Approaching diagnostic messiness through spiderweb strategies: Connecting epistemic practices in the clinic and the laboratory.

Scientific and medical practice both relate to and differ from each other, as do discussions of how to handle decisions under uncertainty in the laboratory and clinic respectively. While studies of science have pointed out that scientific practice is more complex and messier than dominant conceptions suggest, medical practice has looked to the rigour of scientific and statistical methods to address clinical uncertainty. In this article, we turn to epistemological studies of the laboratory to highlight how clinical practice already has strategies for dealing with messiness. We draw on Hans-Jörg Rheinberger's Toward a History of Epistemic Things, in which he invokes the metaphor of a spider's web to explain the role of tacit practices in experimental biochemistry for helping practitioners manage messiness. We argue that diagnostic practices in clinical medicine employ similar, albeit codified, procedures to evaluate epistemic significance, ensure sensitivity to the unforeseen, and allow focused grounds for action. We consider three practices: (a) the pre-set structure of medical records, ensuring broad coverage in initial anamnesis, (b) the use of lists of differential diagnoses and ongoing 'anchoring and adjusting' as inquiry progresses, and (c) shared decision-making as an occasion to synthesize empirical evidence and reopen inquiry for potential missed information. We end by suggesting that while philosophy of medicine may learn from laboratory epistemology, the sciences may learn something from medical practice.

Scale in the history of medicine.

This is a history of medicine that takes its point of departure in the specimens of human bodily material used to produce medical knowledge. An ordering principle of scale prompts a material and epistemic history of 18th-21st century medicine that highlights shifts in interest towards smaller and smaller units of study: from organs in pathological collections, over microscope slides, to samples in biobanks. The account reveals a set of connected scales of the site of disease, time of diagnosis, size of cohorts, number of disease categories, and technologies of investigation. Moreover, the principle of following the scale of specimens demonstrates the continued importance of physical specimens in medicine, it synthesizes studies of important epistemic objects of medicine such as the organ specimen, the microscope slide and the blood sample, and it draws new historical connections from pathological collections to biobanks.

History at the heart of medicine.

With a focus on the challenges of today and tomorrow in the critical medical humanities the role of history is often overlooked. Yet history and medicine are closely intertwined. Right now, with the surfacing of knotty problems such as changing demographics, chronic pain, loneliness and Long Covid - and the consequent necessity to change directions and policies - history seems more urgent than ever. However, historians of medicine have sometimes been reticent to play a role in medicine and policymaking. The recent and welcome development of the critical medical humanities has intervened in medicine in important ways, but often without clear engagement with the history of medicine. In this letter, we make a renewed case for coherence and collaboration between history of medicine, medicine, and medical humanities, emphasising the continuity and links between all three. The skills and focus of the historian of medicine bring crucial historical context to the table, enabling better understanding of medical collecting, new imaginative futures, profound critiques of key medical concepts, and understandings of the body through time. By emphasising what historians can do for medicine and medical humanities, we call for building historical work into how medicine, illness and health are understood now and in the future. We suggest three potential roles for historians: keepers of memories, conversation partners, and futurist thinkers.

'History at the Heart of Medicine' was originally conceived of at a workshop at the Groningen Centre for Health and Humanities in June 2023. The authors worked together to answer how the history of medicine and medical humanities could be more closely integrated with each other and with medicine. We identified that the two fields are typically perceived to have different levels of willingness to engage with policy and intervene directly in medical practices. Although medical history has tended towards greater discretion in these respects, we found that history is a vital part of both medicine and the medical humanities. We make a positive case for history not as prescriptive, but as generative of possible worlds and imagined futures.