One of the touchstone references regularly encountered when reading sociomaterial accounts is The Body Multiple by Annemarie Mol. Since we didn’t have it in our Uni library and because it seemed so important, I took the rather rash step (for a Yorkshireman) of buying a copy. Although it took me a while to fully get to grips with the concepts therein, I now know why it is such a classic. I really should have reviewed it on the blog, however my small but select bunch of educational readers might not have found much of interest in an ethnographic text of medical practice … or perhaps they would. Put far too simply, it’s an ethnographic telling of how the arterial disease, atherosclerosis, is enacted in a hospital. Enacted, yes, because this is tale of ontology and how reality comes to be.
The messages in The Body Multiple resurfaced for me this week as I cycled into Uni., pondering the events of a few months ago, back in August (2017). I’d been invited by my local health centre for a Health Check. No biggie; just one of those things to which people of ‘a certain age’ here in the UK can benefit from. If I had my cynical head on, then I might say my clinic had invited me in order to meet its targets, or to reduce the likelihood of me becoming a future financial burden on an ever more stressed national health service. Since I’m feeling much more generous, I’d say it’s to help spot early symptoms of diseases which might make my later life less pleasant, or even foreshorten it. The check requires you to provide blood and urine samples, then re attend a week later for a nurse to go through the results with you and suggest lifestyle changes if necessary. I wasn’t worried; my last check six or so years ago indicated nothing more than cholesterol levels slightly above those recommended by the medical establishment. In the intervening period, I made adjustments to my diet and was confident I’d now be within the margin. What I hadn’t expected was the phone call from the clinic the day after the blood tests, asking if I could make an appointment to see a doctor, and could I come in the following day.
News like that can be … unsettling. Concerns about cholesterol level or propensity for diabetes would hardly require an immediate visit to the doctors. So it was with some trepidation that I returned at the appointed time. The doctor informed me that my blood counts were low across the spectrum: platelet count, red blood cell count and white blood cell count. Not ridiculously low, demanding my immediate admission to hospital, but low enough to trigger a warning. As the doctor explained, it might simply be a one-off spurious set of results, or it could be an indicator of problems with my bone marrow. Having discussed the matter with a more senior colleague, she advised another sample be taken in a fortnight, just in case it was an anomalous event in my body that had caused it.
Two weeks later I had another sample of blood drawn and a week later, as advised, I arranged a telephone call from the doctor to discuss the new results. It transpired the counts were the similar to before. Not klaxon-sounding, lights flashing low, but enough for her to recommend I see a consultant. She said she would make the arrangements and I should await contact from the hospital calling me to an appointment. I waited. The weeks turned into a couple of months, until on the evening of 25th October I returned from work to find a letter from the hospital in the middle of the door mat. My appointment to attend the blood clinic was for the following week and I should call if I couldn’t make it.
The following Wednesday I cycled the ten or so miles to Rotherham General Hospital for my 09:30 appointment. Parking can be an arduous affair, so I chose not to take the car … but maybe I was just trying to prove something. Here I was at the hospital, cycling helmet, fluorescent jacket, and to all intents and purposes, a healthy man. Perhaps in an hour’s time I wouldn’t be.
With the help of the main receptionist and then the one at the entrance to the Haematology Department, I navigated my way to the blood clinic where four other people were waiting. They looked healthy too. A nurse came out of a room, noticed me and asked if I’d arrived for an appointment. With my affirmative reply she asked me to step behind a curtain where, having introduced herself, she then explained blood clinic procedure as she began the (digital) paperwork. On arrival I should report to the duty nurse and check in, with my blood test results. As this was my first visit, I didn’t have any today, but next time I came I should go straight to have blood samples taken, then come to the clinic to check in at the appointed time. Next time? But I hadn’t been seen by anyone yet!
I wasn’t waiting long before I was called in by the consultant. Once seated and with introductions completed, he then went through my records, monitor screen adjusted so I could follow through with him. After asking a few lifestyle questions, he then addressed the reason for me being called was related to the low blood counts. Not worryingly low, but enough to warrant further investigation. Having asked about other symptoms – tiredness, change in appetite, blood in stools or urine (none), he then conducted a brief examination of my glands, throat, abdomen and groin; apparently there was nothing untoward there. Despite the lack of other symptoms, he decided the most appropriate course of action was to call for another full blood count (FBC) and a couple of additional tests. In six weeks time I should come back and have those tests repeated, unless anything came up in today’s results, in which case I’d be called back in earlier. (Although he didn’t say it, I imagine this strategy is to provide a longitudinal set of data so any change (deterioration?) in the counts can be established).
