Medical Rhetoric

David B. Morris’ The Culture of Pain (1991) offers the reader a wide reaching exploration of medical and cultural approaches to pain and its management. Foundational to his book is Morris’ argument that the then-contemporary biomedical approach to pain was grounded in a mechanistic ontology of the human body. Morris argues that this biomedical approach is ill-equipped to deal with pain because of pain is simultaneously physiological, psychological, social, and cultural. In interrogating this claim, Morris explores a great many conceptions of and approaches to pain as described in a broad literary corpus. Morris demonstrates how pain was differently understood in different societies, cultures, and times. He explores work as far ranging as tribal narratives, the Christian bible, and the writings of the Marquis de Sade. In so doing Morris seeks to demonstrate how a patient’s experience of pain is inextricably tied to his or her social, cultural, and psychological history.

Throughout this broad sweeping exploration of the cultural dimensions of pain, Morris contrasts these elucidated perspectives with biomedical accounts of pain. He highlights conceptions of pain drawn from medical history, practical manuals, journal articles, and disciplinary organizations. In so doing Morris seeks to highlight how the biomedical conceptions of pain are rooted in the modernist division of body and mind and then relegated entirely to the body. Through providing this contrast Morris argues that the modernist biomedical conception of pain needs to be supplanted by a postmodern pain that recognizes the plural social, cultural, psychological, and physiological natures of pains. Morris suggests that the adoption of a postmodern pain in medicine is need to foster more effective and compassionate patient care.

Positron Emission Tomography (PET) scans are currently used by the popular press and the entertainment industry to provoke great excitement. This mysterious and fantastic technology is (seemingly) able to probe deep into the invisible brain and take photographs which can tell scientists more about how the brain works and doctors more about keeping it working. Periodicals now regularly present their readers with exciting multi-colored “brain pictures” that show how the brain of a depressed person, or a drug addict, or a woman is different from the brain of a “normal” person, a non-drug addicts, or a man. Furthermore these same images are used in civil and criminal trials and presented to juries to help them assess guilt or assign punishment.

In Picturing Personhood, medical anthropologist Joseph Dumit explores PET both as technology and cultural phenomenon. Through six chapters and five interludes he presents readers with a thorough ethno-history and ethnography of PET and PET-produced images. In so doing, Dumit interrogates the use of PET and PET imagery in technoscientific, biomedical, popular, and forensic discourse. Ultimately he argues, that while this is an exciting technology warranting further scientific and social scientific exploration, we—as a culture—need to be more careful and critically aware of the impacts of PET on our perceptions of identity.

Chapters one through three focus primarily on PET in the lab. Dumit presents an account of PET as a vastly interdisciplinary technoscientific practice. He highlights the roles of chemists, physicists, physicians, neuroscientists, and radiologists in both the development and use of PET. As Dumit explains, PET is a technology with disputed priority. There are at least three leading contenders for the honor. Rather than attempt the impossible task of ferreting out the “real” history of PET, Dumit offers three ethno-histories (culturally specific and explicitly perspectival histories) he collected from each of the three primary contenders. In presenting these histories Dumit also explores how each history includes different and distinct conceptions of the nature of technoscientific practice.

Following the ethno-histories, Dumit presents the results of his ethnographic research at several PET labs. He describes the process of PET image generation—a process he casts as highly contextual and often problematic. PET scans are the result of a highly sophisticated process, each stage involving decisions and assumptions that contribute to the ultimate representation of the data. Some of these major decisions include what type of radioactive substance to inject into the patient, what angle to scan at, which series of computer algorithms to use in interpreting the data, and which color-palate to use when representing the data. To further complicate matters, PET scan images despite being two-dimensional contain four dimensions of data. The colors used represent depth and change over time. Given this Dumit is understandably concerned with the interpretation of these images by non-experts, e.g. consumers of popular media and more importantly juries.

Marshalling a wide variety of theoretical approaches from anthropology, history, sociology, rhetoric, philosophy, and semiotics, Dumit interrogates how these images are deployed and understood in forensic and popular discourse. In chapters four to six, he explores the history of radiographic and PET imagery in American trial law, as well as the use of PET imagery in anti-drug campaigns. Ultimately, Dumit argues that an inappropriate cultural configuration of the PET image as akin to a photograph creates a situation where the PET image is seen to unproblematically depict the referent. Not only are the nuances of PET technology black boxed, PET images are understood as obviously authoritative. This has a wide variety of ramifications, those of forensics and biomedical identity most important to Dumit. It is in exploring this latter concern (biomedical identity) that Dumit concludes his book. He explores how the brain scans when employed as unproblematically referential configure biomedical identity for both “normals” and people suffering from various illnesses such as schizophrenia, Alzheimer’s, and depression.

In “Strategies of Influence in Medical Authorship,” Judy Z. Segal explores the rhetoric of medical authorship through the lens of three Aristotelian canons, invention, style, and delivery. After a justification of her use or rhetorical analysis for scientific discourse, Segal analyzes rhetorical strategies deployed in 35 medical journal articles selected from a corpus of 200 published between 1982 and 1992.

