The ethical self-fashioning of physicians and health care systems in culturally appropriate health care

"It's a reality that we in medicine should catch up with": Physician's attitudes about self-sourced and managed abortion in the United States

BACKGROUND

The evolution of medical standards in stigmatized areas like abortion is influenced by medical, political, and social factors. Self-sourcing and managing medication abortion (SSMA) is on the rise in the United States, where individuals obtain medications to end their pregnancies outside traditional medical settings. Physician attitudes towards SSMA are not well understood, despite physicians' role in setting care standards, providing medical oversight, and de-stigmatizing healthcare both within and outside clinical environments.

MATERIALS AND METHODS

We interviewed 40 physicians (MD/DOs) who perform abortions about their views on SSMA. We used inductive-deductive coding for transcript analysis and qualitatively assessed how attitudes shifted before and during the interviews.

RESULTS

Most participants were aged 31-35 years (n = 16, 40%), non-Hispanic White (n = 29, 72.5%), and female (n = 33, 82.5%). We oversampled family medicine-trained physicians (n = 31, 78%) compared to OB/GYNs (n = 9, 22.5%). Participants were from 24 states, with half from states supporting abortion rights and the other half from states with hostile or neutral stances. Half of the cohort supported SSMA, while the other half was ambivalent. Medical evidence alone did not sway physician views on SSMA; instead, participants adjusted their attitudes by clarifying their professional values, evaluating SSMA's alignment with these values, and considering values-based frameworks as alternatives to medicalization.

DISCUSSION

Although medical care is typically seen as objective and standardized, physicians' ethics to ensure safe access to care often clash with political restrictions in this stigmatized field. Physicians are more worried about the broader structural issues related to SSMA, such as how political and social vulnerabilities could harm the most vulnerable patients, rather than the medical care itself, which they see as safe and effective, with or without physician oversight. Positive attitudes toward SSMA were strengthened by exposure to values-based frameworks that offer alternatives to strict medicalization.

Intimacy, Anonymity, and "Care with Nothing in the Way" on an Abortion Hotline

This essay is an ethnographic account of a volunteer, anonymous hotline of physicians and advanced practice providers who offer medical advice and guidance to those who are taking medications on their own to end their pregnancies. Attending to the phenomenology of caring on the Hotline reveals a new form of medical expertise at play, which we call "care with nothing in the way." By operating outside the State's scrutiny of abortion provision, the Hotline offers its volunteers a way to practice abortion care that aligns with their professional and political commitments and that distances them from the direct harm they see caused by the political, financial, and bureaucratic constraints of their clinical work. By delineating the structure of this new regime of care, these providers call into question the notion of the "good doctor." They radically re-frame widely shared assumptions about the tenets of the ideal patient-doctor relationship and engender a new form of intimacy-one based, ironically, out of anonymity and not the familiarity that is often idealized in the caregiving relationship. We suggest the implications of "care with nothing in the way" are urgent, not only in the context of increasing hostility to abortion rights, but also for a culture of medicine plagued by physician burnout.

LGBTQIA+ Cultural Competence in Physical Therapy: An Exploratory Qualitative Study From the Clinician's Perspective

OBJECTIVE

The purpose of this study was to understand the lesbian, gay, bisexual, transgender, queer, intersex, agender, and other gender and sexually diverse identities (LGBTQIA+) health care experience and associated cultural competence from the physical therapist perspective (physical therapist and physical therapist assistant).

METHODS

An exploratory qualitative approach implementing semi-structured focus groups and private interviews was utilized. To further anonymity, researchers allowed subjects to keep their camera off on Zoom. An interview protocol included questions guided by Campinha-Bacote domains of cultural competence (cultural awareness, skill, knowledge, encounter, and desire) to collect individual experiences, stories, discussions, thoughts, and opinions. Physical therapist clinicians were recruited from the clinical education affiliation lists of Regis University and Thomas Jefferson University. Seventy-one practicing physical therapists from the USA agreed to be part of the study.

RESULTS

Themes were organized using the Social Ecological Model Framework. Themes are in parentheses following each level of the Social Ecological Model and include intrapersonal level (psychological stress and implicit and explicit biases), interpersonal (acceptance and competency), organizational (experience), community (advocacy), and society and policy (explicit biases and policy).

