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by Susan Greenhalgh
University of California Press, 2001
Review by Lara Winner, MA on Apr 2nd 2002

Under the Medical Gaze

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.