Under the category of invention, Segal explores the “seduction” of the reader in article introductions. She argues that the selective and strategic deployment of statistics in introductory sections serve to engage a reader and demonstrate the importance and need of the research. Similarly these statistics and use of selective citation serve to establish the gap. Segal also argues that medical researcher/ authors employ a trope of “dissociation from the patient” in order to present a more convincing claim.

In discussing the arrangement strategies of medical authorship, Segal interrogates the role of synopsis in introductions and literature reviews and identifies synopsis as a key generic feature of the medical journal article. Furthermore, she explores what she identifies as a standard progression from presenting research. She traces the moves from what is agreed upon in the research to possible objections to the presentation of the hypotheses and research findings and finally to the future implications.

Finally, Segal explores the role of style in medical authorship identifying the use of passive voice, qualifiers, interrogatives, and the avoidance of poetic language as key features. She suggests that these stylistic strategies serve to maintain a sense of scientific investigation, ethos, and objectivism.

Note: While this article was no doubt highly appropriate for Social Science and Medicine at the time of its publication, the contemporary rhetorician of science and/or biomedicine will find little in the way of new information. I recommend this article primarily for those outside the discipline. Ken Hyland (2004) and Charles Bazerman (1996) offer detailed monographs exploring similar issues in scientific and academic scholarly articles.

In The Social Transformation of American Medicine, Paul Starr offers the reader a sweeping, thorough, and detailed history of the American medical profession. Book One interrogates American medicine’s establishment of sovereign cultural/ professional ethos and developing socio-economic dynamics from approximately 1790 to 1930. Book One traces the American medical establishment from fledgling pseudo-profession to cultural elite. He explores the transition from a time of no medical licensure when medical schools offered degrees of little more substance than a specialized high school diploma to the development of the AMA, state-controlled licensing boards and the establishment of the MD as graduate degree. Book One traces the competition among various approaches to healthcare including the not only the confrontations between allopaths and homeopaths, but also botanical physicians, osteopaths, chiropractors, and psychologists.

Book One also traces the establishment of the early medical system including the rise of hospitals and the role of public health. Starr explores how predominantly church or charity run dispensaries transformed into or were replaced by the modern hospital, and how the dominant paradigm of medical care transitioned from home to hospital. Starr also explores how the microbial revolution fostered a change from public health as little more than public sanitation to a vast program of inoculation and medical intervention.

Book Two picks up where Book One leaves off, in about 1920, and traces the rise of the insurance industry, the role of governmental regulation, and the development of medical corporations. Starr offers a compelling history arguing how the rise of unions and the demand for benefits fostered the establishment of an early insurance industry. Starr then explores how this establishment of third-party payment led to the a tremendous inflation in the cost of healthcare in the US. He also explores how various AMA and governmental policies led to a serious physician-shortage that lasted into the 1980s and exacerbated healthcare cost inflation. Finally, Starr argues that a then-recent backlash against the unquestioned sovereignty of the medical profession has created an environment where physicians once again feel the need to secure their position. He agues this need to secure their positions has resulted in the significant corporatization seen of the healthcare industry.

In “The Medical Interview as Rhetorical Counterpart of the Case Presentation,” Dennis Cali and Carlos Estrada conduct a “macrocommunication analysis” reviewing then-recent genre-studies of case presentations and medical interviews. The authors suggest the macroanalytic approach for its ability to respond to three then-recent trends in rhetorically-situated health communication studies: 1) the emphasis on “individual factors within medical discourse over collective communication acts” 2) the confinement of “analysis of medical communication to the single context of either the case presentation…or the medical interview,” and 3) the neglect of “the implicit influences imposed during medical training on the way physicians communicate with patients” (p. 356).

In order to begin addressing these trends, Cali and Estrada synthesize generic studies in three areas of medical discourse: 1) the case presentation, 2) the (observed) medical interview, and 3) the (suggested) ideal medical interview. Distilling a list of generic and formal features and constraints on the case presentation qua genre, the authors identify “maintaining the floor, preempting questions, and interrupting” as key constituents of the case presentation. Cali and Estrada argue that these constituents tend to render case presentations exercises in professional dominance and monologism. The authors focus on these constituents because, as they argue, these cultural features of the case presentation are instantiated in medical interviews. Cali and Estrada cite several studies indicating the role of interruption and preemption during medical interviews in decreased patient outcomes and satisfaction.

In response to this identified problem, Cali and Estrada suggest an ideal medical interview also distilled from then-recent research and theorization. This interview would be dialogic in nature and perform the “four essential tasks of the medical interview: gather data, maintain a therapeutic relationship, educate the patient, and negotiate a treatment plan” (p. 368). Ultimately the authors suggest that if generic features of the medical interview can established distinct from the case presentation, as they are in the ideal form, then physicians will see improved patient satisfaction, outcomes, and fewer lawsuits (p. 370).

