Pain’s Records: An Anthropological Account of Medical Documentation in South Asia

The Institute for Pain Management in Kolkata, like other modern institutions, is organised by record keeping. But the central object of its records, pain, presents a fundamental challenge to documentation. Pain is marked by a non-relational attribute that limits attempts to communicate and express it. In her seminal work, Elaine Scarry

Elaine Scarry: The Body in Pain. The Making and Unmaking of the World, Oxford 1985.

In medical discourse, pain remains a highly ambiguous condition despite being one of the most commonly reported complaints in the clinic. Pain has been at the heart of a number of medical debates such as its status as an ›object‹,

Jane Scott / Edmund C. Huskisson: Graphic Representation of Pain, in: Pain 2 (1976), pp. 175–184; Ronald Melzack: The McGill Pain Questionnaire. Major Properties and Scoring Methods, in: Pain 1 (1975), pp. 277–299; Ronald Melzack / Warren S. Torgerson: On the Language of Pain, in: Anaesthesiology 34 (1971), pp. 50–59; Henry K. Beecher: Measurement of Subjective Response, New York 1959; Henry K. Beecher: Experimental Pharmacology and the Measurement of the Subjective Response, in: Science 116 (1952), pp. 157–162; Arthur S. Keats / Henry K. Beecher / Frederick C. Mosteller: Measurement of Pathological Pain in Distinction to Experimental Pain, in: Journal of Applied Physiology 3/1 (1950), pp. 35–44.

Ethnographic fieldwork at Institute for Pain Management (or the Institute) in Kolkata drew my attention to a proliferation of medical records in clinical production and management of pain. Social studies of medical practice have extensively explored both the role of documentation and decision-making in the face of multiplicity.

Ramah McKay: Documentary Disorders. Managing Medical Multiplicity in Maputo, Mozambique, in: American Ethnologist 39/3 (2012), pp. 545–561; Alice Street: Artefacts of Not-Knowing. The Medical Record, the Diagnosis and the Production of Uncertainty in Papua New Guinean Biomedicine, in: Social Studies of Science 41/6 (2011), pp. 815–834; Mol: The Body Multiple; Marc Berg / Geoffrey Bowker: The Multiple Bodies of the Medical Record. Toward a Sociology of an Artifact, in: The Sociological Quarterly 38/3 (1997), pp. 513–537; Loma A. Rhodes: Emptying Beds. The Work of an Emergency Psychiatric Units, Berkeley 1991.

Six months into my fieldwork I visited Manoj Singh’s home. Manoj Singh is a chronic pain patient who has been seeking medical assistance at the Institute since 2011. He first visited for chronic low back pain but recently has started suffering from pain in his neck and radiating pains in his left arm. He lived in a jute mill township which was mostly deserted on the day of my visit due to an ongoing strike. His wife, Shakti, welcomed me as I entered their home and immediately sent Manoj to get some milk so she could make tea. Before leaving the home, Manoj walked inside and took his hanging shirt from a peg on the wall. He rushed past us while still buttoning his shirt. Hanging on the peg behind him was a polythene bag labelled »Mars Scan Centre«. When I asked Shakti about the bag, she explained that it contains all his »treatment« documents,

By treatment documents, she is referring to his ongoing and future medical treatment. In other words, it contains documents from his medical therapeutic journey.

Manoj and Shakti were routine visitors of the Out Patient Department (OPD), a weekly clinic where physicians in the Institute attend chronic pain patients. Only people who are insured with West Bengal’s Ministry of Labour run insurance scheme are permitted to seek medical help at this centre. There are no consultation or treatment fees involved and all diagnostic and therapeutic procedures are conducted free of cost. Enrolment in this insurance scheme is at a nominal monthly fee which is split between the labourer/employee and employer. Only labour force members who are part of the organised sector are eligible for the scheme. India’s organised sector comprises a very small part of its total labour force.

Various research studies and government reports estimate the organised sector to be between 6% and 15% of the total labour force.

