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

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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
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  Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=hmca20 Download by:  [99.6.41.187] Date:  27 January 2017, At: 18:49 Mind, Culture, and Activity ISSN: 1074-9039 (Print) 1532-7884 (Online) Journal homepage: http://www.tandfonline.com/loi/hmca20 Residual Categories in Medical Simulation: TheRole of Affect in the Performance of Disease Ivana Guarrasi To cite this article:  Ivana Guarrasi (2015) Residual Categories in Medical Simulation: TheRole of Affect in the Performance of Disease, Mind, Culture, and Activity, 22:2, 112-128, DOI:10.1080/10749039.2015.1043000 To link to this article: http://dx.doi.org/10.1080/10749039.2015.1043000 Published online: 10 Jun 2015.Submit your article to this journal Article views: 254View related articles View Crossmark data   Mind, Culture, and Activity , 22: 112–128, 2015Copyright © Regents of the University of Californiaon behalf of the Laboratory of Comparative Human CognitionISSN 1074-9039 print/1532-7884 onlineDOI: 10.1080/10749039.2015.1043000 Residual Categories in Medical Simulation: The Role of Affect in the Performance of Disease Ivana Guarrasi  Department of CommunicationUniversity of California, San Diego Extending Susan Leigh Star’s conceptualization of   residual categories , the author highlights the roleof affect in the construction of standardized symptoms in medical simulation and in the performanceof scientific evidence. The author analyzes two cases, public performances of hysteria in the 19thcentury and standardized patients in contemporary simulation laboratories, revealing potentialitiesin the construction of medically accurate and pedagogically achievable standards. Conceptualizingpatient performers as a  standardization technology  representing medical knowledge of patient expe-rience allows the author to reveal how the performers’ affective perspective becomes appropriatedinto the biomedical discourse to legitimate its categories and educate healthcare professionals. INTRODUCTION The creation of medical categories is a powerful political and ethical act (Bowker & Star, 1999).The process of medical classification produces categories that are mutually exclusive, valorizecertain properties, and disregard others. Bowker and Star defined those cases that do not meetthe requirements of any category, or cannot be formally represented within a given classificationsystem, as “residual categories” (2007, p. 273), which by means of exclusion become function-ally nonexistent. In applying Star and Bowker’s (2007) notion of residual categories to a casestudy of medical simulation in two contexts—public performances of hysteria in the 19th cen-tury and standardized patients’ portrayals of   disease 1 (Mol, 2002) in the present-day simulationlaboratory—I suggest that what is deemed residual is very much a part of the live system thatallows medical categories to be articulated in the first place. Using affect theory on two examplesof medical performance from different periods, practices of medical representation, and politics 1 The concepts of “illness” and “disease” frame disciplinary boundaries between social sciences and biomedicinealong 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 representationsneed to be articulated through social and affective relations in order to operate as a pedagogically productive simulation.Correspondence should be sent to Ivana Guarrasi, Department of Communication, University of California, SanDiego, 9500 Gilman Drive, La Jolla, CA 92093-0503. E-mail: iguarras@ucsd.edu  RESIDUAL CATEGORIES IN MEDICAL SIMULATION  113 of patient care, I show that performance of disease, in contrast to other methods of representationin medicine, is located at the slippages of its representational efforts.In the simulation laboratory of a medical and nursing school, standardized patients are per-formers trained to portray a patient with a disease. Performance-based medical simulations arescripted so that standardized patients’ enactments of diseases are consistent from one session toanother. Such standardization of performances aims to ensure comparable learning and testingconditions for medical and nursing students (Barrows, 1993). But every simulation is a simpli-fied model of the real-world system, so the attempt to standardize biomedical information inactors’ performance does not make each simulation the same. Performance-based medical sim-ulation escapes attempts at its representation in terms of biomedical categories because it aimsto portray the “messy” clinical reality. An emergent system of medical performance is an activeand dynamic version of a medical classification system. The “realistic” and believable simulationemanates from the overlap between the scientifically precise forms of disease representation andthe unpredictable forces permeating the lived encounter