Under the Medical Gaze is
author Susan Greenhalgh’s first-person account of her experience as a sufferer
of chronic pain,specifically,
her misdiagnosis as a fibromyalgic and the disastrous consequences that
misdiagnosis had on the next year of her life. 
A rheumatologist she identifies only as “Dr. D” followed up his overly
aggressive diagnosis of fibromyalgia with even more aggressive pharmacological
and behavioral management treatment, then blamed new symptoms on the
fibromyalgia rather than the strong medications (the symptoms themselves were
generally consistent with either interpretation). It wasn’t until eight months into this new regimen, when
Greenhalgh was at the end of her physical and particularly her psychological
rope, that she got a second opinion which led to the unraveling and correction
of the entire misguided enterprise.

As an anthropologist, she uses the
format of the auto-ethnography to tell her story and seek its deeper
significance for the practice of medicine, the meaning and dangers of
patienthood, especially for female patients, and the challenges of the chronic
pain sufferer. Auto-ethnography is a method
similar to the classic anthropological field study except that the observer is
also one of the participants in the encounter. 
As the patient in the encounter, the method is uniquely suited to her
situation, but if your nose is sniffing out a feminist slant to the book as
well, you are correct; Greenhalgh also chose the auto-ethnography because it
breaks down the traditional barriers between observer and observed, subject and
object, etc.

For the purposes of this review,
then, the $64,000 question is: does Greenhalgh’s experience actually have the
deeper significance for the larger society that she argues it has? After all, as Greenhalgh writes, “It was a
slight slip, really,a
misdiagnosis of an emergent chronic pain syndrome.” (18) How much weight can such an episode
carry? The book certainly functions as
therapy for Greenhalgh herself (successful therapy, one hopes); she admits in
the opening chapters that she wrote the book in part to give herself some kind
of closure on this disastrous medical experience. But does it serve any greater purpose?

While the book has flaws, it also
contains some good analysis. For those
interested in a detailed case study on the phenomenology of chronic illness
and/or pain, the theoretical constraints that make it difficult for the
biomedical model to serve chronically ill patients, the power imbalances
inherent in the doctor-patient relationship, or the methods by which “symptoms”
become “syndromes” or “diseases,” Under the Medical Gaze would be
worthwhile. A quick perusal of the
table of contents and/or the introduction should guide such readers to the
section(s) of interest. The major
weaknesses of the book include a stilted, somewhat repetitive writing style
that sacrifices narrative fluidity for the structure of the argument, potential
bias problems arising from its limited source material, and a feminist analysis
of the situation that is unconvincing in the end (more on the last two
later). First, a word on each of her
major areas of analysis.

Throughout the book, Greenhalgh
vacillates between putting the blame (occasionally) on individuals,both herself and her doctor,and (more often) on the larger
societal structures that shaped them. 
Not surprisingly, then, the biomedical model is one of the first
conceptual frameworks to come under critique. 
Taking a distinctly Foucaldian viewpoint (thus the title), Greenhalgh
focuses on the discourses of medicine which succeeded in transforming her from
a mildly chronically ill, but basically healthy, person into a seriously ill
fibromyalgic. She reserves particular
venom for what she calls the discourses of objectification, which renders her
an object of scientific study rather than a person and severs body from mind,
and quantification, in which symptoms which cannot be measured are given less
weight. And of course, says Foucault,
all of this is done under the guise of beneficence, thus obscuring its violent
nature. (Greenhalgh’s assertion here
that all doctors still take the Hippocratic Oath is simply false, but
illuminates the power this common misperception has on the average patient.)