In the waiting room of the clinic of this Institute (OPD), we find as many polythene bags of documents as waiting patients like Manoj Singh and his Mars Scan Centre bag. These bags, like files of bureaucratic offices, grow over time, as each visit generates a documentary record. The documents are produced quickly and efficiently as the physicians in the Institute attend between 150 and 200 patients each Tuesday. Many encounters are brief, not longer than 5 minutes, and end with short notes. For others, such as patients in acute pain episodes, physicians write that they be admitted and plan surgical ›interventions‹ – pharmacological or surgical administrations. For chronic pain sufferers, physicians prescribe refills and issue instructions for reviews. For first-time visitors, interactions can last 10–15 minutes and an entire OPD slip may be filled up. Every patient leaves the clinic with an OPD slip, a record prepared by the physician, with a time stamp and an account of the patient’s ›current‹ status. These OPD slips may advise further investigations, report key information and developments from previous examinations and list therapeutic courses of action. The formation of one such OPD slip for Manoj Singh is described in the section Crafting Pain’s OPD Slips of this paper. This record embeds people like Manoj Singh as chronic pain patients in Kolkata’s medical networks (Fig. 2). It leads to the crafting of even more evidentiary documents and records such as X-rays, magnetic resonance imaging (MRI) scans and blood tests. As a prescription slip, it grants Manoj Singh free access to his medication. And, it expedites future clinical reviews by providing a base for gauging improvements and deteriorations in his health.

Apart from this record (OPD slip), situated within polythene bags, are written and typed documents of doctors’ notes (referral and discharge slips), haematological and biochemical graphs, X-rays and scan images and also, bills, receipts, insurance documents, claim slips and letters. These artefacts

I use the term ›artefacts‹ in its scientific context as something observed in a scientific investigation or experiment that is not naturally present but occurs as a result of a preparative or investigative procedure. For example, »the curvature of the surface is an artefact of the wide angle view«. Or, at The Institute, »pain is located within a medical grid of habitats, and shifts in bodily dispositions«.

Matthew Hull’s »graphic artefacts« and Elaine Scarry’s »artifact« are specific deployments of the word and I am not using these in the same sense though there are obvious overlaps and resonances given that one is writing about a semiotics of objects crafted through inscriptive practices in bureaucratic regimes, and the latter is discussing the central role pain plays in the making of objects and bodily substantiation that underlies production of all artefacts including scriptures (inscriptions). Both are important influences in the writing of this paper.

All of these lie together in a disorderly state. They are thrown into the bag and pulled out as and when required. These are not maintained as per medical, legal or bureaucratic protocols, but as records of encounters and meetings between Manoj and the medical regime during the course of his treatment. Since many of these documents are incomprehensible to a lay person and are mostly in English, an unfamiliar language for Manoj Singh, they are only stored, not classified or understood. As Shakti said, »We find everything in one place«. Any fragment, any remnant of his pain treatment is carefully stored within this bag. Over time, these bags emerge as another ›habitat of his pain‹, as an assemblage of his medical artefacts. It is a space where accounts of his pain live. These records guide movements within the medical regime and their interactions constitute him as a patient.

Like his phenomenological experience of chronic pain which results in a fragmentation of narrative, temporal coherence and an experiential self, these bags are also indicative of a »struggling along«.

Desjarlais: Shelter Blues.

When a patient is admitted, his records are taken out of polythene bags and ordered as per the medical regime’s bureaucratic logic. As the polythene bag enters the ward spaces in this Institute, it fragments into its constituent elements. An administrative officer may ask for Manoj Singh’s insurance card, a finance officer for his medication bills and a physician for his earlier OPD slips or investigation reports. Once he is admitted, a new temporality and material home for both – himself and his medical records – emerges. A hospital admission document grants him a new location: a bed; his polythene bag moves under his pillow or on a peg by the wall or on his bedpost (Fig. 1).

Figure 1

Figure 2

Some documents from the polythene bag find themselves in another institutional location: in a medical file, ›Bed Head Ticket‹ (BHT) or simply ›ticket‹ as it is referred to at the Institute.

The exact word that is used in Kolkata is a »Khata«, a word which is closer in meaning to an account book, a ledger or register rather than a file. It is an apt name since the BHT records within itself all the transactions that occur between the body, its disease and medicine’s diagnostic and therapeutic attempts. It is an account of every shift in the body.

