Making sure. A comparative micro-analysis of diagnostic instruments in medical practice

Abstract

This article conceptualises diagnosis as ongoing practical judgement in medical care. Based on pragmatist and phenomenological considerations of tools in use, it uses a comparative approach to analyse similarities and differences in the use of diagnostic technologies. In the first part of the paper, a historical perspective on the innovation of the stethoscope is used to highlight the transformations in diagnostic practices occasioned by novel diagnostic instruments. In the second part of the paper, ethnographic accounts of contemporary anaesthesia are presented in order to sketch out the manifold variations of using diagnostic instruments in daily practice. Both cases are analysed on a micro-analytical level, emphasising the interrelations of bodies, tools and knowledge in concrete situations. The analysis shows how diagnostic instruments become embodied in the perceptual habits of physicians and how diagnosing becomes an ongoing activity in the course of managing an illness trajectory.

Introduction

In addition to physical examinations or patients’ descriptions of their symptoms, physicians rely on diagnostic instruments to check for signs of disease. Ever since the invention of the stethoscope, diagnostic instruments appear to permeate medical practice to the point of completely replacing physical examinations or patient accounts. This article seeks to understand the role of diagnostic instruments in medical care not by emphasising them as an autonomous determining force, but by tracing the similarities and differences of technically mediated diagnosis in line with interactionist studies of medical work (Strauss, Fagerhaugh, Suczek, & Wiener, 1997). More generally, it conceptualises diagnosing as ongoing practical judgement, based on pragmatist ideas on the relation of knowledge, tools and action (Dewey, 1930). This view is complemented by phenomenological ideas on tools in use and the relations of bodies and technologies (Heidegger, 1996).

The comparative perspective takes a cue from Hughes (1951, p. 320) and his suggestion of seeking out a “frame of reference applicable to all cases”. Such common themes, as Hughes noted, may be “routine and emergency” or “mistakes and failures” (Hughes, 1951). This article will focus on the theme of technical mediation, i.e. how aspects of diagnostic activities become objectified in diagnostic instruments and how these instruments are then used in medical practice. For these purposes, it takes on a process perspective of diagnosis (Jutel, 2009) by focussing on the micro-level of diagnostic activities. The focus on the situation is well suited for comparing the specific activities found in different places and to analyse the complexities of everyday medical work (Wiener, Strauss, Fagerhaugh, & Suczek, 1979). From this perspective, diagnosis is part of the articulation work that is necessary to manage an illness trajectory (Star, 1991). The following arguments are situated within the numerous areas cohabited by the sociology of medicine, technology and science, which cannot be discussed here in detail (cf. Berg and Mol, 1998, Casper and Morrison, 2010, Clarke and Star, 2003, Elston, 1997, Heath et al., 2003, Lock et al., 2000, Star, 1995, Timmermans and Berg, 2003).

In a broader sense, diagnosing can be understood as a type of classification work (Bowker & Star, 1999). From this perspective, medicine figures as an information infrastructure that not only contains an individual diagnosis, but rather a plethora of primary and subsidiary diagnostic activities subject to continual matching and evaluation as the treatment evolves. Traces of the diagnostic activities – reports, printouts, pictures and letters – are assembled in larger scale information systems, including patient records, which organise both the treatment of the disease and the work of the nurses and doctors. Thus, classifications are ways of ordering the social world. Bowker and Star see a lack of research when it comes to systematically addressing how “the new technological and electronic infrastructures” (Bowker & Star, 1999, p. 5) are constitutive of social and moral order. From an interactionist stance, they see the need for a detailed analysis of classifications as a specific work practice. This emphasis in studying the use of technologies in practice is taken up in the following sections.

Especially micro-studies of work and information systems drawing from the workplace studies (Luff, Hindmarsh, & Heath, 2000) have revealed how technologies shape and are shaped by daily work. There are many propositions as to how to conceptualise the mutual shaping of tools and users. The comparative approach described below looks for specific configurations of humans and artefacts (Suchman, 2007) and seeks to trace the mutual transformations of physicians and instruments to the point at which they constitute a stable diagnostic ensemble. It understands diagnosing – first – as a form of “situated action” Suchman, 2007, p. 69), thus highlighting the contingent nature of routine action in line with Dewey’s notion of “practical judgement” (1954, p. 214). Situated action is – second – viewed as fundamentally embodied. This assumption allows different diagnostic ensembles to be analysed in terms of different perceptual habits (Merleau-Ponty, 2002). As Merleau-Ponty pointed out: “every perceptual habit is still a motor habit and here equally the process of grasping a meaning is performed by the body” (Merleau-Ponty, 2002, pp. 176–177).

The following sections highlight different aspects of technical mediation in medicine. The historical reconstruction of diagnostic practices traces the transformations in the doctor–patient relationship that have often been identified as the roots of subsequent technisation and objectification in medicine. Using Dewey’s ideas on the relation of means and knowledge (Dewey, 1958), it conceives medical diagnosis as being fundamentally mediated by technology. Also in line with Dewey, technical means are considered neither neutral, nor an autonomous force (cf. MacKenzie & Wajcman, 1999), rather, they must always be understood as transformative agencies. Such transformations are most visible in the controversies that emerge when new tools are introduced. Conversely, the transformations become less visible once the technology has been integrated in routine use. Therefore, the ethnographic part aims at comparing contemporary routine medical diagnoses by tracing the peculiarities of “machine work” (Strauss et al., 1997, p. 40) in routine anaesthesia. A phenomenological perspective on tools in use (Heidegger, 1996), on the functioning and the malfunctioning of instruments, can help to identify the perceptual habits associated with diagnostic instruments. The ethnographic study of routine anaesthetic practice shows that technisation is not a simple process of de-skilling, but that medical work contains a rich repository of skills for using, repairing and bypassing technology.

Contrasting two diverse cases, the historic reconstruction of a diagnostic innovation and the ethnographic account of routine medical work, helps to identify common lines of enquiry for a micro-sociology of diagnosis in a field which is characterised by a plurality of diagnostic practices (Berg & Mol, 1998). The conceptual discussions will also be helpful in building a comparative framework and they are therefore tightly interwoven with the empirical cases.