Douglas Maynard’s “On Predicating a Diagnosis as an Attribute of a Person” explores, through conversational analysis, interactions between healthcare workers and patients at the time of diagnosis. Specifically, Maynard explores how practitioners employ two discursive moves, “citing the evidence” and “asserting the condition” to attribute a diagnosis. The article also seeks to shed light on the reception of the diagnosis by the patient.

Maynard interrogates the conversations of diagnosis in two primary settings: 1) a children’s disabilities diagnostic clinic, and 2) a free HIV testing clinic. His explorations of diagnosis are built on a corpus of diagnosis pronouncements from these two facilities. In each of the cases used in the corpus, the diagnosis was eventually confirmed.

Through his analysis, Maynard suggests that diagnostic pronouncements that consist only of “bald assertions” tend to be received as presumptive and confrontational, and result in more patient disputes. The corpus data suggest that diagnostic pronouncements that begin with evidence citation (from tests and inventories) contribute to the patient’s perception of medical authority. Maynard argues that the evidence-based diagnostic pronouncement, with its impact on perceived medical authority, predisposes the patient to be more receptive to the attribution of the medical condition.

In Health and the Rhetoric of Medicine, Judy Segal offers a broad introduction to the idea of rhetorical analysis and criticism as applied to biomedicine. Segal targets an interdisciplinary audience of rhetoricians, historians, philosophers, sociologists, healthcare providers, and industry representatives, suggesting that the tools of rhetorical criticism can help shed new light on a variety of issues in contemporary biomedicine. After her introductory justification for a “rhetoric of medicine”(with particular reference to Aristotle and Burke), Segal provides the reader with six chapters on various issues in health as approached from the standpoint of rhetorical criticism.

In chapter one: “A Kairology of Biomedicine,” Segal uses a concept of kairos as “contingency and fitness-to-situation” (p. 22) to provide a rhetorical history or “kairology” of biomedicine—“the ‘official’ medicine of the Western world” (p. 23). This kairology traces the dominant cultural and rhetorical themes in the history of Western medicine from Hippocrates to the present. Segal explores eighteenth century “heroic medicine,” the establishment of Foucault’s concept of the “clinical gaze,” the medical progress narrative, issues of medical authority, and the metaphor of the gene.

Chapter two: “Patient Audience: The Rhetorical Construction of the Migraineur” explores a conceptual history of the migraine patient. Segal argues that medical practitioners develop a rhetorical construct of the migraine patient through the “inter(textual) play between at least, medical publication and the physician-patient encounter” (p. 39). Chapter two traces the history of the migraineur-as-rhetorical construct from its initial configuration as those of passionate, ambitious, or intellectual personality in the 1800s to an inflexible or sexually maladjusted women in the 1950s, to a pharmaceutically-based conception in contemporary medicine.

Chapter three, “The Epideictic Rhetoric of Pathography” explores the role of narrative and narrative epistemology in the construction of a patients complaint(s) and medical history “pathography.” In this chapter Segal explores how autobiographical illness narratives help configure popular and professional understandings of a given illness.

In chapter four, “Hypochondria as a Rhetorical Disorder,” Segal agues that hypochondria is a disorder that stands out as fundamentally rhetorical in nature. To support this claim, Segal suggests that to be suffering from hypochondria is a function of persuasion—specifically, “Contemporary hypochondriacs are people who have become persuaded in the absence of an organic precipitating cause that they are ill” (p. 74). With this concept as a starting point, Segal explores the persuasive character of hypochondria through the lens of Burkeian dramatism.

Chapter 5, “A Rhetoric of Death and Dying” interrogates argumentation and decision making during “end of life” physician consultations. Using the rhetorical theory of Chaim Perelman and Lucie Olbrechts-Tyteca, Segal argues that these discussions are less than ideal communicative interactions because there is so great a barrier between physician and patient or patient family that there can be no “contact of minds” (p. 91). Segal explores the problems of end-of-life consultations through the personal case-study of her mother’s death and through exploring interview data from healthcare providers interested in improving end-of-life consultations.

“Values, Metaphors, and Health Policy” (chapter 6) explores master metaphors and metanarratives in the discourses of biomedicine. Specifically, Segal interrogates the role of the “medicine is war,” “doctor as hero,” and the “person is genes” metaphors. Ultimately, Segal argues that the discourses of biomedicine are thoroughly metaphor-laden, and that these metaphors have a significant impact not only on popular understandings of biomedicine, but also on the practices of diagnosis and treatment.

Segal, in Chapter 7: “The Problem of Patient ‘Noncompliance’: Paternalism, Expertise, and the Ethos of the Physician,” surveys the discourse responding to the problem of patient noncompliance or as it has been recently recast “concordance” (p. 134). She argues that though western biomedicine is becoming increasingly aware of the challenges to concordance, it is not a new phenomenon in western healthcare. However, Segal suggests that challenges to physician ethos are more prevalent than they have been for sometime, and that problems of concordance can usually be traced to

I’m pleased to announce the beginning of my medical rhetoric reading blog. As I continue with my research into the rhetoric of medicine and healthcare, I will be posting synopses of those readings. This blog is primarily designed as a reference for myself, though I’d be quite happy to discover others had found it useful.