The ›BHT‹ is in sync with a patient through two locations: the institutional location which is the bed in the hospital and the personal location: his/her body (head). This unity, of the bed, head and ticket (BHT), makes it possible to refer to the patient, file and bed by the same number such that when admitted in December 2015, Manoj Singh was simultaneously patient number 23, recorded under file number 23 and placed on bed number 23. This made it possible to refer to him and all matters related to him simply as »23«. Number 23 is a role that may be occupied by other chronic pain patients seeking medical assistance but can be occupied by only one person at a time. Its distinctive feature is that like the polythene bag, the ›BHT‹ is an individual’s and does not speak for more than one ailing body even as it may record multiple ailments. Documents in the ›BHT‹ are ordered temporally with the most recent document placed right on top and the first admission document placed at the bottom. Predominantly, the ›BHT‹ comprises of doctor’s notes about a patient’s ongoing therapeutics, his improvements and changing symptoms. The final note in the ›BHT‹ that terminates its existence and moves both Manoj Singh and his documentary collections out of the hospital’s ward space is the ›discharge note‹ written by a doctor. Once a patient is discharged, the ›BHT‹ disaggregates into records that remain in the hospital’s record rooms and in patient’s records that are carried around in polythene bags. However, the ›BHT‹ may still be called upon. Through the force of law or institutional inquiry, these disaggregated records may be brought together once more to operate as medico-legal accounts. For example, these are called upon and cited at Disability Board meetings to ascertain the ›degree of disability‹ and to decide compensation amounts (disability payments). They are also used for passing administrative judgement on workplace injuries and damages, and as evidence in legal disputes, both against workplace exploitation and medical malpractice.

Berg / Bowker: The Multiple Bodies. For more on documentary productions in bureaucratic and legal worlds, refer to Ilana Feldman: Governing Gaza. Bureaucracy, Authority, and the Work of Rule, 1917–1967, Durham 2008; Akhil Gupta: Red Tape. Bureaucracy, Structural Violence and Poverty in India, Durham 2012; Matthew S. Hull: Ruled by Records. The Expropriation of Land and the Misappropriation of Lists in Islamabad, in: American Ethnologist 35/4 (2008), pp. 501–518; Matthew S. Hull: The File. Agency, Authority and Autography in a Pakistan Bureaucracy, in: Language and Communication 23 (2003), pp. 287–314; McKay: Documentary Disorders; Annelise Riles: Documents. Artifacts of Modern Knowledge, Ann Arbor 2006: Cornelia Vismann: Files. Law and Media Technologies (transl. by Geoffrey Winthrop-Young), Stanford 2008; Max Weber: Economy and Society. An Outline of Interpretive Sociology, New York 1968. On medical documentation and its intersections with law, Lorna Rhodes provides an ethnographic account of subversive practices adopted by medical experts in their daily work; Lorna A. Rhodes: Emptying Beds. The Work of an Emergency Psychiatric Units, Berkeley 1991.

Polythene bags, on the other hand, punctuate everyday lives with pain and are mobile repositories (record rooms) of interactions with administrative, medical and legal powers of the state as these accompany patient bodies. Polythene bags circulate among their homes, public transport, administrative and medical offices, hospitals and factories. While a record of each encounter is stored in the polythene bag which enframes a person as a chronic pain patient, we observe an excess of pain that cannot be neatly settled into any one diagnostic or medical artefact. Pain does not remain limited to any one habitat and comes to punctuate the life-world of a person in pain.

The term »world« is used here in its phenomenological meaning. Edmund Husserl describes »life-world« as the world of our common, immediate, lived experiences. It is also the world of our everyday lives in which we act ›through‹ our bodies. Edmund Husserl: The Crisis of European Sciences and Transcendental Phenomenology, Evanston 1954.

On November 30, Manoj Singh visited his panel doctor seeking medical assistance for pain in his neck and arms. Panel doctors are general physicians of the insurance network who address common ailments but also have the power to suggest hospital admission and specialist attention. Due to large patient volume, the role of panel doctors has shifted to referring patients along. Their clinics have transformed into referral centres. With his referral form, Manoj Singh reached the Institute on December 1.

