I bring you now on Letters from Abroad a special two-part interview with Professor Kelly Joyce—an old friend and one of the most interesting people I’ve ever known—currently a program director at the National Science Foundation, normally a sociology prof specializing in scientific, medical, and technological issues at The College of William & Mary. Egghead alert! Egghead alert! She explores in the real world what science fiction explores through fiction: follows the introduction of technology and how it is adapted into society. Let’s skip the intro and get right into the interview. [Note: Some of the interview refers to her recent book on MRI technology, Magnetic Appeal: MRI and the Myth of Transparency.]
Q. I love your stuff on sniffing dogs and diagnosing illnesses by smell, not sight/images (such as MRI, X-Ray, etc). Who are these diagnostic dogs?
A. The diagnostic dogs reported in the medical literature range from people’s pets to highly trained dogs. In one article, a women’s dog kept sniffing at the same spot on her leg until she sought out medical advice for this spot. The diagnosis was melanoma. Subsequently, lab researchers have begun investigating whether various cancers have an identifiable smell, and if so, if dogs’ sniffing abilities could be used to identify these diseases. If successful, such dogs could be transformed into diagnostic technologies—a new kind of working dog.
For example, one lab trained and evaluated dogs’ abilities to sniff out melanomas, while another lab examined whether trained dogs could identify bladder cancer by smelling urine samples. Yet another study looked at whether trained dogs could signal lung cancer by sniffing a person’s breath. The use of diagnostic dogs to identify cancers is clearly unusual and the research is still marginal and small in scale.
Q. As I mentioned in a previous post of mine, your book Magnetic Appeal does, in reality, what some science fiction books do fictively: It explores a new technology and how it works its way into society, in this case MRI as a medical technology.
A. One thing I personally really love about the research is how following this technology serves a double purpose. On the one hand, it gave me an understanding of medicine and doctors. By following a single technology in medicine, MRI, I get to travel through the worlds of MRI production, interpretation, and use. In that case, I learn, in a complex way, about the people who use the technology in a day to day basis.
And on the other hand, I learn about the technology itself, how it’s used, what it can and can’t do, how it has changed, and how it fits in with other medical diagnosis machines. In this way, I get to explore the cultural, political, and economic dimensions of technologies, which is, as you say, like what science fiction explores.
Q. What is the idea behind doing research of this kind? Is it to explore the culture of doctors and hospitals or the technology itself?
A. In this project, I started with two questions: First, how is medical imaging talked about in the popular press? And, second, how does this view compare to how doctors use MRI in clinical practice?
In the latter half of the 1990s, I noticed that MRI and other imaging technologies were making their way onto magazine covers and into newspaper articles, and they were often talked about as these amazing technologies that will find and cure disease. MRI in particular was held up as a gold standard technology. U.S. journalists and policymakers would, for example, point to the fewer number of machines in Canada, as a way to critique the Canadian single payer health care system.
I was fascinated by these stories and claims, and wondered (a) how common they were (in media stories) and (b) how media stories about MRI would compare with healthcare professionals’ views of the technology. The topic was rich and the research expanded into an analysis of the role of visual information in medicine, and changing work environments in clinical care.
Q. This is an aside, but can I say that I always laugh now when I see House and they use an MRI machine on the show. The doctors themselves conduct the scans and read them that moment right off the computer! Any comment?
A. There are many fantasies portrayed in House (e.g., the idea that a team of doctors can focus on and discuss only your case for days!). In the case of MRI, its astounding how Dr. House and his colleagues create MRI scans and interpret them as part of their diagnostic workups. This portrayal is far from how actual MRI units work.
In the U.S., referring physicians don’t run MRI machines (in fact there are laws against self referral!). Instead, technologists (i.e., professionals who work with the patient and MRI machine to create scans) and radiologists (i.e., medical doctors who specialize in the interpretation of medical images) are the medical professions that primarily do this labor. I am surprised that the technologists and radiologists’ professional organizations don’t challenge their utter erasure from House and other medical shows.
Q. Let’s talk a little about what your book covers. You open with a introductory chapter laying out background so that the reader is set up for what’s to come. I think it’s very interesting to see what kind of background information you chose, it reveals a lot about the book itself. What, then, is covered before you get into the heart of the material?
A. You’re right. I tried hard to give context and set up the topics covered in the book. The opening chapter, then, after a short intro, takes a brief look at the following subjects:
* the booming use of MRI in the US and how this use compares to MRI use in other countries;
* the growth of visualization technologies in general (because MRI, from a sociological point of view, is related even to the growth of visual technologies such as video, TV, etc and also related to more narrowly used medical visual technologies);
* a brief description of how MRI technology works;
* a discussion of technologists (who conduct the scans) and physicians;
* a bit reminding readers that MRI must be looked at within the economic context: the companies that make the machines and related products (GE, Siemens, and Hitachi are three), direct and indirect forms of advertising, government investment in new MRI applications, and health care reimbursement systems.
