As students of medicine, we become familiar with the proper course of questioning that leads us to identify a patient’s problem. We take for granted a traditional paradigm of questioning, asking: “What brings you into clinic today?” and “Where does it hurt?” What we do not realize is that this conditioning is the result of a great epistemological leap taken after the French Revolution, which shaped the face of modern-day medicine.
The French Revolution demanded a re-examination of our basic human rights, and invited insight into the causes and effects of our health. Before the French Revolution, physicians were the personal aides to particular members of the aristocracy. At the beginning of the 19th century, physicians began taking a greater responsibility for the health of their whole community. Through post-Revolutionary health reforms, physicians were subjected to the radical dream of an open practice and uninhibited science. Clinics were formed for the general populace, and forever changed medical science.
Around the same time, physicians were also starting to distance themselves from superstitious, anecdotal descriptions of what ailed their patients. Instead, they were turning increasingly towards the Enlightenment idea of empiricism — the practice of relying on the observation of physical phenomena to develop general principles of how the human body worked. For example, rather than dwell on fanciful cosmic explanations for fever, these new, modern physicians were more inclined to carefully inspect the patient and their surroundings for immediate and discernible causes of afflictions. These modern empirical observations revealed how little the physicians of the time knew, and gradually eroded the ancient perception of the doctor-as-sage.
One of the greatest historians and philosophers of science, Michel Foucault coined an innovative idea to describe this new kind of medicine in his seminal work The Birth of the Clinic: the medical gaze. The medical gaze is a novel way of seeing that involves the physician in a “double system of observation” — one that discovers the disease process and “circumscribes its natural truth.” Under the medical gaze, a person’s “constitution” — the structural body and its functional idiosyncrasies — is a conglomeration that can be traversed by a physician aware of an array of telling signs. The gaze asserts a cognitive relativity, such that the facts about the body are dependent upon the physician’s medical gaze — his sensations, perceptions, experiences, etc. Though subjective by definition, the medical gaze also offers the physician his understanding of the medical knowledge and a foundation for his judgments, so that his knowledge and observation of the body may be made useful.
The medical gaze is what a physician does from the instant he (or she) meets a patient. He observes the patient’s body firstly through conversation, observation and the physical exam, and nowadays draws further inferences by ordering lab tests or imaging. He inquires about the patient’s history, trying to determine the events that could have caused their current condition. He applies the knowledge he learned in his training to help determine what of this particular patient’s circumstances could have caused this particular disease. In Foucault’s terms, the physician’s medical gaze is the observation of physical phenomena pertinent to a person’s medical care, but also supplies the stable structure of medical science to help a physician understand the “positive accumulation” of gradual, changing speculations that occur when encountering a new patient or disease.
The medical gaze — coupled to the radical proposition of surgically opening the body, which also regained prominence during these post-Revolutionary times — created a lens that transformed the meaning of medicine. Previously untouchable, an alleged design of supernatural creation, the human body was now open to discussion, dissection and even doubt. Using the medical gaze, the physician is no longer just reading the impersonal notes of bound-worn literature (as he was once believed to do), but reading the body as it lies before him: fraught with variability, full of possibility, yet fragile with individuality.
Under the medical gaze, the invisible forces of physiology and pathology become visible and rampant, circumscribed within the growing understanding of an advancing medical science. The gaze contemplates and questions what it sees in the corporeal space of symptoms and physical signs. Then, “plunging from the manifest to the hidden,” it draws on the collective structure of medical experience to “see” what occurs on the level of human tissue. The medical gaze organizes the structure of the body into an essential network, which for doctors becomes our physiological understanding of the human body. Ultimately, the abstraction of the medical gaze gives solidity to the abstruseness of the body, and bridges what was once an unbalanced dynamic of power between the physician and the patient.
Furthermore, as the physician’s observations change the gaze, so through this knowledge does the gaze also change the physician. Using the medical gaze, doctors began to systematically describe diseases, and develop esoteric medical terminology (some of which we still use) to classify and compare these diseases. This terminology allowed the modern physicians to communicate with their colleagues about what they encountered in the clinic. This language created an objectivity that allowed doctors to better see past the veil of appearance and tackle the intrinsic mysteries of the living and the dead.
Medical language revitalized the field of medicine, but also accelerated the specialization of the field. Through this understanding, physicians were able to do more for their patients, who now encompassed a greater part of the population. The power of the physician, however, now lay in experience rather than status. The success of medical practice hinged on the clinical performance of the gaze, which lent to medicine its scientific credence. The contemporary, regenerated medical language, refined by the medical gaze, also protected the experience and power of the new physician.
The medical gaze might have been developed by Foucault to understand how the French Revolution changed science, but it is still very much in use in clinics today. Despite modern imaging techniques, a physician’s perception and application of scientific knowledge is still what is necessary to interpret that imaging with its clinical findings, in order to make an accurate diagnosis and deliver proper treatment. The clinician’s gaze is the strongest symbol of the profession, yielding the results of unseen phenomena. The gaze mediates the observation of the patient to the cognition of the doctor to understand the external and internal manifestations of disease. On an existential level, the gaze corroborates existence in a humanistic fashion never accorded to the ancient physician.
As students, it is imperative that while we affix our eyes to the pages of our atlases, we remain aware of their critical role in assessing the real object of our undertakings. With time, we will refine our gaze to meet the needs of our patients, discovering the depths of disease as we once explored the organs of cadavers. Perhaps taking time to appreciate the history of medicine will allow us to question our own questions, and consider the reasons we pose them to our patients who willingly relinquish their privacy for our professional perusal.