Bodies in Formation: An Ethnography of Anatomy and Surgical Education – reviewed by Chris Howe

‘Bodies in Formation: An Ethnography of Anatomy and Surgical Education’ by Rachel Prentice (Duke University Press, 2012).

rachel prenticeSo why has Rachel Prentice chosen to write about surgery – what is essentially described as a ‘body-contact sport’ (p.6)?  It is precisely the physical nature of surgery that lends itself so well to the analysis of embodied ways of being in the world and the potential impact of new technologies on what it means to be a surgeon.  The book’s cover invites us to take part in the theatre of surgery, placing us right in the centre of the action.  The examples of modern equipment introduce the prominent role of technology, which is central to the text.  The title, ‘Bodies in Formation’ is deliberately ambiguous, leading us to wonder whose body is being formed – the patient’s body or the surgeon’s body?  Or rather is it preparing us for the potential complexities involved in making such a clear-cut distinction?  Prentice makes it clear from the outset that the book has a focus on physicians and technology builders, rather than patients.  But the patient remains forever in the background as a reminder of the ultimate relevance and importance of medical work.  Although the text is based on the author’s experiences in North America, the ubiquitous proliferation and success of Western biomedicine makes this material relevant in many healthcare settings.  The author uses ethnographic research, which is a method favoured particularly by anthropologists.  It involves the immersion of the researcher within the environment they wish to study in order to gain as full an understanding of the research area as possible.  To this end, Prentice went into simulator laboratories, operating theatres, and dissection rooms, even performing dissection of a cadaver herself.  Her own experiences are often referred to in the text, alongside interviews and more informal conversations with surgeons, researchers and students.

The introduction explores a range of stimulating and critical questions that will be addressed in the later chapters: How do physicians become prepared technically, ethically, and emotionally to cut open, examine, or repair a human body?  How do changing technologies and practices for learning and working with bodies alter their meaning?  The stage is set for in-depth discussions which draw upon influences from a variety of theories, including phenomenology and cyborg anthropology.  Another question that runs under the surface of much of this book is one that troubles patients and doctors alike – is compassion vital to medicine, or is it an unnecessary adjunct to technical proficiency?   Prentice’s investigation of how ethical practice comes to be embodied in surgery is extremely relevant in the light of recent scandals, such as the damning evidence of neglect and ill-treatment in some UK hospitals, provided by The Francis Report (2013).

One of the greatest strengths of this book is the author’s use of engaging and entertaining real-life characters, along with powerful anecdotes, which help to illustrate and situate her arguments.  We meet a diverse range of people from a skilled surgeon who performs surgery by ‘swimming in the joint’ of a patient (p.193), to an ex-military surgeon turned researcher whose idealised image of the future surgeon ‘resembles a superhero who can defeat time and space and whose X-ray vision allows him to peer through walls’ (p.203).  Prentice builds upon and challenges the work of previous ethnographies in this area (see Bosk 1979, Goffman 1961b, Cassell 1991, 1998 and Hirschauer 1991 as examples).  Where others have focused on the social relations of surgeons (largely inspired by Foucault 1972), she criticises such approaches for viewing surgical power as largely a function of one’s position in a system rather than exploring the notion of the innate qualities possessed by surgeons themselves.

The text is broadly divided into two sections.  The first (and larger) part follows the chronological development of the physician through embodied practice.  This begins with dissection and its importance in the creation of the body of the student through rite of passage, as well as reflecting on the impact of its decline in medical education.  Prentice explores the mysterious duality of the cadaver, which is ‘neither person nor thing.  It is both and neither’ (p.256).  We are introduced to the wonderful notion of ‘ontological choreography’ (Thompson 2005), which allows patients and doctors to use their agency in deciding when to objectify bodies and when to embrace personhood.  We also meet with the idea of ‘mutual articulation’, which is repeated frequently throughout the book.  Mutual articulation is found in interactions between student and cadaver, surgeon and patient, or trainee and simulator, where Prentice reveals how both parties are complicit in the creation of each other.  After looking at dissection, the author studies the experience of the transformation from a student to a surgical resident, and then we finally follow the fully fledged surgeon into the operating room.

Prentice gives a helpful analysis of the so-called ‘hidden curriculum’ (pp.104-110) from the perspective of embodied surgical knowledge as developed in a specific socio-technical milieu.  These ideas draw from the likes of Bourdieu (1977) and Goffman (1961a), and place a great emphasis on the importance of emotions and affect in embodied learning.  We learn about what senior surgeons value in a student (and equally what they do not) and how this can conflict with new directions in medical education.  Prentice argues that ethics, rather than being an abstract set of ideas, come to be embodied by the expert surgeon through the acquisition of skill and control.  Throughout this first section, much is made of the powerful influence of mind vs. body dualism on the discourse of learning.  We are repeatedly reminded that socio-historically, emotion has been seen as an enemy of reason.  As well as fighting against this embedded tradition, Prentice also attacks the widespread rhetoric of ‘knowledge defined as mental imagery’ (p.15) as this neglects the essential role that the rest of the body plays in knowing.