of the performance.Star and Bowker (2007) pointed out that the long and messy stories that go into the productionof neat categories become obscured and forgotten after the production itself has taken place.What remains available is “a desiccated form of a complex narrative” (p. 272). In the contextof representing medical practice in simulation, those categories of the “patient” experience thatare not easy to describe or categorize in medical terms and with scientific precision becomepart of the residual category of subjective perspectives that, according to medical educators, is“not important” for the correct representation of biomedical facts in simulation. In contrast toinformation systems discussed by Star, 2 performances in medical simulation are dynamic andlive versions of pen-and-pencil tests and medical checklists. Performance of disease, which iscommitted to realistic portrayals of patients’ suffering, cannot be contained by medical categoriesor represented by a computerized information system.I suggest that affect is key to explaining how “residual categories” (Star & Bowker, 2007) areproduced and sustained in the performance of disease. The subject of affect has gained scholarlyattention in recent years. According to the cultural anthropologist Kathleen Stewart (2007), affectis at the center of an unstable interplay between subjective experiences and the social structuresand institutions that organize everyday encounters. Stewart described affects as lines of forcesthat produce a set of relations: Ordinary affect is a surging, a rubbing, a connection of some kind that has an impact. It’s transper-sonal or prepersonal—not about one person’s feelings becoming another’s but about bodies literallyaffecting one another and generating intensities: human bodies, discursive bodies, bodies of thought,bodies of water. (p. 128) 2 Star’s examination of tensions between situated work practices and the ways practices become formalized in classifi-cation systems deals primarily with abstract, computational, and mathematical representations. She explores the creationof standardized forms and knowledge representation in scientific work practices of neurophysiologists (Star, 1989), biol-ogists (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 sys-tem aimed to promote the visibility and professional autonomy of nursing that has been traditionally “lumped in with theroom price” (p. 250).  114  GUARRASI According to Stewart, affect manifests itself through individuals, but it can be traced in theorganization of sociability. Affect is seen as a connecting force between the individual and otherontological domains. Brian Massumi (2002) made a similar distinction between the personaland societal when he differentiated between affect and emotion. The domain of the operation of emotion is also related to the register of the encounter, but it is formed by the individual. Affect,on the other hand, is a vibration of intensities that is not based on the individual. 3 Medical simulation, like medicine itself, is invested in making language serve science byreducing its semantic multiplicity. By paying attention to the affective aspects of medical simula-tion I propose to take seriously something that medical educators and simulation trainers cannotdefine in terms of standard biomedical categories but that they can recognize as “something”important in medical simulation. The nonrepresentability of affect is at odds with the ratio-nal medical categories used to construct the simulated encounter. By focusing on the affectsof the subjects’ experiences, I highlight the implicit conditions of medical simulations that arenot explicitly named. Performers enunciate the affective relations that animate the meaningsof medical discourse and legitimize the scientific order of its meticulously constructed medi-cal categories. The performer in the medical simulation is a “body-in-interaction” (Alaˇc, 2009),dynamically produced with affective qualities in interaction with other subjects and objects.I develop my analysis in two parts. As a contrast case embodying the same principles, butin radically different form, I focus on the case of Blanche Wittmann, a famous performer of hysteria 4 in the late 19th century. Analyzing literature and drawing on the historical study of female hysteric patients in 1870s Paris (Hustvedt, 2011), I discuss how Wittman’s “realistic”embodiments of hysteric suffering coextended with imagined performance of disease and affectinelaboratingdiagnosticcategoriesofhysteriaasaneurologicalcondition.Performersofhysteriaoperated in a domain where affects were tapped, exceeding biomedical categories of diseaserepresentation. This historical example helps especially to illustrate the role of affect for theproduction of modern scientific and “realistic” simulation of disease.For the contemporary part of my analysis, I begin with an account of standardization prac-tices in the simulation laboratories used to train student doctors and nurses, and an account of