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LEARNING MEDICINE AND
THE MEDICAL GAZE
GLBH 148. Class 4
Learning Medicine and the Medical Gaze
Tales from the Field:
■ Participant Observer / sociologist /anthropologist in the land of contemporary
medicine – from academic medicine to community cl inics to inpatient and outpatient
psychiatry
■ What’s intriguing – l i fe worlds – ways of thinking, seeing, doing, presenting,
performance – differ from worlds of the social scientist / researcher/ academic
■ Cross-national consistency – biomedical docs are docs in a very essential way
regardless of country, community and resources, why?
Questions
Life Worlds and Multiple Voices of Medicine:
■ How does medicine construct its objects?
■ How do physicians come to acquire the
“medical gaze”?
■ How are diverse narrative forms and strategies
learned and employed?
■ How are these produced through relationships
of power and knowledge?
The Inner Life of Medicine
Entering the L ife World of Medicine
“medica l school i s rea l ly we i rd… a forced emot iona l exper ience. We
handle cadavers , have feces lab, go menta l hospi ta l where we are
locked up wi th screaming pat ients . These are tota l exper iences…you
have to in teract wi th the in format ion. When you d issect a bra in , you
have to in teract wi th these th ings and your own fee l ings. I fee l l i ke I
am changing my bra in every day”…
• Medicine formulates the human body and disease in a
cultural ly dist inctive fashion…(Good Byron)
• Biology is not external but internal within a culture
• Medicine as symbolic form – formative processes through
which i l lness real it ies are formulated (or constructed)
Medicine, Rationality, Experience
■ B. Good asks: How does biomedicine construct persons,
patients, bodies, diseases and human physiology? i .e . “ its
objects”?
■ What are the formative processes in the culture of medicine
that mediate and organize dist inctive forms of real ity?
■ Processes are pract i ces and embodied exper iences as we l l as
learn ing and knowledge –> const ruct ing new wor lds.
■ The soteriological qual ity of contemporary biomedicine in
modern civi l izations l inks human suffering to salvation, joining
the material to the moral.
■ Mora l out rage when i t fa i l s to p lay th is ro le .
Medicine, Rationality, Experience
Medicine’s Soteriological Vision
❏ Medicine joins the material to the moral domain
❏ Max Weber – civi l izations are organized around a soteriological vision – an
understanding of the nature of suffering, and means of transforming or
transcending suffering and achieving salvation – in Western civi l ization
medicine is at the core of our soteriological vision (p.70)
Learning Medicine:
Fundamental Practices
Seeing: deve lop ing a medica l gaze
■ The r i tua l and sacred space of the anatomy lab
■ Think ing anatomica l ly and reconst ruct ing bodies
■ Worlds wi th in wor lds: h ierarch ies of b iomedica l knowledge from the
molecu lar to the soc ia l
Writing: The creat ion of a case, pat ient as document and project “ to
be worked on”
■ Wri t ing in charts and the publ i c domain
Speaking: Learn ing the language of medic ine
■ Presentat ion and performance
Inhabiting a life world: a deep experience- near sense
Developing Knowledge by entering a dist inct ive l i fe world and real ity system –
specialized medical ways of “seeing,” – “writing,” and “speaking.”
– Sacred and ritual space with distinctive moral norms
– Demarcated space – as skin is drawn back, a different “interior” emerges “ l ike the
peel of an orange.”
– “thinking anatomically” central to the medical gaze – “all of a sudden, I start to
think if I took the scalpel and made a cut right here, what would you look
like?”
– Reconstituting the person into an object of medical attention.
– Imaging techniques reveal worlds within worlds l inking anatomical to cel lular to
genetic levels, biology ’s natural hierarchical order.
The Body and the Anatomy Lab
■ The body is the object of attending and manipulation. Within the l i feworld
of medicine, the body is newly constituted as a medical body, quite distinct from the
bodies we interact with daily.
■ Intimacy experiences with that body create a distinctive perspective, an
organized set of emotional responses and perceptions that emerge with the
body’s emergence as the site of medical knowledge.
The Body and the Anatomy Lab
What does this mean? The site of medical knowledge?
Distinctive from bodies we interact with in daily l i fe?