Chapter Five marks the transition of the book towards a focus on the role of technology in the formation of bodies.  Prentice uses discussion of minimally invasive surgery to explore how new technologies have formed new relationships between perception and action.  In this setting, surgical instruments have strong agency, determining how and where the surgeon sees the operating site and in some instances enabling practitioners to feel they become merged into the site itself.  Here, the book really gathers pace and offers a sense that this is what the author has been leading up to, taking the reader out of the theatre and into the dizzying world of virtual surgical simulators.  There is a stream of fascinating ideas about the potential future of surgical education, practice, and patient identity in an industrialised world of data fragmentation, distribution and reconstruction.  How do you model all the embodied sensations and intricacies of a surgical procedure?  The author enters a laboratory and speaks to the researchers coming together across many varied disciplines who are trying to answer these questions.  Hot on the tail of these enticing discussions come moral questions – is it acceptable to allow a surgical trainee to kill a virtual patient?  How much agency will patients lose if they become a ‘Holomer’ (p.204), a packaged point of data that is analysed with a focus on imaging and functionality, the patient-as-product?  Alongside these philosophical and moral debates, Prentice also theorises about the possible change in the role and agency of surgeons in a future where their skills are increasingly bureaucratised and fragmented into profitable pieces.  We look at examples of simulators which focus on data interpretation and quantifiable measures at the expense of those subtleties which cannot be conveyed by numbers alone.  As Prentice points out, ‘Few acknowledge that difficult-to quantify aspects of this relationship, such as the effects of a physician’s kind words or gentle stroke on the hand, get written out of the equations’ (p.226).  In conclusion, Prentice looks towards the future and wonders how new technologies ‘might open new questions and offer new solutions for medical care’ (p.266).

The pace of this text speeds and slows between topics, rather like the shifts that occur in medical education and training.  Some areas offer minute detail of environment and technology, while others tackle much wider and often unanswerable questions about the nature of being a body in the world.  These aspects complement each other very well, and the two broad sections of the book mutually enforce other to give a full understanding of this area.  Also, the book’s occasional focus on the repetition of detailed specifics neatly mirrors the pattern of learning adopted by surgeons themselves.  There are moments when it feels unclear as to whether Prentice is taking a stance on the issues presented or remaining neutral.  Perhaps this sense of unease is a direct result of the larger conflict between technical proficiency and compassion that permeate throughout the book.  It is also a reminder of some of the tensions that can arise from ethnographic research, when the researcher’s own thoughts and feelings have an influence on data and conclusions.  There are important things in this work for many groups of people, including surgeons and doctors (both trainees and trainers), anthropologists, social scientists, patients, and the list goes on.  Although a basic grasp of some key anthropological concepts would help the reader, this is by no means necessary and the text itself serves as a lovely introduction to these ideas.  I myself will certainly be taking lessons from this book forwards into my career and will keep a keen eye on the development of technology in medicine.  If these advances are going to find a place in medicine, and there is every reason to expect that they will, we should all concern ourselves with how they will change and shape what it means to be both a doctor and a patient.

Reviewed by Chris Howe, who is a final year medical student and wrote this review during a surgical rotation that was undertaken as part of his clinical training at the James Cook University Hospital, Middlesbrough (UK).  Chris completed an MSc Medical Anthropology in 2012-2013 through an intercalated degree at Durham University and will complete his medical education at Newcastle Medical School.

Correspondence to Chris Howe.

References

Bosk, C. L. 1979. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press.

Bourdieu, P. 1977. Outline of a Theory of Practice. Cambridge: Cambridge University Press.

Cassell, J. 1991. Expected Miracles: Surgeons at Work. Philadelphia: Temple University Press.

Cassell, J. 1998. The Woman in the Surgeon’s Body. Cambridge, Mass.: Harvard University Press.

Foucault, M. 1972. The Archaeology of Knowledge and the Discourse on Language. Translated by A. M. Sheridan. New York: Pantheon.

Francis, R. 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry: Executive Summary. London: The Stationery Office.  Available online at: http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf (accessed January 23, 2014).

Goffman, E. 1961a. Asylums. New York: Anchor.

Goffman, E. 1961b. Encounters: Two Studies in the Sociology of Interaction. Indianapolis: Bobbs-Merrill.

Hirschauer, S. 1991. “The Manufacture of Bodies in Surgery.” Social Studies of Science, 21:279-319.

Thompson, C. 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. Cambridge, Mass.: MIT Press.

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