Innovations in Health and Medicine

Diffusion and Resistance in the Twentieth Century

Jenny Stanton

• Publisher: Taylor & Francis
• Year: 2012
• eBook ISBN: 9781134543656
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

This volume brings together cutting edge research by historians from Britain, Germany, France, the US, Japan and New Zealand. Innovative in its approach to innovation, it focuses on diffusion and resistance, and organization as well as technology.The collection features issues such as control and compliance, professional power and economic constraint, cultural divides, 'configured users' and ingenuity. The introductory essay relates the collection to history and sociology of innovation and technology, asking 'what is distinctive about medicine and health?' Explorations of recent cases, along with deeper probing of the past century, call into question how the past relates to the future. Health policy makers and analysts, practitioners, users and historians will find the editor's claims for the uses of history provocative.With its emphasis on clarity of writing, its mix of empirical details and analysis, and its rich bibliography, this volume offers rewards to academic and health service readers alike.

Part I

Close neighbours

1 The effects of local context on the development of obstetric ultrasound scanning in two Scottish hospitals¹

Debbie Nicholson

One of the most noteworthy features of the development of obstetric ultrasound in Scotland is the high degree of diversity involved. From hospital to hospital, differences can be detected in such areas as the organization and funding of ultrasound services, the number of scans performed and at what stages in pregnancy, the professional specialties that control and operate the technology, and so on. Furthermore, it is also possible to detect ways in which the technical elements of the technology have been reconfigured to suit different contexts: to enable it to function as the ‘right tool for the job’ in each specific location.² This is done either through careful choice of specific models and designs (selective adoption) or by ‘tinkering’ with existing models in use. Thus the technology develops in subtly different ways from location to location. How can this be explained?

Historians of medicine have demonstrated that the introduction of new medical tools, techniques, and practices to new users has provided opportunities for technological change.³ Furthermore, the utility of new forms of equipment often developed during use at the level of clinical practice – technologies have not, in other words, appeared fully fledged and ready-to-use. New skills, new personnel, and new institutional arrangements create problems and opportunities in implementing technology, which have to be addressed. This can result in equipment being used in previously unimagined ways – stimulating further innovation.

In an attempt to provide a theoretical framework to explain this sociologically, the Social Construction of Technology (SCOT) approach highlights the ‘interpretative flexibility’ of technical artefacts.⁴ The same artefact can be perceived differently by various ‘relevant social groups’ and it is the manner in which these differing perceptions are accommodated or overcome which drives technological change. In highlighting this, such studies have emphasized the problematic nature of a distinct linear ‘stage’ model of technological development.⁵ Instead, the spread of new technologies is viewed as a more dynamic phenomenon – new users can form novel interpretations of a particular artefact at any point in its overall development – stimulating further change.⁶

The aim of this chapter is to make use of the SCOT concept of ‘interpretative flexibility’ in order to explain innovative practices and site-specific differences. However, in doing so, two important points of divergence from the SCOT approach will be highlighted. First of all, in its conceptualization of ‘relevant social groups’, SCOT tends to obscure the role played by local, contextual factors in moulding actors’ interpretations of technology.⁷ Within SCOT, ‘relevant social groups’ are treated as any group of social actors who share the same view of an artefact. This characterization, however, does not pay adequate attention to the fact that actors’ interpretations of technology are often shaped through their interactions with it on a practical basis. A variety of historical and contextual factors, situated in specific locations, shape actors’ perceptions of technologies. The net result may well be a conglomeration of interested actors who can be identified as a ‘relevant social group’. However, to rely on such groups as the sole explanatory tool of technological change eclipses the nuanced ways in which change is effected on a daily basis.