This section describes how dispersed expressions of his pain were recorded to frame it as a medical object. The section dwells in a physical examination of Manoj Singh conducted by Dr. Pia who observes behaviours and bodily movements, grants them clinical significance and records these as evidence. Bodily conversations of pain gestures

Joanna Bourke’s essay on gestures explores these non-verbal expressions of pain in detail. She writes of the body as a »semiotic instrument«, of pain’s gestures as expressions of pain, as performances and as a »component of communication«. They may »›punctuate‹ speech, but they also complement, enhance, replace or serve as alternatives to speech«. Joanna Bourke: The Story of Pain. From Prayer to Painkillers, New York 2014, pp. 159–192, at p. 160.

Such ways of being constitute embodied knowledge, »something that one is«.

Ibid., p. 74.

Below I present an account of Manoj Singh’s visit to the weekly clinic and the making of an OPD slip: On 1 December 2015, patients began arriving at 7 a.m., 3 hours before the clinic of this Institute opens. Each one of them deposited a referral form from his respective panel doctor or an OPD slip from an earlier visit in the ›pain box‹, a cardboard box placed outside the emergency room of the hospital for the patients in this Institute. Today, Manoj Singh is assigned the position of patient number 78, which is quickly scribbled on his referral form by the clinic administrator. At 3 p.m., Dr. Pia calls out, »78!«, as his form has found its way into her allotted set of documents and thus, patients. Shakti and he walk over. He moves a little stiffly, rarely turning his neck and instead shifting his torso to face someone or shift his orientation. Over a 15 minute interaction, Manoj Singh answers and Dr. Pia takes notes, occasionally looking up at him while Shakti stands on his right, holding a polythene bag of documents.

Dr. Pia: »What is the problem?«

Manoj Singh responds while holding his left arm: »We’ve been here earlier. I had pain in my back. Now, neck and arm are giving me trouble«.

Dr. Pia writes down, »cervical pain. Lf sided. Radiculopathy (Left hand)« and examines him. She stands up, holds his head and rotates it from side to side. She stops when she either sees him wincing or hears him cry out. Under one such movement, Manoj Singh jerks forward and holds the edge of the table. She stops. Next, she tilts his head backwards, then to the left and using the palm of her hand presses downwards. He winces. She repeats, tilts his neck backwards and to the right. He sits unaffected. She sits back down and writes, »Increases with cervical joint movement (Range of Motion test). Increases with sitting«.

She enquires about the durational history of his pain and about any accident or injury that he may have suffered in the past. He describes how the pain had slowly begun 2 years ago and then started interfering with his ability to work and to move around. »When I go to buy vegetables, I can’t carry the load«.

I was struck by Manoj Singh’s complaint: he did not talk about difficulties at work as other patients did nor about pain as an ailment but about the difficulties it introduces in completing tasks at home. Since his jute mill has been closed for over a year, the limits pain has introduced in his familial obligations and everyday responsibilities have brought him to the Institute seeking therapy.

She asks if he has received any treatment for pain. He mentions his lower back pain history. She writes it down and asks for his documents from that hospital admission. Shakti reaches into the polythene bag and pulls a few documents out. She hands them over and Dr. Pia searches for the ones she needs. »How is your back pain now?«, Dr. Pia asks glancing through the discharge slip from his last hospital admission. She notes a cervical procedure that was performed 2 years ago but is uncertain of the exact intervention. Before she can dwell on this, Shakti replies, »He’s much better now. After getting treated from doctors at this institute, he’s not had any trouble. Because of this, we asked the panel doctor to refer us to you«.

Writing about his earlier treatment, Dr. Pia instructs Manoj Singh to stand up, place his hands on his waist and bend forwards and then backwards. He resists moving forward. He winces when she tries to force him. She writes, »Increases on bending forward«.

She asks if he has been subjected to any medical investigations such as imaging tests, »Have you got any photographs of your neck?«

Photograph is the word commonly used for X-ray, CT and MRI scan images since these are printed and carried on photographic film.

