Resisting and promoting new technologies in clinical practice: the case of telepsychiatry
Introduction
Clinical practice in the twentieth century has been characterized by tremendous shifts towards the development of new technologies and treatment modalities. But rapid bioscientific and technological ‘advances’ in the field of biomedicine seem to be consistently met with contradictory impulses. On one hand, there are demands and expectations for ever more effective medical treatments and interventions; while on the other, there is growing mistrust of the complex of professional and commercial interests that underpins it, and of the potentially iatrogenic form that clinical practices might take (e.g. Elston, (1992), Latimer in press).
It is not surprising, therefore, that a significant sociological literature has now emerged which seeks to critically interrogate clinical science and technology. However, studies of the ‘invention’ and ‘implementation’ of medical science, what Latour calls ‘science in action’ (1987) seem — as Elston, (1997), has observed — to have marginalized the very kinds of practice that are encountered in the everyday world of the clinic. She observes that this is, ‘the world of ready-made textbook science’ and of ‘routinely black-boxed technologies’ (1997, p. 4) where it is not so much the invention or fabrication of a particular scientific or technological knowledge and practice that is at issue, but its pragmatic implementation and enacting. There are a number of key studies that explore disputes and contests in the interpretation of scientific/technological knowledge and its translation into practice (e.g. Collins, Kendall, & Michael, 1998; Prout, 1996), but this paper takes a slightly different tack by exploring the interaction between technologies of psychiatric practice.
In this paper, we are interested in the way that technologies, spoken and unspoken, are defined and contested in everyday health care practice. We focus our attention upon a project intended to demonstrate, in practice, the use of a ‘telepsychiatry’ system permitting videophone interaction between psychiatrists and other mental health professionals, and their patients located in a general practice some miles away. The videophone unit enabled patients referred for psychiatric assessment by their general practitioner to be ‘seen’ and assessed by a duty psychiatrist without their having to make a journey, or wait for an appointment, at the psychiatric outpatients’ clinic. This videophone equipment forms a ‘hard’ technology, literally taking the form of a black box on the psychiatrist's desk and on the patient's table. This ‘hard’ technology is not the only technology that is ‘in play’ in the psychiatric consultations encountered in this study. Bloomfield and Vurdubakis (1994) have observed that when we attend to the material properties of a ‘technology’ there is no concrete boundary between the ‘technical’ and the ‘social’, but rather there are practices of differentiation and demarcation on the basis of agreements (or disagreements) about its properties. They caution against attributing a ‘false solidity’ to the realm of the technical, and argue that,
any account that takes the ‘properties’ of a particular technology as its starting point, is from the beginning caught up in those practices that generate and sustain the objectively given quality of those properties. Hence this type of account will, however reluctantly, tend to reinforce the whole notion of a technology as something that develops, outside, as it were, the social relations upon which it impacts (1994, p. 10)
Bloomfield and Vurdubakis are concerned with developing a set of ideas about how technologies are recognized as such, and locating the boundary between the ‘social’ and the ‘non-social’. In this paper we blur those boundaries: emphasizing that not only is there a ‘thing’ that mediates between clinician and patient, but that there is also a ‘soft’ technology, that is diffuse and almost taken-for-granted in the doctor–patient encounter. This ‘soft’ technology is constituted by the body of knowledge and practice possessed by health professionals around structuring, framing, and enacting their ‘interactions’ with patients. It is formed around the intricately constructed set of interactional techniques and ‘communications skills’ employed by clinicians as they try to know or assess or manage the patient in the medical interview. In this context, Goldberg, Benjamin, and Creed (1994) provide a detailed account of the assessment and diagnostic interview. Their account sets this up as an interaction between the construction and articulation of the ‘history’ of the patient, using specific ‘interview’ techniques and postures, and the application of nosological knowledge to distinguish aspects of the ‘mental state’. It is this set of practices to which we assign the label ‘soft technology’. They are no less a technology by not having a constant material form, but are made so by their generality and reiteration.
Our interest here is in two features of the telepsychiatry system in play. First we are concerned to illuminate the contest between ‘hard’ and ‘soft’ technologies. In particular, between the deployment of material artifacts that mediate human interaction, and ‘soft’ technologies — revealed in the employment of what Foucault (1988) has called, ‘technologies of the self’, the discursive means by which individual subjectivities are constructed and revealed. Second, we are concerned with the ways that ideas about the value of professional–patient interaction as a craft were deployed to frame the new technology in practice and to contest its legitimacy as an intermediary between patient and clinician in community mental health care.
Section snippets
The problem and the promise of telemedicine
At the end of the twentieth century, there are no surprises to be had in video conferencing and in the transmission of sound and vision through analogue or digital relays. These kinds of technologies seem to have become unremarkable components of normal social experience and their ubiquity has become almost unquestionable, even though they are the harbingers of a ‘revolution’ in communications on an epoch making scale (Robins & Webster, 1999). The possibilities that these new technologies
Context, study group and method
The study reported in this paper was undertaken as part of a six month service evaluation of a telepsychiatry demonstration project intended to explore the potential of the videophone as a means of organizing routine psychiatric referrals from general practice to a community mental health team (CMHT). The CMHT included psychiatrists, community psychiatric nurses, and other mental health professionals at a hospital about ten miles away. The two centres (and another general practice which joined
Communications technology and clinical practice
The existing literature on telemedicine has for the most part taken as its primary focus the utility and efficacy of the technology itself, as it is applied to particular clinical problems and settings. This is primarily a clinical literature that is about establishing the safe practice of medicine using a diverse set of communications technologies. This literature itself sub-divides according to clinical specialty, so that there is an emerging body of work describing and championing tele
It's hard to talk: videophone technologies can make communication difficult
Once the system was fully in service it became apparent that the clinicians found it shaped their encounters with patients in ways that they had not anticipated. In particular, they found that it demanded reciprocal adjustments by both psychiatrist and patient about their expectations of the psychiatric interview and their concrete behaviors within it. These adjustments took a number of forms, but a key problem for the psychiatrist was how to present her or himself to the patient in this kind
What is being contested around telepsychiatry?
The interactional difficulties that the psychiatrists experienced could be regarded as matters of presentation, and other professionals recognized impression management as being a crucial part of the therapeutic encounter. Interactional problems could perhaps be resolved by more closely attending to communications skills, and by training both patients and clinicians to deal with frame tension and frozen screens. However, an insurmountable problem for a number of respondents was that the patient
Conclusion: contest, technology and practice
One way to read this paper is to see it as the story of the implementation of a technology that effected a kind of ‘reality shock’ amongst its intended users when they found that it limited, rather than liberated, their clinical practice. Although the whole CMHT initially evinced enthusiasm about the therapeutic potential of this technology, we have seen that over the six months that they had access to the system, they found the videophone increasingly problematic because it was difficult to
Acknowledgements
We wish to thank the health professionals who took part in this study for their time and candour. We are grateful to the NHSE NW Research and Development Directorate for their financial support of this study. Ms. Allison Burgess and Mrs. Denise Mukadam are thanked for their secretarial support of this work. Tracy Williams, Mike Gavin, Maggie Mort and Christine May made helpful comments on various drafts of the manuscript.
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