CONCLUSION

Cultural competence in physical therapy is influenced by intrapersonal, interpersonal, organizational, community, and social and policy factors. Themes of psychological stress, limited awareness, decreased acceptance, and competency as well as limited exposure and experience, and a lack of advocacy and broader societal and policy issues prevent adequate LGBTQIA+ cultural competency of physical therapist providers. Further research in the physical therapist profession is needed to elaborate on the student, educator, and patient perspectives and how this information informs the LGBTQIA+ cultural competence of clinicians.

IMPACT

This project may have a significant impact on suggestions for the delivery of content for health profession education to best impact health equity goals and save lives. Implementation of this content may have a direct impact on health disparities in LGBTQIA+ populations by reducing stigma and discrimination from health care providers, thus improving quality of health care and decreasing rates of patient mortality for LGBTQIA+ individuals.

Patient identity narratives through the cultural formulation interview in a New York City outpatient clinic

Anthropologists have critiqued cultural competence programs in medical settings while introducing mental health clinicians to social theories on culture for practice. We explore how patients articulated narratives about themselves and how clinicians responded to such narratives through an intervention known as the Cultural Formulation Interview that anthropologists have helped develop. We conducted over 500 hours of fieldwork from 2014 to 2019 at an outpatient clinic in New York, analyzing multiple data (participant observation, medical records, patient-clinician sessions, and individual debriefing interviews) in a trial joining clinical and ethnographic methods. Our study enrolled 45 patients and six clinicians, yielding 117 patient-clinician appointments and 98 debriefing interviews. Most patients differed in how they presented their identities through demographic forms and discussed them in sessions with their clinicians. Two-thirds of the patients drew connections between their personal identities and experiences of mental illness. These results reveal why cultural identities should not be taken for granted in clinical settings.

Articulating the canon: The sociology of medical education from 1980 to 2000

An exciting development in the sociology of medical education has been its recent return as a distinct scholarly conversation in medical sociology. During the 1980s and 1990s, the sociology of medical education, an historically prominent subfield in sociology, seemed to disappear from the scholarly conversation despite ongoing development in this area. In this narrative review I describe this "missing period" of sociology of medical education, discussing complementary explanations for why it receded and describing what research activity did take place during those decades. In reviewing this work, I argue that articulating theoretical advances made within sociology of medical education research during these decades allows us to link foundational research from the 1950s and 1960s with the renaissance of this subfield in the early 2000s. Fundamentally, understanding the intellectual history and development of this subfield supports a broader movement to understand the import of studies of medical training for exploring questions of interest in general sociology.

Beyond biopolitics: the importance of the later work of Foucault to understand care practices of healthcare workers caring for undocumented migrants

Background

Undocumented migrants experience multiple institutional and legal barriers when trying to access healthcare services. Due to such limitations, healthcare workers often experience ethical dilemmas when caring for undocumented migrants. This article aims to understand how individual healthcare workers who regularly take care of undocumented migrants deal with these dilemmas in practice. So far, the role of healthcare workers in this context has mainly been theorized through the lens of biopolitics, conceiving of healthcare workers as merely obedient instruments of humanitarian government or gatekeeping.

Methods

Based on semi-structured, in-depth interviews and ethnographic observations with healthcare workers in Belgium, we explore how they ascribe meaning, reflect upon and give shape to care practices in relation to undocumented migrants. We use Foucault’s later work on care of the self to interpret the accounts given by the healthcare workers.

Results

Healthcare workers in clinical roles exercise a certain degree of freedom in relation to the existing limitations to healthcare access of undocumented migrants. They developed techniques such as purposefully being inattentive to the undocumented status of the migrants. They also try to master their affective responses and transform their bodily attitude towards undocumented patients. They perform practical mental exercises to remind themselves of their role or position in the wider healthcare system and about their commitment to treat all patients equally. These techniques and exercises are inspired by colleagues who function as role models, inspiring them to relate in an ethical way to limitations in healthcare access. The developed care practices sometimes reproduce, sometimes transform the legal and institutional limitations to care for undocumented migrants.

Conclusions

The findings nuance the biopolitical analysis regarding the role of healthcare workers in healthcare delivery to undocumented migrants that has been dominant so far. Theoretically this article provides a reconceptualization of healthcare ethics as care of the self, an ethical practice that is somewhat independent of the traditional professional ethics.