Manoj: »No madam«

She replies, »You’ll have to get a photograph. Get a photograph and come back to us, then we’ll see«.

Next, she guides him to the corner of the room where the physical examination table is placed. She tells him to, »Lie down«. She asks him to turn over and lie on his stomach. She asks him, »Where does it hurt?« as she touches and presses with her fingers various parts of his lower back, hips and buttocks. He tells her it is hurting in the entire lower back. She also checks for muscle tenderness, muscles that give way more easily than others and offer lesser resistance in comparison with those around it and for any lumps or trigger points that may exist in the muscle.

A Trigger Point is a hyperirritable spot, a palpable nodule in the taut bands of the skeletal muscles’ fascia. Direct compression or muscle contraction can elicit jump sign, local tenderness, local twitch response and referred pain which usually responds with a pain pattern distant from the spot. For more information, see: https://www.physio-pedia.com/Trigger_Points (17. 10. 2019)

Figure 3

Inherent in a record like the OPD slip are future acts of medical documentation. After the OPD slip, Manoj Singh is scanned at a private diagnostic centre that produces a MRI scan and report. As he visits the clinic with this new report, he meets with another pain physician – Dr. Bijoy. This meeting results in a second OPD slip that refers him to more physiological testing. As medicine tries to record various facets of his pain experience, multiple medical documents are produced (Fig. 4).

Figure 4

These are recordings from different medical sites but each presents a facet of his pain. As evidentiary documents produced by multiple experts, these are translations from a body in pain to records of pain. Each new document is added to his polythene bag. In these papers, we witness the formation of a ›file-self‹, a concept proposed by Roma Chatterji in her paper, »An Ethnography of Dementia«, which she describes as a discursive object that emerges in the clinic between what is written and in expert discussions around such writings.

Chatterji: An Ethnography of Dementia.

Despite regular contact with the medical regime and production of multiple documents recording Manoj Singh’s pain and prescribing therapeutics, his pain worsens. On December 26, he is admitted at the Institute which is accompanied by the allocation of a ›BHT 23‹ and a hospital bed (Number 23). His current medical records starting with Dr. Pia’s OPD slip and up until his admission advice by Dr. Bijoy shift to the BHT. New documents continue to be added to this BHT: blood report on December 27, biochemistry report on December 27, a haematology report on December 29 and an Electromagnetic Nerve Conduction report on December 30. As medical work aligns these documents with manifestations in a body and life, a unity is produced between pain’s inscriptions in the documents and its inscriptions in the body. The work of medical writing is to produce and perpetuate this unity between Head (body) and Ticket (medical artefact). During Manoj Singh’s hospital admission, medical records are stored in ›BHTs‹ and upon discharge in polythene bags. These records include haematological, biochemical, neural and biophysiological accounts of him with multiple diagnostic interpretations and therapeutic prescriptions. This interpretive multiplicity lies at the heart of his prolonged contact with the medical regime and a lack of improvement of his pain as until January 11 Manoj Singh did not undergo any specialised pain management procedure or intervention and was only being treated with a routine course of pain medications.

The routine course of pain medicines at the Institute comprises of paracetamol (NSAID), gabapentin (anticonvulsant medication) and amitryptyline (medication for mood and anxiety disorders). In exceptional circumstances, tramadol (opioid) may also be prescribed.

Figure 5

Irrespective of the diagnosis the physicians settle upon and the disease category they enact, it is evident from this documentary proliferation and anxious diagnostic search that pain is apprehended only in a fragmented form in each document. This multiplicity captures different possibilities of Manoj Singh’s neck aches as pain is enacted differently in each documentary formation. Annemarie Mol recognises multiplicity as a fundamental feature of medical practice in which coordination occurs by contrasting and combining various evidentiary productions.

Mol: The Body Multiple.

As we entered the neurosurgeon’s clinic on January 8, we found two neurosurgeons sitting on either side of a large desk. The surgeon across the table was already seeing a patient. When the neurosurgeon on our side of the table was ready for us, he held out his hand without looking at any of us. Manoj Singh gave him the ›referral letter‹ Dr. Pia wrote for him, an introductory letter for her patient (presented below).