Q. Great, I think that list helps readers of this interview with context too. Okay, now, briefly—and I know that’s hard when your book is packed with information—can you describe the heart of the material covered in Magnetic Appeal?
A. I’ll do my best. First, I examine the development of the technology. I interviewed some of the scientists involved in the invention of MRI scanners. Paul Lauterbur and Peter Mansfield were recently awarded the Nobel Prize for that work. Of particular interest to me was the way the technology moved away from output in numbers toward output as images, and the roles individual creativity, professional training, and cultural contexts played in this transformation.
Then I delve into the actual creation of MRI exams: how scans are taken and by whom, the issues involved with reading the scans, the clinical exam that usually precedes a scan—scans are taken and read in the context of a medical history.
A sociologist such as myself understands an MRI scan as the creation of people, even the machine and its design, its parameters, these are all the product of people and are shaped by institutional practices and policies. This is something I think science fiction readers and writers understand implicitly. Science happens in a human context, and even the most advanced machines don’t operate outside of culture. Machines are built, sold, and operated, and what they produce depends especially on the designers and operators of the machine.
A simple tool like an axe, we all understand that it cuts according to the hand that wields it. It doesn’t jump up and cut on its own. And the cut it makes depends on the person holding it and how it was built. Advanced technology is arguably even more dependent on the people who design and use it.
That’s the whole point of the sociology of science. There is no time in this interview to get into the huge variety of factors that affect MRI scans. One thing of particular interest to me in my research was how much people’s understanding of the accuracy of an MRI scan depends on the fact that the end result of an MRI exam is presented as an image of the inner body produced by a high tech machine. The combination of tech with the idea that “seeing is believing” help creates the idea that the end result must then be accurate.
Of course, MRI is an incredibly valuable medical technique. But looking at the human dimensions of the technology and the realities of scan production can help consumers/patients/medical professionals/policy makers understand better the process and questions to ask. If people assume that the scans are transparent windows into the body, they may not ask critical questions about the quality of production or interpretation.
Q. Your book covers even more ground than this, though.
A. Yes, I also researched the relationship between the physicians and the technologists who actually conduct the scans, and bring out issues such as safety, production schedules, and interactions between the two professions. People don’t tend to think of an assembly line when they think of high medical technology, but there is an assembly line aspect to work in MRI units.
The fee for service payment system we have in the U.S. puts pressure on units to increase the volume of scans done per day. More scans means more money. The units I observed (which were high quality units known for exceptionally good work) were under pressure to speed up production, and this has costs for both patients and healthcare workers.
After looking at life in MRI units, I expand the lens back out to look at the political economy of medical imaging. Obviously, exploring the economics and politics of MRI scans is critical to my research. The pay-per-scan system we have in the US, so that more scans per day means more money for scanning centers and MRI units in hospitals, the sale of peripherals such as coils, coolant, and contrast (there is a lot of money in peripherals), indirect and direct forms of advertising, and concerns about malpractice are crucial. Exploring these issues is a must if one wants to understand the patterns of MRI use in the context of U.S. society.
More recently, I investigated the role government research funding plays in the development of new MRI applications. This piece will be published in the edited volume Biomedicalization: Technoscience, Health and Illness in the United States (2010, Duke University Press).
Keith McGowan (the interviewer) here: Those interested in Kelly’s work can look at her William & Mary homepage (with cv) here and her book on MRI use in the United States, Magnetic Appeal: MRI and the Myth of Transparency, here.
From a couple of reviews of Kelly’s recent book:
Canadian Review of Sociology: “…thoroughly researched book about magnetic resonance imaging (MRI)... The book will certainly appeal to sociologists interested in science, medicine, and processes of biomedicalization... given its breadth, it will also appeal to sociologists in a variety of subspecialties. Sociologists of work will be interested in Joyce’s analysis of the hierarchies and assembly-line production found in MRI clinics. Political economists will appreciate Joyce’s description of the relationship between the biomedical industry and the astounding growth in MRI use.”
Registered Nurse: “Magnetic Appeal is a fascinating and superbly researched book... Relying on fieldwork at imaging sites, conferences, and interviews with medical professionals, Joyce focuses on how radiologists, referring physicians and technologists make sense of anatomical scans in clinical practice. We come to understand how the U.S. desire for scans reflects anxieties about the quality of healthcare, physician skills... The reader is drawn into the pressure-cooker of imaging units, where radiologists and technologists are under constant demand to accelerate their work practices.”
Keith McGowan is the debut author of The Witch’s Guide to Cooking with Children, which was named an “inspired recommendation for children” by independent bookstores nationwide. He is published by Christy Ottaviano Books, Henry Holt & Company.
Kelly Joyce is a program director at the National Science Foundation and an associate professor of sociology who studies technology, medicine, and science at The College of William & Mary. Her book Magnetic Appeal: MRI and the Myth of Transparency is published by Cornell University Press.