The Polyphony’s very own Associate Editor Chase Ledin reviews Feeling Medicine: How the Pelvic Exam Shapes Medical Training (New York: New York University Press, 2020) by Kelly Underman.
Feeling Medicine investigates the role of the pelvic exam in US medical school education. Drawing out the affective politics of gynaecological teaching associate (GTA) programmes, the book traces the feminist histories of patient empowerment, medical agency, and changing access to informed care. Underman argues that affective politics have helped to foreground the employment of body-knowledge among trained lay people who ultimately teach medical practitioners using precise understandings of their own bodies and guiding practitioners using sensations. Remaining with the affective dimensions of this procedure, Underman suggests, helps to create accountability and reaffirm the importance of patient-driven health education in an increasingly privatised, neoliberal healthcare system. Broadly, as an academic text, this book will appeal to both scholars and general readers interested in feminist theories of healthcare, sociology, modes of empowerment and knowledge production, and broader themes of participatory medicine and medical humanities.
Much of Feeling Medicine engages the historical tensions between biomedical authority and patient experience. Underman uses the terms “affective governance” and “regimes of affect” to “capture how affect has become a target of contemporary forces of governance in the training of the next generation of medical students” (18). These terms draw from Foucauldian analysis to articulate “technologies of affect” that “measure, manage, harness and produce the affective capacities of medical students, and by extension patients” (19). Put simply, Underman brings together interviews with programme administrators, doctors, current students, the GTA participants, as well as her own experiences as a GTA, in order to describe and assess the extent to which the pelvic exam creates particular power relations. The relevance of this reading is made evident in her claims that contemporary GTA programmes are moving increasingly away from the empowerment strategies of the 1970s and towards more automated approaches (often via advanced prosthetics and simulators). The shift toward what might be considered a “posthuman” approach to the pelvic exam raises important questions about how students gain social skills by working with trained GTAs.
Underman’s affective critique presents a unique opportunity to engage with broader discussions about bodies, critical health and posthumanism. By exploring the entanglement of medical objects, bodies, and medical knowledge(s), Underman illuminates how issues of the right to treatment and care are complicated by access to and production of medical knowledge and experience. If we understand Underman’s study in the context of increasingly technoscientific conditions in the medical sphere, we can begin to consider how bodies are captured through multiple embodied forms, including hybrid technologies, new instruments for examination and diagnosis and simulation programmes. Underman rightfully cautions against the features of agency and embodiment within this techno-apparatus, questioning whether greater efficiency through simulated bodies (e.g. techno-prosthesis) will ultimately improve medical practices or whether such practices will further entrench power hierarchies and structural inequalities. By attending to the affective networks produced by the live GTA encounter with students, Underman skilfully assesses the extent of growing tensions between medical practice and technoscience – effectively raising serious inquiries about the role of the human in an automatising medical sphere.
As Neda Atanasoski and Kalindi Vora write in Surrogate Humanity, “the liberal subject is an effect of the surrogate relation” (2019: 5). In other words, the modern individual is now a relation and reflection of a surrogate – a complex identity filtered through a technoscientic prism. As medicine and healthcare become entangled with non-human interfaces (e.g. prosthetics) and technologies employed to optimise the education process (e.g. A.I. and simulated tutorials), the problem of affective relations becomes embedded in the technologies themselves. For instance, Atanasoski and Vora detail how commercial sex robotics “resemble human beings in ways that keep them nonautonomous, yet simulatepleasure, and therefore simulate consent” (189, emphasis original). In the GTA encounter, the use of the prosthesis simulates the pelvic exam using sensors and materials that resemble human bodies. Such an encounter simulates the social cues and values required to interact with the patient. Yet, as Underman argues – and as Atanasoski and Vora would argue – the displacement of the human from the educational encounter fails to teach doctors how to gain informed consent – and thus serves as a surrogate rather than embodied knowledge. A key tension, here, is the potential lack of translation that will inevitably occur as more medical schools cut GTA budgets and integrate technological options. The socialisation of medical students through direct contact with trained GTAs – or, potentially, indirect contact with AI simulations – will change the educational experience offered. How will doctors gain invaluable social practice as medical practices are increasingly simulated?