Trial Registration Medical ethics committee UZ Jette, Brussels, Belgium – Registration date: 18/05/2016 – Registration number: B.U.N. 143201628279.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00726-z.

The influence of culture on care receivers' satisfaction and aggressive tendencies in the emergency department

Introduction

Reducing aggressive tendencies among care receivers in the emergency department has great economic and psychological benefits for care receivers, staff, and health care organizations. In a study conducted in a large multicultural hospital emergency department, we examined how cultural factors relating to ethnicity interact to enhance care receivers’ satisfaction and reduce their aggressive tendencies. Specifically, we explored how care receivers’ cultural affiliation, individual cultural characteristics, and the cultural situational setting interact to increase care receivers’ satisfaction and reduce their aggressive tendencies.

Method

Data were collected using survey responses from 214 care receivers. We use structural equation models and the bootstrap method to analyze the data.

Results

Care receivers’ openness to diversity (an individual cultural characteristic) was positively related to their satisfaction that was associated with lower aggressive tendencies, only when they were affiliated with a cultural minority group and when the cultural situational setting included language accessibility.

Conclusion

Our results demonstrate that cultural affiliation, individual cultural characteristics, and cultural situational setting can affect care receivers’ satisfaction and aggressive tendencies in a multicultural emergency department context. In particular, high cultural openness of care receivers, and making information accessible in their native language, increased satisfaction and reduced aggressive tendencies among cultural minority care receivers in our study.

EPA guidance on cultural competence training

The stress of migration as well as social factors and changes related to the receiving society may lead to the manifestation of psychiatric disorders in vulnerable individuals after migration. The diversity of cultures, ethnicities, races and reasons for migration poses a challenge for those seeking to understand how illness is experienced by immigrants whose backgrounds differ significantly from their clinicians. Cultural competence represents good clinical practice and can be defined as such that a clinician regards each patient in the context of the patient's own culture as well as from the perspective of the clinician's cultural values and prejudices. The EPA Guidance on cultural competence training outlines some of the key issues related to cultural competence and how to deal with these. It points out that cultural competence represents a comprehensive response to the mental health care needs of immigrant patients and requires knowledge, skills and attitudes which can improve the effectiveness of psychiatric treatment. To reach these aims, both individual and organizational competence are needed, as well as teaching competence in terms of educational leadership. The WPA Guidance on Mental Health and Mental Health Care for Migrants and the EPA Guidance on Mental Health Care for Migrants list a series of recommendations for policy makers, service providers and clinicians; these are aimed at improving mental health care for immigrants. The authors of this paper would like to underline these recommendations and, focusing on cultural competency and training, believe that they will be of positive value.

Rethinking Goals: Transforming Short-Term Global Health Experiences Into Engagements

The authors challenge the conventional wisdom guiding what participants in short-term experiences in global health (STEGHs) should be learning. Medical students and residents from the United States have been told to focus on standardized competencies and ethical principles, in addition to the biomedical knowledge, skills, and attitudes highlighted by working internationally. The authors suggest that although these training goals are important, they may divert learners from developing their professional identities in ways that contribute to the health of all persons, especially those who are economically poor and socially marginalized. The authors postulate that such a professional transformation will occur only if STEGH participants attend to 5 key learning goals: develop contextual inquisitiveness, grow in insightful understanding, nurture global humility, cultivate structural awareness, and critically engage in the pursuit of creating equitable and just societies. Further, the authors argue that only by attending to these goals will any genuine change in the root causes of inequities in health outcomes occur. The authors review these goals and encourage their use for professional and pedagogical purposes over the duration of any STEGH-before departure, while in host communities, and upon return home.