■ Anatomy lab as a r itual space (72-73)
■ Body in everyday l i fe: skin, hands, eyes, face, clothing
convey personhood – the interior of a person are thoughts,
feel ings, experiences, personalit ies.
■ In the lab – the hands, feet, head are bound, and the
torso
■ Sundering natural structures: shock of bisecting
The Worlds of Small Things and Learning to See and Name
■ Biochemistry and now molecular and genetic languages –have become l ingua
franca of medicine
■ Learning a new language – entering a new world
■ Celebrations and satires of technical languages of medicine
■ The great chain of being – the natural hierarchy is implicit in the order of
teaching– sl ides at different levels – from the wider world of “disease” to its
smallest part – from the social to the molecular
■ “The biopsychosocial” model still has biology at the center
Formulating the patient
■ Writing a case – authorizes the student, justifying
the interaction with the patient
■ Medical history – organizes the conversation with
the patient and written for an audience of supervisors
and others who wil l do things to the patients based on
the document
■ Patient Interview questions are selected with
the ultimate written case presentation in mind
Formulating the patient
■ “you do a write up, you sign it, you date it.
It’s an official hospital document. It goes in
the chart. Everyone reads it … “oh my God,
people are going to read this!” “I finally
belong here!”
Formulating the patient
■ “You’re authorized by your writ ing, you’re not just a
voyeur. You’re producing a document, so this is for real. You
have to do something with this person, they become
yours in the sense that you’re going to present them at
rounds and you’re going to be evaluated , suddenly now
they’re a commodity in a certain sense that you have to
process and present .”
■ Writing authorizes and provides cultural authority
and professional power and obligation “to do
something”. Writ ing ref lects and shapes conversat ions with
pat ients: the medical narrat ive – history etc. highly structured
in writ ing.
Speaking
and
Presenting:
Performance
Narratives in
Sites of
Moral Drama
Central speech acts in medical training are
not interviewing patients or talking with patients
but presenting patients
•Morning rounds are bullets, short stories
•Presentation rounds (M and M and other teaching sessions)
are longer stories
•Fascinomas: good case no dx for hr, great case no dx for
day, a week, “thatʼs what they call a fascinoma”
•Technological management of experiential world that
can be disrupted and frightening at times
•Technological management of writing and speaking
(now structured by electronic medical records)
Voice of Medicine, Voice of the Life World:
From Patient Narratives to Clinical Narratives
Illness Narrative: Voice of the l i fe world of patients.
Patientsʼ accounts of i l lness experience from within their
l i fe world.
Clinical Narratives: Stories created by physicians and
health care teams for and with patients over the
treatment course. They are interpretive stories about
meaning of symptoms, technological interventions
and treatments, side effects. As used by physicians
and health care teams, it inscribes upon the body
experiences of treatment, framing and interpreting
symptoms and bodily sensations. Creating stories in
the making through reading the body and the disease
and treatment progression.
The cl inical narrative is dominated by the voice of medicine and
shaped by biomedical action . Research medic ine enters the c l in ical
narrat ive as evidence from c l in ical tr ia ls and c l in ical invest igat ions
shaping the c l in ical narrat ive and just i fy ing is “direct ion” or plot and i ts
content.
Therapeutic Narratives: Stor ies in the making about progress, hope,
redef in ing oneʼs bodi ly state and personhood from; dominated by the
“voice” and actions of therapists.
Therapeutic Emplotment – This is the interpretive action of
healthcare team and patient in which together patient and
physician and team members create a larger therapeutic story ,
within which therapeutic act ions are given meaning. Therapeutic
emplotment means story making .