Having presented the consultant’s instructions at the blood clinic reception so my future appointment could be made, my next port of call was the phlebotomy department, three floors up and along a myriad of corridors. Despite the proliferation of signage and having asked directions from a couple of folk on the way, it still proved a difficult find. Navigation is not normally a weakness of mine, but it was today. After once more checking in at a reception, I then sat down in yet one more waiting area. When my name was called, I passed on the consultant’s laboratory instruction card, took a seat and presented my left arm as instructed. This isn’t a big deal for me; I was a blood donor for nearly thirty years. The phlebotomist assembled six or seven tubes, some with different coloured labels, performed the initial prep, then inserted the needle. At one point as she fumbled with a couple of the tubes, and the fingers of the hand holding the needle in place shifted, resulting in the procedure becoming rather less comfortable than it ought to have been. Although she apologised and I thought no more of it, even six weeks later I find that whenever I flex my elbow under load, the site from where the blood was drawn still gives me a mildly painful reminder.
Here I am then, almost three months after being told there might be a problem with my bone marrow, but still none the wiser. I’ve written this post prior to my return hospital visit next week when matters might, or might not be cleared up.
The Body Multiple provides a tale of how different atheroscleroses are enacted in a hospital, depending on the procedures used. In the clinic, an interview with the patient presents the condition as leg pain after walking for a short while. The doctor may feel for foot temperature and pulsations in the veins, suspect atherosclerosis, then refer the patient to a consultant. She or he then has different options through which to call on the services of colleagues with different specialisms who enter the story with different equipment: doppler imaging techniques, angiograms and so on. Each involves different method assemblage (Law, 2004) involving different people, different rooms, different equipment, different techniques. Each renders a different atherosclerosis, or not, in a different way: a verbal account, a set of data, a photographic image, a graph. Atherosclerosis is not one disease but many. Multiplicity. It is different again when diagnosis shifts to treatment. Is it severe enough to warrant surgery, or might it be better to manage it? The outcome for the patient, who has only one body, depends on the ways in which the different threads from the different atheroscleroses might be drawn together.
Back in August, I was simply Ian Guest, PhD student and former physics teacher. One health check, one sample of blood, one set of anomalous results (when compared with some predetermined threshold levels) later, and I become Ian Guest, medical case. A different Ian Guest. Had the threshold levels been set slightly lower, I might not have been done differently. Let’s return to the cholesterol check for a moment. The test results six years ago were slightly above the threshold levels, so I was therefore a (slight) cause for concern. I changed my diet in the meantime and that brought me below that threshold when I was rechecked in August. But wait, the threshold has since been changed to a much lower value, so I remain a (slight) cause for concern, even though my level is below the original threshold. [Interestingly, elevated levels of LDL cholesterol can lead to atherosclerosis (narrowing of the arteries) but that’s not the subject of this story]. Now, with the August health check blood test, I become a medical case, although not for atherosclerosis. If not that, then what? Having platelet, red and white blood cell counts below a threshold does not make me a patient … yet. For that, a medical condition which can be addressed has to be established, hence the hospital visit and further tests. At the moment then, my medical condition remains, like Schrödinger’s Cat, neither or both, a bone marrow concern or not.
The tests I will have next week may lift the lid of the box, or not, and suggest a course of action, or not. If the blood counts have lowered further, then the health check, GP, consultant, hospital, appointment card, needle, phlebotomist, blood counts, threshold levels will have succeeded in enacting a condition. Without them, at least from sociomaterial method assemblage, that condition would not exist. With them, it may become enacted into reality. We shall see … or not.
I’m not unduly worried. Until Schrödinger’s lid is lifted, or a new method assemblage brings a different reality into existence, there’s no point in fretting. However, I will confess that each time I flex my elbow, the pain from that earlier clumsy blood extraction returns and for a few brief moments my mind wonders …
Law, J. (2004). After method: Mess in social science research. Routledge.
Mol, A. (2002). The body multiple: Ontology in medical practice. Duke University Press.