Second, the chapter will employ a broader definition of ‘technology’ than that used by the SCOT theorists. Common to all technologies is an interactive, performative dimension in which human actors engage with material forces and man-made structures. Thus ‘obstetric ultrasound’ does not simply denote a complex piece of medical equipment. Instead, the term also incorporates a form of human activity (the actual practice of ultrasound scanning with its own division of labour and social interactions) and a form of specialized knowledge (in terms of how to operate and maintain ultrasound machines and understand the images created).⁸ Thus, even where the same artefact is employed, the technology itself can develop in different ways from location to location as other dimensions (such as, for example, the division of labour) develop differently.

In what follows it will be argued that a variety of material and social factors specific to individual institutions (from geography to inter-professional relations) affected the development of ultrasound in subtly different ways from location to location.⁹ Ultrasound technology was, in other words, shaped by local contextual factors as much as by the interests of ‘relevant social groups’. A variety of site-specific elements moulded the technology’s development in ways which ‘fit’ the circumstances associated with each location. From choice of equipment and location of the ‘scan department’, to staffing decisions and routine procedures, the precise make-up and development of obstetric ultrasound were the outcome of a site-specific configuration process: matching users to machines and vice versa.

These arguments will be illustrated through examples taken from the development of obstetric ultrasound in two Scottish hospitals from the mid-1970s, using evidence drawn from interviews with the actors involved, correspondence, and official documents.¹⁰ The chapter is organized into three broad sections: The first provides some background about the main technical features of ultrasound as an artefact, and its uses in obstetric medicine, during this period. The remaining two sections will examine what occurred when ultrasound was introduced to each of the two hospitals.

The changing nature of obstetric ultrasound in the 1970s

Ultrasound creates images on the basis of pulsed sound waves. Piezoelectric crystals emit inaudible sound waves which are transmitted into the body, via a device known as a transducer.¹¹ Each pulse is absorbed or reflected by the different types of tissue or structure it encounters. The resultant echoes are picked up by the transducer and then processed to create visual representations.

From its commercial introduction in 1963¹² until the mid-1970s, obstetric ultrasound machines had largely worked on the basis of creating static images. A still image was gradually built up as the transducer was swept back and forth across the abdomen. A high degree of craft skill was involved with this – too many sweeps and the image would be over-exposed, too few and structures would be difficult to identify. The only way to preserve the images created was to photograph them. Furthermore, because of the way in which these images were generated, static scanners were large and cumbersome pieces of equipment, requiring metal scanning frames which reached over a hospital trolley on which the patient would lie. At this point in the technology’s development, it was not used as a routine procedure. Only women characterized as ‘high risk’ (such as those with suspected complications like placenta praevia or those with histories of previous miscarriage, multiple pregnancy, etc.) would be examined using ultrasound.

Around the mid-1970s, however, new scanners using different methods of image production began to appear on the market.¹³ Such machines had multiple-element arrays, which were either mounted on a spinning wheel, or arranged alongside one another on a long, hand-held probe. The synchronized ‘firing’ of each element in turn created an image that, although considered initially to be of poorer quality than the static images of the earlier machines, enabled rapid image renewal. In other words, the image appeared in ‘real time’, allowing motion to be displayed. Furthermore, since there was no need with these machines for the large scanning frame which stabilized the images generated by static scanners, the new real-time (RT) machines were smaller, lighter and more portable. They were also, at least initially, less expensive.

The 1970s, however, was not only a time of technical change in obstetric ultrasound. This period also saw ultrasound increasingly being used as a routine feature of the antenatal care of all pregnant women in many centres. A number of advantages were cited, including the possibility of detecting gross foetal abnormalities early enough in pregnancy to offer selective terminations. However, the main perceived advantage of universal screening related to accurate dating of pregnancy. Many of the clinical research trajectories developed in the 1960s and 1970s were aimed at finding reliable means of dating the gestation of the foetus.¹⁴ By the time RT scanners appeared, such methods had stabilized around two main measurements: bi-parietal diameter (BPD) – from either side of the foetal skull – and crown-rump length (CRL) – from the top of the head to the base of the spine. Such measurements could provide information for possible later diagnoses such as intrauterine growth retardation, or for procedures such as induction of labour. Furthermore, alpha-feto protein tests (AFP) – in which samples of maternal blood are analysed for indications of Down’s syndrome and spina bifida – were found to have greater accuracy if they were performed between sixteen and twenty weeks’ gestation. This, again, underlined the clinical utility of accurate dating of all pregnancies via ultrasound screening. Thus, the very nature of obstetric medicine was changing, as ultrasound technology and the clinical possibilities it presented became increasingly interwoven with obstetric practice.