To,

The Medical Officer Specialist

M. Hospital

(Through proper channel)    Date – 7/1/16

Sir/Madam,

This 49 yrs old male patient presented with Left sided neck pain with Radiation to left hand along with Left arm movement restriction. Got Admitted in the Institute.

On examination (O/E),

Left upper limb

– Deltoid weakness

– Range of Motion of Shoulder joint – restricted (all)

– Tenderness over left upper trapezius muscle

Investigations:

NCV – Normal amplitude, conduction velocities of median and ulnar nerve

EMG – Denervation pattern MUPs over left deltoid Biceps & supraspinatus muscles at sub maximal volitions.

MRI of Cervical Spine:

– C6–C7 paracentral disc (Left) protrusion

– Central canal stenosis

– C4–5 and C5–6 level disc bulge

– Cervical spondylosis with disc degeneration

Kindly give your valuable opinion whether pt. needs further surgical interventions & do the needful.

Patient Particulars  Yours faithfully,

Manoj Singh/49 years Pia M, General Medical Officer, The Institute

The neurosurgeon glanced through the letter and asked, »Photo?«. Shakti handed him the MRI scan. The neurosurgeon looked at the scan and fairly quickly remarked, »There will be a surgery. Come next Friday. Bring someone from the family. It’ll take about 3–4 days« However, before he could finish, Manoj Singh said, »I don’t want a surgery«.

With a short acknowledgement, »Hmm!«, the physician quickly prescribed some medicines on the Neurosurgery OPD slip and handed the document to Manoj Singh before another word could be said. We were ushered out of the door by his attendant. We were there for less than 2 minutes and he had not once looked up at any of us.

Since the referral letter was written 6 weeks into Manoj Singh’s time at the Institute, it contained far more information as a medical document than the first OPD slip discussed in the paper. The referral letter is a collectivised, though fragmented, account of medicine’s efforts at apprehending pain. We encounter a ›file-self‹ which is a list of physiological signs of pain and its medically produced evidence. As a collection of inscribed statements, it demonstrates the trials and tribulations Manoj Singh has undergone in his search for treatment. It is a habitat of his pain in a double sense. It contains various artefacts produced over the course of his struggle with pain (pain records). Second, it lists various evidentiary translations from his body to documents of pain (signs of pain). And it appears this act of translation has reached an end. On the one hand, the Neurosurgeon does not feel the need to examine or even glance at Manoj Singh for making as important a therapeutic decision as surgery. He finds sufficient information in the referral letter to understand his case. On the other hand, the same document is a result of an impasse at the Institute. It has been inscribed because of an ever-increasing multiplicity that can no longer be coordinated, and which impeded therapeutic decision-making. The referral letter to neurosurgery department is an attempt towards a therapeutic solution. It has moved Manoj Singh’s case from pain physicians at the Institute to Neurosurgery department at Hospital M. It is hoped that this transfer to a new medical site can propel the production of new knowledge in his case.

While mirroring the transportability of a scientific document, medical documents are peculiar.

Bruno Latour: Pandora’s Hope. Essays on the Reality of Science Studies, Cambridge 1999, pp. 24–79.

As his pain reduced in the last few days of his hospital admission, Manoj Singh along with other patients wrote a letter. This letter, addressed to the Hospital Superintendent, was a letter of appreciation for the physicians in the Institute. In particular, they credited the doctors in this Institute for »understanding their pain« and for continuing to provide therapeutic assistance in the face of a disease that plagues them. This letter was the only documentary record produced during his hospital admission which did not record him as a bodily fragment in the institution and is not an account of his subjection to a bureaucratic or medical force. Instead, produced after a successful therapeutics, it is the reverse. As its author, it expresses his gratitude not as a disaggregated and dispersed subject but one with a unified voice. This return of voice from medical records to a letter could only be possible due to a successful therapeutics. As a chronic pain patient, Manoj Singh knew that his pain will return and he will be seeking medical assistance soon but he wanted to »place on record« his appreciation.

Manoj Singh underwent two more periods of admission during my fieldwork – in March and August 2016 – and visited the OPD clinic every 2 weeks for his reviews and refills.