The purpose of this article is to review Annemarie Mol’s paper “Pathology and the clinic: An ethnographic presentation of two atheroscleroses,” and discuss its implications in medicine. Mol is a philosopher and ethnographer (i.e., person who researches social and cultural relations1), and her paper describes her study in a hospital in the Netherlands examining the diagnosis and treatment of atherosclerosis (i.e., the buildup of plaques within arteries that can result in the restriction of blood flow) in leg vessels.2 She ultimately changes the concept of disease within the context of Western medicine. Diseases are typically defined, perceived, and thought about in biological terms (i.e., the underlying molecular mechanisms). However, people should view them with a philosophical mindset in order to approach and evaluate medicine more holistically. In her article, Mol portrays diseases as performances in order to depict the importance of all the skills, materials, and steps necessary in diagnosing diseases. She compares atherosclerosis performed in the pathology department versus atherosclerosis performed in the outpatient clinic to illustrate the various diagnostic methods implemented by specialists, the various versions of atherosclerosis that exist, and the importance of these varying performances in creating a composite image of the disease. To do this, Mol uses her first-hand shadowing experiences in the pathology department and the outpatient clinic as evidence.2
Performances of Diseases
Drawing from her observations with the pathology resident, Mol asserts that atherosclerosis as a disease can only exist in the pathology department through the performance of atherosclerosis in this specific setting.2 The performance here consists of a microscope, preparation of the slides, and a specialist’s trained eye. Without all of these key components, atherosclerosis cannot be diagnosed and cannot exist as a disease in the pathology department. For example, if a slide is not prepared correctly, a patient’s tissue may not seem to show signs of atherosclerosis when the pathologist examines it through the microscope. The pathologist may not diagnose the patient with atherosclerosis even if the patient truly has a buildup of plaques in their arteries. It is the performance of atherosclerosis in the pathology department that allows atherosclerosis to be diagnosed by pathologists.
Likewise, drawing from her observations with the vascular surgeon, Mol asserts that atherosclerosis as a disease can only exist in the outpatient clinic through the performance of atherosclerosis in this specific setting.2 The performance of atherosclerosis in the outpatient clinic consists of the clinician’s questioning and patient’s reporting of symptoms. Without all of these key components, atherosclerosis cannot be diagnosed nor exist as a disease in the outpatient clinic. For example, if a practitioner forgets to ask a patient if they experience pain while walking, then the patient may not seem to show signs of atherosclerosis. It is the performance of atherosclerosis in the outpatient clinic that allows atherosclerosis to be diagnosed by providers.
These are just two examples of different performances, but there are multiple performances of atherosclerosis in many other settings. Furthermore, there are numerous performances of other diseases and conditions that exist. By viewing diseases as performances, it can be understood that diseases are diagnosed, acknowledged, and treated due to the fact that the performance took place.
Relationship Between Multiple Performances of Diseases
Drawing from her observations with the pathologist, Mol discusses the death of a seemingly healthy patient, who never reported any pain or other symptoms to her provider.2 After the patient’s death, the pathologist examined her tissues to find out the cause of her death, and he discovered that her vascular system was atherosclerotic. By recounting this patient’s situation, Mol implies that atherosclerosis in the outpatient clinic was not entirely performed because the patient did not report pain during her visits, so atherosclerosis did not exist in the outpatient clinic. The performance of atherosclerosis in the pathology department explained the cause of the patient’s death. This solidifies the idea that diseases exist due to performance of that disease. Atherosclerosis can exist in one department (e.g., pathology department) but may not exist at all in another department (e.g., outpatient clinic). By connecting performances, a better understanding of the disease is created. In other words, people can grasp the specificities of a disease more clearly when it is viewed as a result of a performance.
Applications for Medicine
Mol’s use of firsthand shadowing experience as evidence is effective due to the following reasons: 1) even though her experiences are based on a few hours of observation, they are still representative of the different diagnostic methods utilized in different departments 2) they clearly exhibit the different versions of atherosclerosis that exist in different settings through the different actions and perceptions of the specialists that diagnose atherosclerosis and 3) they depict the importance of these versions in understanding atherosclerosis as a whole. Her philosophical framework for perceiving, analyzing, and understanding diseases can be implemented in many ways.
