Knowledge and ambiguity. How GPs manage tensions between systemic biomedical ideals and medically unexplained symptoms

This thesis is a sociological exploration of the management of ambiguity in medical work, and of the relationship between knowledge and ambiguity in that regard. As its case, it takes the management of ‘medically unexplained symptoms’ (MUS), a category of symptoms that are widely considered ambiguous in their nature, cause and treatment. Although increasingly the topic of medical research, MUS have been comparatively little studied in sociology and the social sciences. In particular, there are few sociological inquiries into professional perspectives and work related to MUS. In this study, I therefore explore MUS as a professional problem, as problems faced by medical professionals when working with ambiguous cases such as MUS. The study centres on general practitioners (GPs) and the primary care context, since MUS is mainly managed in primary care by GPs. While it has been widely established in the medical research literature that GPs consider MUS to be difficult work, much less is known about why they think that and what they think they can do about it. This is the central problem under investigation here: what is it that makes MUS difficult medical work and how are these difficulties addressed? These questions are explored by analysing data from focus groups and follow-up interviews with GPs working in Norway, and a document study of medical research articles in scientific journals. Drawing on work in the sociology of knowledge, cultural sociology and medical history, GPs’ work of managing ambiguity in medicine is conceptualized as a form of interface management, referring to the knowledge-based managing of contact between categories, persons, institutions and systems. This conception usefully positions GPs as operators in the midst of complex social systems that consist of various interfaces, and proposes that a crucial part of GPs’ work is making connections between these interfaces as a means to resolve medical problems. Interface management thus indicates the relevance of systemic embeddedness and institutional arrangements in managing ambiguity. Based on four empirical articles, the thesis suggests 1) that the problematic status of MUS results (at least in part) from frictions between systemic biomedical ideals and clinical reality, and 2) that managing these frictions require creative and reflective interface management, drawing on a wide repertoire of knowledge. From the point of view of biomedicine, certain things are expected from medical conditions, and MUS violate these expectations. Although this alone need not cause difficulties, the systems of health care and health insurance employ and enforce biomedicine as a regulatory ideal in matters of health and illness. For GPs, their work with MUS in different ways puts them in conflict with this ideal; in response, GPs (to varying degrees) work to manage and adapt themselves and their institutional surroundings to remove or smooth over frictions between the enforced biomedical ideals and clinical reality. The argument, then, is that biomedicine, as a regulatory ideal, makes MUS ambiguous and problematic work and that medical professionals strive in various ways to manage those problems by reorienting themselves and the system to the practical challenges at hand. The thesis suggests that medical knowledge, as resource and restraint, is implicated in both the making and management of medical ambiguity. That is, ambiguity is caused as much from what we know as from what we do not. The thesis contributes theoretically to the sociology of medical knowledge and the sociology of professions, and to the understanding of MUS as a medical problem in the contexts of health care and health insurance

Rhetorical work and medical authority: Constructing convincing cases in insurance medicine

This article explores general practitioners’ (GPs) persuasive efforts in cases where biomedical evidence is absent but expected. Health insurance in Western countries is based on the biomedical ideal that legitimate complaints should have objective causes detectable by medical examination. For GPs responsible for assessing sickness and incapacity for work, the demand for objective evidence can be problematic: what if they as experts deem that a patient is in fact sick and eligible for benefits, but are unable to provide objective evidence to that fact? How can they convince bureaucrats in the insurance system to accept their judgment? Taking ‘medically unexplained symptoms’ as my case, I draw on focus group and follow-up interviews with GPs in Norway to explore how GPs attempt to persuade bureaucrats to accept their professional judgment. Proposing the concept of ‘rhetorical work’, I reconstruct a typology of such work that doctors engage in to influence bureaucratic decision-making and provide long-term health benefits for patients. I then discuss the potential societal implications of GPs’ rhetorical practices and the applications of the concept of rhetorical work in future research

Making and managing medical anomalies: Exploring the classification of ‘medically unexplained symptoms’

This article explores the making and management of anomaly in scientific work, taking ‘medically unexplained symptoms’ (MUS) as its case. MUS is a category used to characterize health conditions that are widely held to be ambiguous, in terms of their nature, causes and treatment. It has been suggested that MUS is a ‘wastebasket diagnosis’. However, although a powerful metaphor, it does neither the category nor the profession justice: Unlike waste in a wastebasket, unexplained symptoms are not discarded but contained, not ejected but managed. Rather than a ‘wastebasket’, I propose that we instead think about it as a ‘junk drawer’. A junk drawer is an ordering device whose function is the containment of things we want to keep but have nowhere else to put. Based on a critical document analysis of the research literature on MUS (107 research articles from 10 medical journals, published 2001–2016), the article explores how the MUS category is constituted and managed as a junk drawer in medical science

Making and managing medical anomalies: Exploring the classification of ‘medically unexplained symptoms’

This article explores the making and management of anomaly in scientific work, taking ‘medically unexplained symptoms’ (MUS) as its case. MUS is a category used to characterize health conditions that are widely held to be ambiguous, in terms of their nature, causes and treatment. It has been suggested that MUS is a ‘wastebasket diagnosis’. However, although a powerful metaphor, it does neither the category nor the profession justice: Unlike waste in a wastebasket, unexplained symptoms are not discarded but contained, not ejected but managed. Rather than a ‘wastebasket’, I propose that we instead think about it as a ‘junk drawer’. A junk drawer is an ordering device whose function is the containment of things we want to keep but have nowhere else to put. Based on a critical document analysis of the research literature on MUS (107 research articles from 10 medical journals, published 2001–2016), the article explores how the MUS category is constituted and managed as a junk drawer in medical science