However, greater routine use of ultrasound involved much greater workloads and thus entailed increasing use of lower-grade staff such as radiographers and midwives. In turn, the greater reliance on such non-clinical staff provoked concern over the appropriate training of ultrasound operators, and calls for standardization of training and supervision. This issue was first raised in 1979 and appropriate means of achieving such standardization were debated until well into the 1980s among the relevant professional societies (such as the Royal College of Obstetricians and Gynaecologists, the Royal College of Radiologists, the Hospital Physicists Association, and the College of Radiographers).¹⁵ These debates were also followed closely by the most important diagnostic ultrasound interest group in the UK – the British Medical Ultrasound Society.¹⁶

These events – changing technological design, increasing routinization, and attempts to create standardized structures of delivery – form the general context of obstetric ultrasound from the mid-1970s. However, as will be outlined in the next two sections, the way in which these issues were played out differed from location to location.

Reconfiguring a medical hierarchy

In 1977, obstetric ultrasound was introduced for the first time to Hospital A – an average-sized maternity hospital located in a small town on the East coast of Scotland. The technology’s introduction was part of a large-scale capital investment in the hospital by the local Health Board, which culminated in a new extension, housing additional ward space and an on-site radiology facility. As with most developments of this nature, the funding for the new wing covered the purchase of equipment, including an ultrasound machine with real-time capabilities.

Initially, ultrasound was conceived as part of a general obstetric imaging service alongside x-ray imaging and was thus a radiological procedure, operated and controlled by the main Radiology Department. This Department, however, was based in the main district general hospital, located a mile from the maternity hospital. Under the Health Board system and, later, the Hospital Trust system, the maternity hospital was viewed as an attachment to the district general hospital, despite the fact that they were not located on the same site. This would turn out to be an important factor in the shaping of ultrasound in this centre.

To staff the new facility, the Chief Radiologist (Dr A) advertised for, and employed, a radiographer from the district general to be based at the maternity hospital. This radiographer (Mrs Y) was given additional training in ultrasound so that she could perform both x-ray and ultrasound imaging.

In the traditional division of labour associated with x-ray imaging, non-medically qualified radiographers performed the role of image constructors, while clinically trained radiologists were solely responsible for the interpretation of those images.¹⁷ Therefore, in addition to the radiographer, a consultant radiologist was placed in charge of the maternity x-ray imaging service on a visiting basis.

There were, however, problems associated with transporting this division of labour directly to the technology of ultrasound. With x-rays, an image can only be created from very well-defined planes and so, providing the radiographer is competent in creating those standard views, a radiologist can discern from what direction the section has been imaged.¹⁸ For this reason, the division of labour in radiology was amenable to a structured, hierarchical separation of roles.

With ultrasound, on the other hand, there were an infinite number of planes from which an image could be created. Thus, when viewing a still image, the clinician would need to know where exactly the probe had been placed to produce the picture. This meant that, without actually watching the scan being performed, it was more difficult to translate and make sense of the resultant image.

In this sense, with ultrasound the locus of diagnosis was more intimately centred on the interactive scanning process itself, at the time in which it was performed. The person who performed the scan would simultaneously interpret the images and draw diagnostic conclusions. Thus, the technique of real-time imaging created a much more interactive relationship between the ski...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of illustrations
• Notes on contributors
• Acknowledgements
• List of abbreviation
• Introduction: On theory and practice
• PART I. Close neighbours
• PART II. Across nations
• PART III. Re-innovation and the state
• Bibliography
• Index