Diagnosis: a critical social reflection in the genomic era

Misophonia matters: A case study of the role of brain imaging in debates over new diagnoses

Misophonia has gained attention in scientific circles that utilise brain imaging to validate diagnoses. The condition is promoted as not merely a symptom of other psychiatric diagnoses but as a discrete clinical entity. We illustrate the social construction of the diagnostic category of misophonia through examining prominent claims in research studies that use brain imaging to substantiate the diagnosis. We show that brain images are insufficient to establish the 'brain basis for misophonia' due to both technical and logical limitations of imaging data. Often misunderstood as providing direct access to the matter of the body, brain images are mediated and manipulated numerical data (Joyce, 2005, Social Studies of Science 35(3), p. 437). Interpretations of brain scans are further shaped by social expectations and attributes considered salient to the data. Causal inferences drawn from these studies are problematic because 'misophonics' are clinically pre-diagnosed before participating. We argue that imaging cannot replace the social process of diagnosis in the case of misophonia, nor validate diagnostic measures or otherwise substantiate the condition. More broadly, we highlight both the cultural authority and inherent limitations of brain imaging in the social construction of contested diagnoses while also illustrating its role in the disaggregation of symptoms into new diagnoses.

The social value of genomic sequencing for disadvantaged families facing rare disease

This study explores parental expectations and value-making processes in respect to pediatric clinical genomic sequencing for socially disadvantaged families. Drawing on interviews and ethnographic observations with parents of children with undiagnosed physical and/or intellectual differences seeking to find whether these differences have a genetic etiology, we explore expectations and parental assessments of the value of genomic sequencing within the context of an ongoing research study. We demonstrate how the value of sequencing to parents goes well beyond finding diagnostic results or receiving prescriptive guidance as to the best care and treatment of their child; instead, value is co-created by parents, clinicians, and genetic counsellors throughout the enrollment and return of results process. Parents in our study found that clinicians and genetic counsellors repeatedly reenforce that parents need to lower their expectations and be prepared to wait for genetic science to provide more definitive answers. At the same time, parents experience that clinical teams validate parents for having made a good choice in their undertaking of genomic sequencing and, no matter the result, that they are not to blame for their child's symptoms. The experience of many parents (although not all) is that genomic science reduces or removes their sense of guilt for their child's condition, providing a platform that affirms them as "good parents." Moreover, rather than being voiceless and isolated, socially disadvantaged parents who enter into diagnostic sequencing find themselves in a familial-biosocial framework wherein they are co-partners in a socially and biologically authoritative vision of the future.

Re-imagining ‘the patient’: Linked lives and lessons from genomic medicine

How ‘the patient’ is imagined has implications for ethical decision-making in clinical practice. Patients are predominantly conceived in an individualised manner as autonomous and independent decision-makers. Fields such as genomic medicine highlight the inadequacies of this conceptualisation as patients are likely to have family members who may be directly affected by the outcome of tests in others. Indeed, professional guidance has increasingly taken a view that genetic information should, at times, be regarded as of relevance to families, rather than individuals. What remains absent from discussions is an understanding of how those living through/with genomic testing articulate, construct, and represent patienthood, and what such understandings might mean for practice, particularly ethical decision-making.

Employing the notion of ‘linked lives’ from lifecourse theory, this article presents findings from a UK-based qualitative longitudinal study following the experiences of those affected by the process and outcomes of genomic testing. The article argues that there is a discord between lived experiences and individualised notions of ‘the patient’ common in conventional bioethics, with participants predominantly locating their own decision-making within the matrix of linked lives in which they are embedded. In the quest to gain ‘answers’, many took an intra or intergenerational view, connecting their own experiences to those of past generations through familial narratives around probable explanations, and/or hopes and expectations for the health of imagined future generations. The article argues that a re-imagining of ‘the patient’, that reflects the complex and shifting nature of patienthood, will be imperative as genomic medicine is mainstreamed.

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How ‘the patient’ is imagined has implications for ethical decision-making.

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Genomic medicine shows the shortcomings of individualised notions of ‘the patient’.

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Instead, a ‘linked lives’ lens highlights the ensembles of relationships affected.