Clinical Narratives
STORIES OF THERAPEUTIC
ACTIVITIES CREATED BY
PHYSICIANS FOR
PATIENTS OVER TIME
DRIVEN BY PROGRESSION
OF THERAPEUTIC
ACTIVITIES AND IMPACT
ON PATIENT EXPERIENCE
GROUNDED IN THE
CLINICAL SCIENCES BASIC
TO ONCOLOGICAL
SPECIALTIES
SHAPED BY DISEASE
PROGRESSION OR
REMISSION/ CURE/ AND
PATIENT EXPERIENCE
Narrative Strategies
Plot, Emplotment, Temporality
• Creating a therapeutic plot for patients
• Establishing a treatment course
• Giving meaning to treatment actions over t ime, creating an integrated “story” and
patient experience
• Reading the unfolding “actual plot” determined by disease process and patient response
• Tailoring multiple subplots for specif ic audiences: patients, kin, col leagues, cl inical trial
col laborators
• Constructing narrative t ime, l i fet ime, cl inical trial t ime
• Patients as Partners, Patients as Readers
Culture and
Clinical
Narratives
Good et al. (1995) “A Comparative Analysis of the
Culture of Biomedicine: Disclosure and Consequences
for Treatment in the Practice of Oncology”
The American way: cult ivating hope in the face of bad
news
The Japanese way: “protective, posit ively paternalistic,
and emotionally deep” – disclosure general ly masked
for patients and famil ies
The Mexican way: frankness to ensure compliance and
to help face the “f ight” ahead along with deep
consoling
The Ital ian way: mask diagnosis for the “good of the
patient”
Remarkable cultural distinctions about the ethics of
disclosure, variations in physician-patient relationships, the
cultural authority of physicians, and in patient access to
and societal investment in anticancer therapies – Intimately
t ied to polit ical economy and biomedical innovation
Culture and Clinical
Narratives
Narratives of truth and freedom:
“By explaining diagnosis, prognosis, and treatment
options to the patient, I was creating the basis for
freedom: freedom not only from symptoms and disease,
but also freedom to make informed choices”
“I f irmly believe that truth is essential for a therapeutic
relationship, but I have to acknowledge that the Italian
society is not prepared for the American way…I am
concerned that Italian physicians may communicate vast
amounts of complicated information to unprepared
patients only out of a fear of l it igation…it probably wil l
not give rise to real truth tell ing”
— Antonel la Surbone, Ital ian physic ian who practiced in the
U.S. and Italy, letter to the Editors of
JAMA (1992)
Culture and Clinical Narratives
Gordon and Paci (1997): Disclosure practices are embedded in and enact
personal, professional, and societal narratives. These narratives are not
given but contested and evolving. Local norms of “social embeddedness,”
social unity, and hierarchy are challenged by the cosmopolitan culture of
medicine characterized by practices such as open disclosure, informed
consent, advanced directives, and the Patient Self-Determination Act –
the “autonomy-control narrative.”
Clinical narratives of disclosure are a site of contestation where these
conflicting social trends are embodied.
Clinical Narratives in Oncology
What is “The Biotechnical Embrace”?
Cultural power and scientif ic robustness of cl inical oncology
as a profession
Plot a coherent therapeutic course
Structure c l inical t ime
Insti l l desire for treatment
Give meaning and hope
Invite patients with disease resistant to treatment to open their
bodies to experimental treatment of uncertain ef f icacy
Features of
Narrative
and
Emplotted
Time
Desire and Hope – time organized within a ʻgapʼ between
where one is and where one hopes to be
Transformation and change – time not simply linear, tricks and
reversals twists and turns
Dramatic – time is dramatic, filled with obstacles and risks,
challenges, suffering, and troubled quests.
Uncertainty- suspense, unknown endings, what one hopes may
not be
Configured Events – not one thing after another but
meaningful, part of a temporal whole, ʻa therapeutic journeyʼ
Discussion
I f one of your o lder fami ly members (parent or grandparent) were
seeking care for a deadly condi t ion such as cancer , would you want
the i r doctor to be complete ly f rank and open with them at each
stage of the treatment process — and d i rect ly g ive them a d iagnosis
of cancer i f that ‘s what the test ind icate?
Under what condi t ions might you not want the d iagnosis to be fu l ly
d isc losed?
What ro le do you th ink stat ist ics might p lay in your des i re to know?
What d i f ference do you th ink “knowing” might make for the u l t imate
outcome of treatment?
How Medic ine Constructs i ts Object .
Please address the fol lowing prompts, which refer to Chapter 3 in Byron Good’s book Medicine,
Rat ional i ty, and Experience:
1. What are the fundamental shifts that occur in medical students’ minds
as they learn to become “doctors”?
2. What are the essential practices that facil itate this transformation?
How is it accomplished?
3. Why does Good argue that the core practices of medicine described are
“cultural” rather than reflective of objective biological reality?
