Residual Categories in Medical Simulation: The Role of Affect in the Performance of Disease

Abstract

Extending Susan Leigh Star’s conceptualization of residual categories, the author highlights the role of affect in the construction of standardized symptoms in medical simulation and in the performance of scientific evidence. The author analyzes two cases, public performances of hysteria in the 19th century and standardized patients in contemporary simulation laboratories, revealing potentialities in the construction of medically accurate and pedagogically achievable standards. Conceptualizing patient performers as a standardization technology representing medical knowledge of patient experience allows the author to reveal how the performers’ affective perspective becomes appropriated into the biomedical discourse to legitimate its categories and educate healthcare professionals.

Notes

¹ The concepts of “illness” and “disease” frame disciplinary boundaries between social sciences and biomedicine along the culture/nature divide (Kleinman, 1980; Taussig, 1980). Following Mol’s view, in this article I move beyond the binary between “illness” and “disease” by showing that in the context of medical performance biomedical representations need to be articulated through social and affective relations in order to operate as a pedagogically productive simulation.

² Star’s examination of tensions between situated work practices and the ways practices become formalized in classification systems deals primarily with abstract, computational, and mathematical representations. She explores the creation of standardized forms and knowledge representation in scientific work practices of neurophysiologists (Star, 1989), biologists (Star & Griesemer, 1989), engineers (Star, 1991a, 1991b), and computer scientists (Bowker & Star, 1999; Star, 1995). Bowker and Star’s (1999) ethnographic investigation examined the process of designing a universal computerized information system for the U.S. hospitals in the mid-1990s called Nursing Interventions System. Such classification system aimed to promote the visibility and professional autonomy of nursing that has been traditionally “lumped in with the room price” (p. 250).

³ Massumi (2002) related affect to the notion of “intensity.” The notions of “intensity” and “expression” allowed him to develop a nonsignifying theory of communication.

⁴ Current psychiatric clinical practice does not recognize hysteria as a medical diagnosis. The symptoms that had been previously labeled as hysteria of the female body have resurfaced as diagnostic categories that are more acceptable in the current medical model. Whereas today the label “hysteric” is used largely pejoratively, the symptoms that cannot be explained by a biological source are still stigmatized. Before Freud proposed unconscious causes of hysteric symptoms (Gay, 1989), however, the distress of “hysterical” patients had not only been legitimated by the medical discourse, but these patients also participated on the construction of neurological categories that would describe and validate hysteria as a medical condition (Hustvedt, 2011).

⁵ Freud solved the puzzle of the location of lesions for hysteria by removing its diagnostic category from the domain of biological explanation and attributing its source to nonorganic traumas and repressed memories (Gay, 1989).

⁶ In Deleuze’s (2003) words, “This is the double definition of painting: subjectively, it invests the eye, which ceases to be organic in order to become a polyvalent and transitory organ; objectively, it brings before us the reality of the body, of lines and colors, freed form organic representation” (p. 52).

⁷ For Deleuze, an event “is a sign or indicator of its genesis, and the expression of the productive potential of the forces from which it arose” (Parr, 2010, p. 90). An event is the result of changes in the set of relationships generated by affects. It creates potentialities that are actualized in other events, each of them immanently expressed.

⁸ Nosology is the branch of medicine that deals with the classification of diseases.

⁹ In her discussion of realism in the standardized patient portrayal of suffering from the perspective of medical anthropology, Taylor (2011) summarized the arguments in support of using the standardized patient form of instruction as opposed to traditional classroom learning, mannequins, and other nonhuman simulators.

¹⁰ In these moments the notion of affect comes alive. The interruptions, when the machine does not work, when the flow stops, those are the intensities and forces in which affect can be traced. Deleuze and Guattari (1977) conceive a machine as “a system of interruptions or breaks” (p. 36) that conditions the continuity of flows connected to it.

¹¹ Hanna and Fins (2006) asserted that the social relationship between the doctor and patient in the real medical setting is highly asymmetrical. The doctor holds the power of both medical knowledge and practices that submit the patient’s body to a thorough examination, and the patient’s life experiences get redefined through the medical framework. They argued that in laboratory simulations this power dynamic is inverted. Standardized patients possess knowledge of their diagnosis and are evaluating student doctors and nurses, who have not been yet fully reified as competent practitioners. In addition, the students endeavor not to heal the “patient” but to obtain a good grade for their performance. According to Hanna and Fins, such projection of a good doctor–patient relationship not only fails to be a faithful representation of reality but is a simulation of an abstracted reality that cannot be found in real clinical practice.

¹² I follow Tim Ingold (2014) in order to distance myself from the understanding of performance-based simulation as a simulacrum (Baudrillard, 1994) of the “real” clinical practice. Ingold argued against the opposition between creation and imitation: “Copying is inhabiting the stream of work of the original.” Each copy is original in its movement that carries on the work that goes into making a copy through the “yet unformed world.” Each encounter in the context of medical simulation unfolds as an original enactment of a disease case, in spite of it following the same medical script and training that aims to standardize the performance of disease.

¹³ Bakhtin’s (1981) theory of semiotic mediation considers the ways different voices come into contact and infiltrate one another. Individual users of language construct their voice in an inner dialogue with the social community. In the process of acquiring, simultaneously encompassing, and interanimating a number of voices they cocreate meanings that are multivoiced.