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Participants reported more collective inter/intra-generational views of patienthood.

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Re-imagining patienthood beyond the individual is vital as genomics is mainstreamed.

Enacting Woundedness and Compassionate Care for Recurrent Metastatic Breast Cancer

This analysis integrates Arthur Frank's timeless revelations about woundedness within the communication context of an oncology interview. A Patient whose life is threatened by recurrent metastatic breast cancer claims personal knowledge and visibly demonstrates impacts from illness experiences. Conversation Analysis (CA) was conducted on a video recorded and transcribed case study involving a Patient, her husband, and co-present oncologists. By focusing on narratives as talk-in-interaction, grounded exemplars are provided of primary interactional achievements: How woundedness gets displayed and responded to with empathy and compassionate witnessing; Patient's flooding out with emotion and potential embarrassment; attempting to regain control and resume talking about her condition; and the serial organization of crying and laughter when managing noticeably delicate moments. In this interview, woundedness is not discounted or dismissed but recognized as legitimate suffering meriting shared commiseration. Understanding how to enact humane and communicatively competent skills during emotionally uncertain moments can enhance medical education.

Values, skills, and decision-making: A cultural sociological approach to explaining diagnostic disclosure

This paper provides an analytical framework for explaining the practice of diagnostic disclosure by drawing on theoretical developments regarding the question of "culture in action." Based on ethnographic and interview data collected from fieldwork at a major cancer hospital in China from 2015 to 2019, this paper explains how doctors and family members make decisions about diagnostic disclosure. We argue that it is important to understand the practice of diagnostic disclosure as motivated by the actors' values on the one hand, and constrained and enabled by the actors' skills on the other hand. It is also necessary to distinguish between personal and public values, as well as medical and interpersonal skills. Based on these distinctions, we will be better equipped to explain why diagnostic disclosure has encountered difficulties in family-centered societies, such as China.

Managing “Stable” Cancer News

This study focuses on oncology interviews with returning patients who have been diagnosed with cancer, are undergoing various treatment regimens, and have been informed by doctors of their current “stable” medical condition. Conversation analysis was conducted on 112 video recorded and transcribed oncology interviews involving 30 doctors. In 44 of 112 (39 percent) interviews, doctors announced stable as good cancer news. In response, patients rarely affirm stable as good news for them. Nonreponses and minimal responses lacking enthusiasm occurred in one third of instances, and in the majority of interactions, patients resisted and questioned impacts of the need to endure ongoing treatments yet reduced possibilities for cancer shrinkage or remission. These interactional disjunctures reflect epistemic dilemmas for doctors seeking to provide quality care and especially for patients who must simultaneously manage good and bad news. Findings extend ongoing research and theoretical development that address the social psychological burdens inherent in disappointment, medical diagnosis, and prognosis. A focus on how patients and doctors manage stable cancer reveals recurring tensions between patients’ lay experiences with illness and how doctors give biomedical priority to controlling cancer.

'That thing in his head': Aboriginal and non-Aboriginal Australian caregiver responses to neurodevelopmental disability diagnoses

Little is known about the significance of cultural differences to how caregivers receive a diagnosis of neurodevelopmental disability. As part of a Fetal Alcohol Spectrum Disorder prevalence study among sentenced, detained youth, our qualitative study explored the experiences of diagnostic assessment among detained young people and their caregivers. We present findings from the perspectives of caregivers. In conversation with the sociology of diagnosis literature, we present vignettes of three Aboriginal and two non-Aboriginal caregivers' experiences of the diagnostic assessment process. We found that Aboriginal caregivers conceptualised their children's diagnosis and ongoing management in the context of their family networks and community. In contrast, non-Aboriginal caregivers focused on how the diagnosis would affect their child and interactions with various institutions including healthcare systems and schools. Caregivers' engagement with diagnostic reports and resources also followed cultural lines. Reflections on intergenerational drinking were voiced by Aboriginal caregivers, who expressed shame at receiving diagnosis. These findings advance our appreciation of cultural difference in receiving a diagnosis, the examination of which is in its nascent stages. We also suggest ways to mitigate harm from a stigmatising diagnosis and soften the well-established effects of medical dominance over the process of defining a person's capacity and status.