Impossible, unknowable, accountable: Dramas and dilemmas of data law

On May 25, 2018, the European Union's General Data Protection Regulation (GDPR) came into force. EU citizens are granted more control over personal data while companies and organizations are charged with increased responsibility enshrined in broad principles like transparency and accountability. Given the scope of the regulation, which aims to harmonize data practices across 28 member states with different concerns about data collection, the GDPR has significant consequences for individuals in the EU and globally. While the GDPR is primarily intended to regulate tech companies, it also has important implications for data use in scientific research. Drawing on ethnographic fieldwork with researchers, lawyers and legal scholars in Sweden, I argue that the GDPR's flexible accountability principle effectively encourages researchers to reflect on their ethical responsibility but can also become a source of anxiety and produce unexpected results. Many researchers I spoke with expressed profound uncertainty about 'impossible' legal requirements for research data use. Despite the availability of legal texts and interpretations, I suggest we should take researchers' concerns about 'unknowable' data law seriously. Many researchers' sense of legal ambiguity led them to rethink their data practices and themselves as ethical subjects through an orientation to what they imagined as the 'real people behind the data', variously formulated as a Swedish population desiring data use for social benefit or a transnational public eager for research results. The intentions attributed to people, populations and publics - whom researchers only encountered in the abstract form of data - lent ethical weight to various and sometimes conflicting decisions about data security and sharing. Ultimately, researchers' anxieties about their inability to discern the desires of the 'real people' lent new appeal to solutions, however flawed, that promised to alleviate the ethical burden of personal data.

Adoption of the National CLAS Standards by State Mental Health Agencies: A Nationwide Policy Analysis

OBJECTIVE

This study reports the extent to which states have adopted the national culturally and linguistically appropriate services (CLAS) standards.

METHODS

Officials from public mental health agencies in the 50 states, Washington, D.C., and Puerto Rico were contacted between January and June 2016 to obtain information about adoption of CLAS standards in current policies. Each policy was coded through thematic analysis to determine its correspondence with any of the 14 national CLAS standards, which are grouped into three domains.

RESULTS

Officials from 47 states and territories (90%) responded. Eight states (17%) reported adopting all national CLAS standards. Ten (23%) had adopted no CLAS policies, five (12%) had adopted policies under one domain, three (7%) under two domains, and 25 (58%) under all three domains.

CONCLUSIONS

Most states do not have policies that meet all CLAS standards, raising questions about how CLAS standards should be adopted.

The Irrelevance Narrative: Queer (In)Visibility in Medical Education and Practice

How might heteronormativity be reproduced and become internalized through biomedical practices? Based on in-depth, person-centered interviews, this article explores the ways heteronormativity works into medical education through the hidden curriculum. As experienced by my informants, case studies often reinforce unconscious heteronormative orientations and heterosexist/homophobic stereotypes about queer patients among straight and queer medical students alike. I introduce the concept of the irrelevance narrative to make sense of how queer medical students take up a heteronormative medical gaze. Despite recognizing that being queer affects how they interact with patients, my informants describe being queer as irrelevant to their delivery of care. I conclude with a discussion of how these preliminary findings can inform research on knowledge production in biomedical education and practice with an eye toward the tensions between personal and professional identity among biomedical practitioners.

Development of an Inventory for Health-Care Office Staff to Self-Assess Their Patient-Centered Cultural Sensitivity

BACKGROUND

Patient-centered culturally sensitive health care (PC-CSHC) is a best practice approach for improving health-care delivery to culturally diverse populations and reducing health disparities. Despite patients' report that cultural sensitivity by health-care office staff is an important aspect of PC-CSHC, the majority of available research on PC-CSHC focuses exclusively on health-care providers. This may be due in part to the paucity of instruments available to assess the cultural sensitivity of health-care office staff. The objective of the present study is to determine the psychometric properties of the Tucker-Culturally Sensitive Health Care Office Staff Inventory-Self-Assessment Form (T-CSHCOSI-SAF). This instrument is designed to enable health-care office staff to self-assess their level of agreement that they display behaviors and attitudes that culturally diverse patients have identified as office staff cultural sensitivity indicators.

METHODS

A sample of 510 health-care office staff were recruited at 67 health-care sites across the United States. These health-care office staff anonymously completed the T-CSHCOSI-SAF and a demographic data questionnaire.

RESULTS AND LEVEL OF EVIDENCE

Confirmatory factor analyses of the T-CSHCOSI-SAF revealed that this inventory has 2 factors with high internal consistency reliability (Cronbach's αs= .916 and .912).

CONCLUSION AND IMPLICATIONS

The T-CSHCOSI-SAF is a useful inventory for health-care office staff to assess their own level of patient-centered cultural sensitivity. Such self-assessment data can be used in the development and implementation of trainings to promote patient-centered cultural sensitivity of health-care office staff and to help draw the attention of these staff to displaying patient-centered cultural sensitivity.