Healthcare Professionals
By viewing diseases as performances, healthcare professionals can adopt a blended way of perceiving disease and diagnostic methods in order to minimize gaps in understanding a patient’s health status. For example, a vascular surgeon would understand not only the mechanisms behind atherosclerosis but the presentation of atherosclerosis by patients who report symptoms. Furthermore, this philosophical framework allows providers to acknowledge the potential for missing a patient’s disease due to the performance of that disease. The provider of the seemingly healthy patient should not impose responsibility on themselves for not diagnosing the patient with atherosclerosis even though the pathologist found that she had atherosclerosis. The provider completed the tasks to screen the patient for atherosclerosis with the interviewing process, but without the patient’s reporting of pain or issues, atherosclerosis did not exist in the outpatient clinic.
Students
By viewing diseases as performances, students can study the history of medicine and public health with less bias against non-Western medicine. The process of diagnosing diseases is normally carried out in terms of “correct” and “incorrect.” For example, diagnosing the presence of a fever with a thermometer in the doctor’s office may be perceived as “correct” while diagnosing the presence of a fever by touching one’s hand to the patient’s forehead before the invention of the thermometer may be perceived as “incorrect.” Viewing this situation through Mol’s philosophical lens would allow individuals to perceive fever as a product of the performances of a particular time period rather than “correct” and “incorrect.” Fever used to only exist through the performance of feeling a patient’s temperature with one’s hand and deciding whether someone felt “too hot.” Fever continues to exist through this performance in other cultures. In modern day Western medicine, fever now exists through the performance of a thermometer and clinical judgment that a temperature is out of normal range. The performance of fever may change in the future, which would change the way in which fever exists. Because understanding of diseases is constantly changing and what is considered “correct” now may be “incorrect” ten years from now, it is more accurate and respectful to view diseases as products of performances. This mentality may allow students to be more open-minded and develop cultural competence, which means being able to care for people with different languages and cultures.3 Future studies could examine medical students’ perceptions of traditional medicines before and after learning about diseases and performances to see if they become more positive and accepting of non-Western healing practices with applications for developing strong cultural competence.
Conclusions
By analyzing the various diagnostic methods of atherosclerosis through a performative lens in her article, Mol argues that diseases exist in specific settings because a set of key components was present and carried out.2 Viewing diseases with this mindset can produce a synthesized understanding of that disease by considering the various ways in which a disease exists. A philosophical lens should be adopted when studying and practicing medicine so that individuals can analyze situations more holistically.
Bibliography
[1] “What is Ethnography?.” Princeton University. Accessed May 5, 2020. https://anthropology.princeton.edu/programs/ethnographic-studies/what-ethnography.
[2] Mol, Annemarie. 2000. Pathology and the clinic: an ethnographic presentation of two atheroscleroses. Cambridge Studies in Medical Anthropology : 82-102. https://books.google.com/books?hl=en&lr=&id=5kZkE9TTlBUC&oi=fnd&pg=PA82&dq=Mol,+Annemarie,+%22Pathology+and+the+clinic:+an+ethnographic+presentation+of+two+atheroscleroses,%22+Cambridge+Studies+in+Medical+Anthropology+(2000):+82-102.&ots=teg84uJ8dA&sig=qwecN-F0TjzYbWzfufUW5olS43w#v=onepage&q&f=false.
[3] Seeleman, Conny, Jeanine Suurmond, and Karien Stronks. 2009. Cultural competence: a conceptual framework for teaching and learning. Medical education 43, no. 3: 229-237.
About the Author
Clare is a nursing student at the University of Pennsylvania. Currently, she is a coordinator for her own pilot project testing smartphone-delivered compassion training to healthcare professionals. She is aspiring to be a psychiatric nurse practitioner.