this the formation of the domains described. Analyses of further domain terms were sorted into taxonomies. The taxonomy showed how the relationship among the included terms in a domain revealed subsets and interrelationships to the whole (Table 4.2). I was able to identify distinctions regarding the practice and organization of TCM in the social and cultural context of the clinical encounter from domains organised into subsets. Domains were organised systematically for the exploration of semantic relationships between terms used by clients to describe illness and the clinic environment of the practitioner. These terms were then organised into subsets, each subset organised by relationships in description and variables of meaning.

Figure 4.3 Domain – Practitioners in the clinic

An example of a domain identifying the subset of the practitioners provides an illustration of the qualifications of those involved in the practice of TCM at the clinic. Practitioner (1) had highly developed diagnostic skills from his past experience as a western medical heart specialist at Beijing Medical University. The partnership with practitioner (2) was a synergistic one where the skills of one enhanced those of the other (Fig.4.3) For example practitioner (2) was skilled as an herbalist whilst the other was skilled as both a practitioner of Western and Chinese medicine and able to perform complex diagnostic procedures.

Domain = Practitioners in the clinic

Practitioner 1 Chinese &Western medicine

Practitioner 2 Herbal medicine

Figure 4.4 Domain – People in the clinic

The Domain ‘People in the Clinic’ (Figure 4.4) identified four subsets of people. A search was made from the recorded data for cultural meaning from which a domain could be created. Each domain was identified by three elements: a cover term, a semantic relationship and included terms that identified the symbology of TCM language. To identify a cover term in the data a single semantic term to pose the question in the interview was used. From observation attended in the clinic, specific recurrent daily activities were identified which formed part of the domain analysis of practitioner activities (Figure 4.5). An analysis of the cultural milieu within the clinic revealed cultural patterns of behaviour and formed the basis on which the categories of TCM practice were revealed.

Figure 4. 5 Domain – Categories of Activities

Domain = People in clinic

Chinese practitioner 1 Chinese practitioner 2 Clients with problems Relatives of clients Subsets Categories Assessment Recording Diagnosing Prescribing Dispensing Instructing Maintaining Subsets

Figure 4.6 Domain – Assessment

Figure 4.6 identifies the domain of performing an assessment (see Chapter Five). Cultural patterns that were found to underlie the activities performed by the practitioners in the clinic formed a domain specific to the assessment of the client. The assessment was based on an analysis of the tongue and pulse diagnosis.

Figure 4. 7 Domain – Performing Assessment (Sizhen)

The aspect of assessment known as Sizhen involves four methods of examination of the client, inspection, auscultation and olfaction and palpation. Sizhen provides the information upon which an analysis of the relevant signs and symptoms is derived. A connection is made between pathogenic factors and the vital energy and is then

Domain = Sizhen

Inspection

Observation of colour and vitality

Observation of appearance

Observation of the five senses Domain=

Assessment Obtaining a full history from

The client

Observing the clients Physical condition and

Performing Tongue and

Pulse Diagnosis Differential Diagnosis

summarised into Zheng meaning of a certain syndrome (Enquin, 1988b, p. 34). A further differentiation of the syndrome is made through domain Ba Gang (Figure 4.8).

Figure 4.8 ‘Ba Gang’ – Differential diagnosis

‘Ba Gang’ enabled sub-systems to be formed: interior/exterior, cold/hot, deficiency/excess, Yin/Yang. These describe how the exploration of a specific syndrome is to be determined by the practitioner. As a system, Ba Gang provides a basis for the explanation of how the illness experience is described and formed through the identification of specific sub-systems. Description of differential diagnostic terms assisted the researcher to understand the meaning attached by practitioners to their process of an assessment. From what the informant says, patterns emerge “… that are meaningful to the native speaker” (Black, 1968, p. 432) which require interpretation by the researcher. Patterns are represented through the formation identified as subsets that revealed different themes of the assessment procedure.