The meanings of cultural competence in mental health: an exploratory focus group study with patients, clinicians, and administrators

Cultural competence training is mandatory in the United States of America to alleviate minority health disparities though few studies have examined perceptions across stakeholders. We conducted separate focus groups with patients, clinicians, and administrators from the psychiatry department at one community hospital and compared responses to hospital policies. Stakeholders defined cultural competence through group-based or person-centered traits despite policies recommended person-centered approaches. Administrators and clinicians named clinician techniques for psycho-education whereas patients named these techniques for enlistment in treatment planning as equals. All groups named patient cultural views and institutional challenges as barriers to care, but only patients and administrators additionally named clinician biases as possible barriers. We discuss these discrepant perceptions and possible solutions to improve research, practice, and policy on cultural competence in mental health.

Practice to research: integrating evidence-based practices with culture and context

There are ways to integrate culturally competent services (CCS) and evidence-based practices (EBP) which can improve the experiences of patients and their families and communities when faced with health problems, as well as the effectiveness and positive experiences of practitioners. CCS and EBP evidence should be jointly deployed for helping patients and clinicians. Partnership research models are useful for achieving the integration of CCS and EBP, since they involve close observation of and participation by clinicians and practitioners in the research process, and often use integrated qualitative and quantitative mixed methods. We illustrate this with 3 examples of work that can help integrate CCS and EBP: ongoing collection of information from patients, clinicians and staff, or "evidence farming"; close study and continuous improvement of activities and accommodations; and use of evidence of tacit, implicit cultural scripts and norms, such as being "productive," as well as explicit scripts. From a research practice point of view, collaborative partnerships will likely produce research with culture and context bracketed in, and will contribute stronger research models, methods, and units of analysis.

A model for translating ethnography and theory into culturally constructed clinical practices

This article describes the development of a dynamic culturally constructed clinical practice model for HIV/STI prevention, the Narrative Intervention Model (NIM), and illustrates its application in practice, within the context of a 6-year transdisciplinary research program in Mumbai, India. Theory and research from anthropology, psychology, and public health, and mixed-method ethnographic research with practitioners, patients, and community members, contributed to the articulation of the NIM for HIV/STI risk reduction and prevention among married men living in low-income communities. The NIM involves a process of negotiation of patient narratives regarding their sexual health problems and related risk factors to facilitate risk reduction. The goal of the NIM is to facilitate cognitive-behavioral change through a three-stage process of co-construction (eliciting patient narrative), deconstruction (articulating discrepancies between current and desired narrative), and reconstruction (proposing alternative narratives that facilitate risk reduction). The NIM process extends the traditional clinical approach through the integration of biological, psychological, interpersonal, and cultural factors as depicted in the patient narrative. Our work demonstrates the use of a recursive integration of research and practice to address limitations of current evidence-based intervention approaches that fail to address the diversity of cultural constructions across populations and contexts.

Cultural competence in health care: an emerging theory

This study examined the current state of cultural competence in health care using a qualitative descriptive design. Interviews were conducted with 20 multidisciplinary experts in culture and cultural competence from the United States and abroad. Findings identified 3 themes; awareness, engagement, and application that crossed 4 domains of cultural competence; intrapersonal, interpersonal, system/organization, and global.

Barriers to implementing the DSM-5 cultural formulation interview: a qualitative study

The Outline for Cultural Formulation (OCF) in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) marked an attempt to apply anthropological concepts within psychiatry. The OCF has been criticized for not providing guidelines to clinicians. The DSM-5 Cultural Issues Subgroup has since converted the OCF into the Cultural Formulation Interview (CFI) for use by any clinician with any patient in any clinical setting. This paper presents perceived barriers to CFI implementation in clinical practice reported by patients (n = 32) and clinicians (n = 7) at the New York site within the DSM-5 international field trial. We used an implementation fidelity paradigm to code debriefing interviews after each CFI session through deductive content analysis. The most frequent patient threats were lack of differentiation from other treatments, lack of buy-in, ambiguity of design, over-standardization of the CFI, and severity of illness. The most frequent clinician threats were lack of conceptual relevance between intervention and problem, drift from the format, repetition, severity of patient illness, and lack of clinician buy-in. The Subgroup has revised the CFI based on these barriers for final publication in DSM-5. Our findings expand knowledge on the cultural formulation by reporting the CFI's reception among patients and clinicians.