Underman offers a few helpful reflections. As the “potentiality of life is increasingly being harnessed by capital, and the capacities of bodies to affect and be affected by [become] both the target of biopower and [modes] of intervention” (208), advocates will need to attend to critical forms of decision-making. That is, the affective dimensions that characterise the medical encounter cannot be seen simply as an individually driven task; instead, the entire encounter must be reconfigured to attend to the “forms of relationality and futurity” (209) that emerge from trained layperson encounters with medical practitioners. This collaborative process will only work, Underman argues, if attention to the “technologies of affect […] are billed as empowering for patients – unshackling them from the physician-centred era of professional dominance” (211). For Underman, there is something necessarily reparative about the politicisation of affect in the GTA encounter: a technology of the self, to use Foucault’s terms, which is not simply in the service and reproduction of technoscience but necessarily critical of the forms of power that push individuals toward a medical hegemony. In this sense, the empowered GTA and medical practitioners can resist the existing hierarchies that preclude certain populations from participating from the start – including women of colour, LGBTQ+ folx, and disabled people – by remaining attentive to the (future) affects that pervade the medical encounter. Hence, the argument for a sustained GTA culture not only centralises a collective and collaborative movement for change but necessarily draws out the value of teaching consent through human interactions and working to uncover social, economic and cultural barriers in the process.
In the final chapter, Underman drives home the need for renewed investment in patient empowerment – especially for disadvantaged patients who are always already disadvantaged by the US healthcare system. “Patient empowerment requires a structural basis,” Underman writes. “Securing access to healthcare via affordable – perhaps even nationalized – insurance would allow patients the ability to seek preventative healthcare, to get screenings that could save their lives, to even get the laypeople who make their living playing patients the ability to be them” (2020: 213). And so, the intensification of technoscience within the medical sphere requires an equal balance of social reform – in the case of the US, greater access to affordable or free healthcare – or, Underman suggests, a national insurance scheme. The speculative claims of socialised medicine is outwith the study’s central argument, and greater consideration of how this affective argument might operate within an Underman’s idealised system (such as via the NHS in the UK) might help to provide more concrete reflections on health policy reform. Indeed, this gesture toward socialised medicine may have a potential political barrier that prevents such social changes, creating real challenges to the idealised health reform from which this research draws. To put it crudely, the optimism of such a wide-ranging critique becomes subject to economic considerations (e.g. institutional and national budgets) which prioritise technoscience and simulation in times of austerity coupled with conceptions of progress. Thus, the urgency of a human-centred policy over a hybrid posthuman policy becomes opaque in the face of social conditions radically different from the 1970s health movements.
Overall, the potential reach of Feeling Medicine will include both the intended medical sociology audience but will also speak to scholars concerned about the role of patient experiences within an increasingly technoscientific medical environment. The tension between the affective experience and the posthuman will sustain important questions about the role of medicine to facilitate individualised but progressive care for patients, particularly for patients who may not identify according to gender or sexual binaries. Thus, Feeling Medicine reminds us of the need for empowerment and accountability across a host of embodiments. As a sociological text invested in larger systemic change, it adds to the canon a critical specificity that helps to broaden our understanding of how to change US healthcare policy – through careful and rigorous case studies that present compelling counter arguments to the increasing technoscientific norms of US medicine.
Reference
Atanasoski, Neda, & Kalindi Vora. 2019. Surrogate Humanity: Race, Robots, and the Politics of Technological Futures. Durham: Duke University Press.
Chase Ledin is a PhD researcher in the Centre for Biomedicine, Self and Society at the University of Edinburgh. His research explores the epistemologies of “end of AIDS” public health campaigns and transformations in HIV intervention strategies in the Global North. You can find him on Twitter here: @chaseledin.