how educators create categories for the training of disease simulation. My description focuseson the tensions that performers need to resolve in order to appropriate biomedical informationinto “realistic” encounters with students. I consider the performers as a key resource that moldsabstracted rational constructs of medical categories into live simulations. To examine this processI use ethnographic methods to analyze the case of Chandler, a standardized patient performer ata major hospital who navigates a twofold tension in his work: the standardization of his per-formance of disease in the context and the need to make the simulation resemble an authenticclinical encounter. Through the example of Chandler, I show that affect in standardized patients’ 3 Massumi (2002) related affect to the notion of “intensity.” The notions of “intensity” and “expression” allowed himto develop a nonsignifying theory of communication. 4 Current psychiatric clinical practice does not recognize hysteria as a medical diagnosis. The symptoms that had beenpreviously labeled as hysteria of the female body have resurfaced as diagnostic categories that are more acceptable inthe current medical model. Whereas today the label “hysteric” is used largely pejoratively, the symptoms that cannot beexplained 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, butthese patients also participated on the construction of neurological categories that would describe and validate hysteria asa medical condition (Hustvedt, 2011).  RESIDUAL CATEGORIES IN MEDICAL SIMULATION  115 performances is fundamental to the construction of disease for simulation. Affects that permeatestandardized patient and student encounters function as points of contact between the expressionsof disease by standardized patients and the categories of medical knowledge student doctors andnurses are trained to use in order to regiment “patient” narratives. To produce live and authenticperformances, the standardized patient acts out behaviors and affective relations. These forms of expression allow students to apply medical knowledge learned from books on the standardizedpatient, and thus to practice how to solidify control over patient narratives, which need to befiltered in order to maintain the boundaries of biomedical categories.This analysis is made through observations of standardized patient training and open-endedinterviews with both trainers and standardized patients. The ethnographic approach allows accessto the affective and nonrepresentational aspects of medical simulation that might not be fullydetermined and acknowledged. I explore the richness of experience that is always situated andcontingent on a set of relations that are at work at any specific moment (Suchman, 2007) in orderto show that subjects are a product of affects that permeate their encounters with the world. PERFORMANCE OF “RESIDUAL” SYMPTOMS: THE CASE OF BLANCHEWITTMANN Almostacenturybeforestandardizedpatientsbecameapartofclinicaleducationpractice,patientperformers and research subjects were already used in the presentation of clinical cases, playingan integral part in the development of clinical discourse in the 19th century (Ellenberger, 1970;Hustvedt, 2011). Public performances of hysterics played a role in the development of psychol-ogy and psychiatry (Ellenberger, 1970). Engaging in performances of symptoms that could notbe traced to their organic cause, these patient performers were instrumental in helping clini-cal professionals classify the symptoms of hysteria in the pre-Freudian era. Given the absenceof pathological findings, these patient performers helped legitimize hysteria as a neurologicaldisease (Alvarado, 2009).The purpose of this section is not to trace a historical lineage of standardized patients but todraw a connection between standardized and hysteric patients in order to highlight the role of affect for a “realistic” performance of disease during different historical periods. In the absenceof medical categories to describe nonbiomedical knowledge that constitute the patient’s experi-ence of disease, performances are seen by health care educators as a way to teach medical andnursing students to sort out patient expressions into medical diagnosis. Model hysteric and stan-dardized patients both construct patient experiences of disease that need to be transformed intothe categories of medical representation. They both simulate diseases that are conceived of asphysical ailments but whose symptoms cannot be easily traced to organic causes. Performing and Classifying Hysteria in the 19th Century According to Star (1989), “mind” problems such as hysteria, senility, and depression, which wereimpossible to anchor into physiological bodies, have been relegated into the diagnostic “garbagecategory.” Neurologists and surgeons in the 19th century sought diagnostic certainty by tryingto localize, or map, functions and diseases of the brain onto distinct areas of the brain. In her
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