Confronting a "big huge gaping wound": emotion and anxiety in a cultural sensitivity course for psychiatry residents

In his seminal volume From anxiety to method in the behavioral sciences, George Devereux suggests that any therapeutic or scientific engagement with another human being inevitably will be shaped by one's own expectations, assumptions, and reactions. If left unacknowledged, such unspoken and unconscious influences have the capacity to torpedo the interaction; if subjected to critical reflection, however, they can yield insights of great interpretive value and practical significance. Taking these reflections on counter-transference as point of departure, this article explores how a range of unacknowledged assumptions can torpedo good faith efforts to engender "cultural sensitivity" in a required course for American psychiatry residents. The course examined in this paper has been taught for seven successive years by a pair of attending psychiatrists at a longstanding New England residency training program. Despite the instructors' good intentions and ongoing experimentation with content and format, the course has failed repeatedly to meet either residents' expectations or, as the instructors bravely acknowledged, their own. The paper draws upon a year-long ethnographic study, conducted in the late 2000s during the most recent iteration of the course, which involved observation of course sessions, a series of interviews with course instructors, and pre- and post-course interviews with the majority of participating residents. By examining the dynamics of the course from the perspectives of both clinician-instructors and resident-students, the paper illuminates how classroom-based engagement with the clinical implications of culture and difference can run awry when the emotional potency of these issues is not adequately taken into account.

Patrolling your blind spots: introspection and public catharsis in a medical school faculty development course to reduce unconscious bias in medicine

Cultural competence education has been criticized for excessively focusing on the culture of patients while ignoring how the culture of medical institutions and individual providers contribute to health disparities. Many educators are now focusing on the role of bias in medical encounters and searching for strategies to reduce its negative impact on patients. These bias-reduction efforts have often been met with resistance from those who are offended by the notion that "they" are part of the problem. This article examines a faculty development course offered to medical school faculty that seeks to reduce bias in a way that avoids this problem. Informed by recent social-psychological research on bias, the course focuses on forms of bias that operate below the level of conscious awareness. With a pedagogical strategy promoting self-awareness and introspection, instructors encourage participants to discover their own unconscious biases in the hopes that they will become less biased in the future. By focusing on hidden forms of bias that everyone shares, they hope to create a "safe-space" where individuals can discuss shameful past experiences without fear of blame or criticism. Drawing on participant-observation in all course sessions and eight in-depth interviews, this article examines the experiences and reactions of instructors and participants to this type of approach. We "lift the hood" and closely examine the philosophy and strategy of course founders, the motivations of the participants, and the experience of and reaction to the specific pedagogical techniques employed. We find that their safe-space strategy was moderately successful, largely due to the voluntary structure of the course, which ensured ample interest among participants, and their carefully designed interactive exercises featuring intimate small group discussions. However, this success comes at the expense of considering the multidimensional sources of bias. The specific focus on introspection implies that prior ignorance, not active malice, is responsible for biased actions. In this way, the individual perpetrators of bias escape blame for their actions while the underlying causes of their behavior go unexplored or unaccounted for.

A diversity of voices: the McGill 'Working with Culture' seminars

The Working with Culture seminar is offered as a course during the month long Annual McGill Summer Program for Social and Transcultural Psychiatry, attended by local and international participants each May since 1994. The article outlines some of the premises and pedagogical approaches of this clinically oriented biweekly seminar series with discussions and didactic teaching on cultural dimensions of mental health care. The course readings, seminar topics and invited speakers focus mainly on therapist client encounters constructed by the multiple voices with dimensions of psychiatric, social, historical, legal, ethical, political, systemic and intra-psychic domains. The dual leadership emphasizes the gaps and complementarity amongst voices, and it invites and supports a destabilizing decentering process and the creation of solidarities amongst participants. Applying a bio-psychosocial case study method, each 3-h seminar engages the participants in a critical dialogue on apprehending the enmeshment of social suffering with psychiatric disorders whilst examining the usefulness and the limits of cultural formulation models. The seminar working group and teaching approach acknowledges cultural hybridity as a dynamic process marked by continuous therapist attunement to uncertainty or 'not knowing' which implies a dethroning of an expert position.