Greenhalgh also criticizes the
rhetorics, particularly reification, by which the doctor, having created an
illness story from the “facts” his discourses and practices have generated,
must persuade the patient that this story is true and that the ensuing medical
interventions are justified. In her
case, of course, the story was not true and the rhetorics served to do more
harm than good. While discourses and
rhetorics certainly played a role in her story, her near exclusive emphasis on
them is unwarranted by the facts. By
her own account, it was an improperly (overzealously?) administered “pinch
test” (a diagnostic exam intended to assess sensitivity at the 18 classic tender
points of fibromyalgia) that served as the basis of the misdiagnosis and all
that followed. In her case, then,
practices seem to play a more important role than words. The way Greenhalgh draws an analogy between
the clinical art that is medicine and dry laboratory science, where facts are
more neatly cut and dried, is also annoying; any practitioner can tell you that
people are much messier and more difficult to analyze than your average
chemical compound.

Greenhalgh also writes extensively
on the nature of the doctor-patient relationship (while she does not consider
it separately from her critique of the biomedical model, it is). She emphasizes the informational and power
imbalances inherent in the relationship, with all the risks to the patient that
entails. Despite the fact that she has
a Ph.D., she did not know that fibromyalgia is a new and still somewhat
controversial syndrome, or that its diagnosis and treatment are still a matter
of debate. She didn’t know that Dr. D’s
practices were considered quite aggressive by the standards of the profession
(although she had heard that he was a bit unorthodox and rather
controlling). She also argues that the
chronically ill are particularly vulnerable because they are often weakened by
constant pain and chronic sleep deprivation and desperate for a savior who can
heal their ills. This desperation can
also affect an ongoing doctor-patient relationship; Greenhalgh writes that she
often stifled doubts and questions to avoid threatening her good relationship
with her doctor, thus harming communication. 
Overall, this was one of the stronger parts of the book.

Lastly, Greenhalgh submits her
experience to a feminist analysis, but after all the analytical work she has
already done, there doesn’t seem to be a whole lot of explanatory work for
feminism to do. It’s not so much that
the feminist analysis is poor, but rather unnecessary, in an Occam’s razor sort
of way. Greenhalgh talks a great deal
about the “feminine” self that submitted meekly to all of Dr. D’s interventions
and worried more about her relationship with her doctor than her own health,
contrasting it with the “feminist” self that silently harbored doubts and
eventually exploded in rage. (This
feminist self existed before becoming Dr. D’s patient and is all the stronger
after the experience.) But the “what
went wrong” in her case seems well accounted for by weaknesses in the
doctor-patient relationship and the biomedical model, which is ill-equipped to
deal with the subjective, hard to quantify symptoms that characterize many
chronic illness experiences. There
didn’t seem to be much here that would have gone differently if Greenhalgh
happened to be a man, rather than a woman. 
Any work this analysis does appears to be primarily personal; Greenhalgh
needs to explain to herself how she, well-versed in feminism, could have made
such crucial mistakes, allowing herself to fall under the spell of a
domineering doctor and an objectifying medical system.

The other major weakness of the book
is its source material; Greenhalgh writes almost exclusively from her own
experience, supplemented by her diaries and medical journals (kept at the time
for the purpose of improving her health and later turned into ethnographic
source materials). The only material
that shows Dr. D’s side of the story are his initial history of Greenhalgh,
obtained at some point by the patient, and an audiotape of a public lecture he
gave on fibromyalgia. Greenhalgh tries
to downplay this bias by consistently referring to herself in the third person
(as “S.”) throughout the auto-ethnography and thus creating an artificial
distinction between Susan the patient and Susan the anthropologist (so much for
removing the barrier between subject and object!). But this distinction often breaks down; the voice (often angry)
of Susan the patient routinely comes through in the analytical sections of the
book. This is not to say that
Greenhalgh deliberately misconstrues events in her favor; indeed, she is often
self-critical. It is simply to say that
one should take her criticisms, particularly of Dr. D, with a grain of salt; he
never has a chance here to defend himself.

© 2002 Lara Winner

Lara
Winner, M.A., is a doctoral candidate in philosophy with a concentration in
medical ethics at the University of Tennessee, Knoxville. She is interested in
mental health/mental health ethics both because it is a traditionally
underserved area of medical ethics and because it can provide valuable insights
into the interrelationship of mind, body, and spirit.

Categories: General

Tags: Pain, Medical Disorders