Enkel og trygg pårørendekontakt: Forskningsrapport fra et pandemiprosjekt om bruk av sosial teknologi for eldre på langtidshjem

OsloMet Skriftserie 2022 nr 4 av Erik Børve Rasmussen og Sehrish Akhtar, CEDIC, Institutt for sosialfag, OsloMet – storbyuniversitetet.  ISSN 2535-6984 (trykt)/ ISSN 2535-6992 (online)ISBN 978-82-8364-392-3 (trykt)/ ISBN 978-82-8364-393-0 (online

How general practitioners understand and handle medically unexplained symptoms: a focus group study

Abstract Background Medically unexplained symptoms (MUS) are a common yet challenging encounter in primary care. The aim of this study was to explore how general practitioners (GPs) understand and handle MUS. Methods Three focus group interviews were conducted with a total of 23 GPs. Participants with varied clinical experience were purposively recruited. The data were analysed thematically, using the concept of framing as an analytical lens. Results The GPs alternated between a biomedical frame, centred on disease, and a biopsychosocial frame, centred on the sick person. Each frame shaped the GPs’ understanding and handling of MUS. The biomedical frame emphasised the lack of objective evidence, problematized subjective patient testimony, and manifested feelings of uncertainty, doubt and powerlessness. This in turn complicated patient handling. In contrast, the biopsychosocial frame emphasised clinical experience, turned patient testimony into a valuable source of information, and manifested feelings of confidence and competence. This in turn made them feel empowered. The GPs with the least experience relied more on the biomedical frame, whereas their more seasoned seniors relied mostly on the biopsychosocial frame. Conclusion The biopsychosocial frame helps GPs to understand and handle MUS better than the biomedical frame does. Medical students should spend more time learning biopsychosocial medicine, and to integrate the clinical knowledge of their peers with their own

How general practitioners understand and handle medically unexplained symptoms: a focus group study

Background: Medically unexplained symptoms (MUS) are a common yet challenging encounter in primary care. The aim of this study was to explore how general practitioners (GPs) understand and handle MUS. Methods: Three focus group interviews were conducted with a total of 23 GPs. Participants with varied clinical experience were purposively recruited. The data were analysed thematically, using the concept of framing as an analytical lens. Results: The GPs alternated between a biomedical frame, centred on disease, and a biopsychosocial frame, centred on the sick person. Each frame shaped the GPs’ understanding and handling of MUS. The biomedical frame emphasised the lack of objective evidence, problematized subjective patient testimony, and manifested feelings of uncertainty, doubt and powerlessness. This in turn complicated patient handling. In contrast, the biopsychosocial frame emphasised clinical experience, turned patient testimony into a valuable source of information, and manifested feelings of confidence and competence. This in turn made them feel empowered. The GPs with the least experience relied more on the biomedical frame, whereas their more seasoned seniors relied mostly on the biopsychosocial frame. Conclusion: The biopsychosocial frame helps GPs to understand and handle MUS better than the biomedical frame does. Medical students should spend more time learning biopsychosocial medicine, and to integrate the clinical knowledge of their peers with their own

Stability and change in disease prestige: A comparative analysis of three surveys spanning a quarter of a century

In this paper, we present a comparative analysis of three survey studies of disease prestige in medical culture. The studies were conducted in 1990, 2002 and 2014 using the same research design. In each of the three rounds, a sample of Norwegian physicians was asked to rate a set of 38 diseases on a scale from 1 to 9 according to the prestige they believed health personnel in general would award them. The results show a remarkable stability in the prestige rank order over 25 years. The top three diseases in all three surveys were leukaemia, brain tumour and myocardial infarction. The four lowest ranked were fibromyalgia, depressive neurosis, anxiety neurosis and hepatocirrhosis. The most notable change concerns apoplexy (brain stroke), which moved from a rank of 33 to 29 and then to 23 over the three rounds. We argue that the stable pattern, as well as this change, substantiate the interpretation of previous research, i.e. that the prestige of a disease is affected by the localization of the affected organ or body part, the effect and style of its typical treatment, and the social attributes of the typical patient. Analysing physicians’ shared evaluations of different diseases, the paper contributes to the cultural understanding of disease conceptions in medicine. Understanding these conceptions is important because disease prestige may influence decision-making in the healthcare sector

Student at a distance: exploring the potential and prerequisites of using telepresence robots in schools

‘Homebound’ children are unable to attend school for illness-related reasons. To lessen their predicament, schools have begun experimenting with ‘telepresence robots’ that can enable remote participation. While promising, we know little about the use of telepresence robots in practice. To begin to redress this, we draw on 159 semi-structured interviews to explore the experiences of 37 child users of the robot ‘AV1’ in Norwegian schools. The children’s experiences varied, with some benefitting greatly and others not getting any benefit from using the robot. To explain these variations, we reconstruct the robot’s critical component structure – that is, the assembly of sociomaterial elements that determines whether and how the robot works in practice. We also explore the benefits of using the robot when these critical components align. In so doing, we provide in-depth knowledge about the potential and prerequisites of using telepresence robots in schools – to the benefit of users, producers and scholars of telepresence technology