A patient who has chronic symptoms but no objective indications of a disease risks being perceived as problematic or troublesome, and the doctor risks appearing incompetent or not very compassionate. Sociological perspectives on the roles and the power structures in which the doctor’s practices and the patient’s health problems are embedded may improve our understanding of the matters at stake for the patient as well as the doctor.
Illustration Stein Løken
Many patients who suffer from chronic muscular pain can give negative accounts of their medical consultations. They report having been met with scepticism and lack of interest, or having been reproached for not exercising sufficiently or not getting enough rest. Doctors sometimes also relate stories of consultations that have been difficult; they describe experiences of helplessness and powerlessness.
With the aid of qualitative interviews with ten women suffering from chronic muscular pain, I have studied their accounts of meetings with the doctor (1). They told me that they had worked hard to appear credible – «just ill enough» – so that their complaints could be perceived as «real» diseases and not as signs of mental imbalance. Their experience can reveal what goes on: The patients were not only struggling to maintain their own credibility and dignity, they also attempted to live up to the hidden rules of the game of the medical consultation. In the following, I will argue that sociological perspectives can help provide a better understanding of «difficult» consultations.
Sociology is a contemplative discipline
Sociology is the study of the relationship between the individual and society (2). Sociology is concerned with how we influence each other mutually by way of our actions, and how institutions shape individual actions and decisions. This discipline does not specialise in the study of a particular sector of society, but attempts to transcend the boundaries between the sectors to show the common features of social life and interaction.
Medical sociology is the study of how social and cultural conditions affect illness, health and medical practice (3). This subject has emerged from a need for knowledge in the health sector, and represents an alternative perspective to the prevailing view in the medical community, which perceives illness and health primarily in bio-medical or psychological terms. For example, «medicalisation» denotes a process in which medicine assumes a progressively larger role in society, and which can contribute to excessive treatment and unwarranted applications of the concept of illness. Various sociological approaches have provided concepts and models for analyses of illness and interaction related to illness.
Illness as social deviance
Functionalism, which is based on Parsons’ system theory, regards illness as socially deviant behaviour which requires social control (4). The role of ill person implies obligations as well as rights. Being defined as ill legitimises exemption from the obligations of daily life. The condition, however, is that the patient seeks help and cooperates with the doctor. The ill person has an obligation to attempt to be healed, and the doctor is obligated «to do everything» to help the patient.
The patients whom I interviewed had tried «everything» – and had not been healed (1). However, they were not accepted as being ill. They had needed to insist on being examined, on getting a sick leave or being referred to a physical therapist. In their experience, the doctor’s medical understanding was opposed to their own understanding of their complaints.
Parsons’ concept of the sick role has had a major impact and has encountered widespread criticism, including for being single-mindedly focused on acute diseases that can be healed, and for providing an idealised image of the doctor-patient relationship (3).
Illness as an outcome of power and inequality
Conflicts of interest and class divisions are key elements of conflict theory (3). Illness, diagnostics and treatment are conceptualised as expressions of relations of power in society and unequal distribution of resources. In his analysis of medical professions, Friedson uses the concept of «professional dominance» to describe the superior power wielded by doctors in relation to other professions in the health services, a power that stems from the doctor’s legitimised right to define medical reality (5). On the other hand, Berg describes how the autonomy of the medical profession has been reduced in the health sector in favour of non-medical professions (6).
Freidson’s conflict theory assumes that the doctor and the patient come from different social and cultural worlds (5). This social positioning shapes their conceptions and knowledge, and the same phenomenon may have a different relevance, be interpreted differently and assume a different importance. Medicine is regarded as embedded in an ideology and as a wielder of power and control.
Løchen’s study of life in a psychiatric hospital in the 1960s in many ways represented the start of medical sociology in Norway (7). He used the diagnostic culture to denote forms of interaction that are expressed in conflicts. Within this culture, conflicts are interpreted as being of an individual and emotional nature. Institutional conditions and rules are not taken into consideration.
The patients whom I interviewed described the medical consultation as a credibility test (1). They were apprehensive about being perceived as healthy or as mentally ill, and being suspected of attempting to swindle the doctor into giving them a diagnosis or access to welfare benefits to which they were not entitled. The doctor was perceived as «the enemy» or as the guardian of the welfare state.
Illness as stigma
Symbolic interactionism is a theory of how our awareness of ourselves and our environment develops through interaction with other people (3). Here, Goffman’s studies of personal interaction occupy a central position (8, 9). His concern is that the illness does not create the role of the ill person (8), it is rather the other way round – a person who is deemed ill does what is expected of him or her. Goffman uses the word «stigma» to denote social reactions to illness. Various diseases can give rise to degrees of stigmatisation. In Norway, Album has shown how the medical prestige of various diseases is hierarchically ranked, with the lowest rank being awarded to chronic disorders such as fibromyalgia (10).
Goffman assumes a «dramaturgic» perspective to describe how we «act» in roles with a strategic goal of influencing the understanding of others (9). With the aid of external characteristics such as clothes and manners of speech or movement, we demonstrate who we are. Album uses Goffman’s theories to study how we learn to be patients (11).
The patients whom I interviewed described various strategies that they used in order to be believed and taken seriously in the medical consultation (1). They made an effort to be «appropriately assertive», but also to appear as «appropriately surrendering» and «appropriate» in their appearance in terms of body, clothing and manner. The women struggled to communicate an impression of suffering from a somatic disease. Goffman’s analyses help us see the consultation as an arena in which the parties contest the power of definition. The patients’ displays of illness appear as ways to live up to the doctor’s expectations.
Illness as a social construction
The core idea of social constructivism is the notion that reality is socially constructed (3). It does not exist independently of the observer, and we conceptualise our environment by way of the language. Foucault’s perspectives on power and social control have been extremely influential in this respect. Studies of the emergence of modern medical science and the power of the state describe the introduction and enforcement of new, strict requirements to normality (12, 13). Social control is expanded through a more subtle disciplining of the human body and mind. According to Foucault, power is exercised in human interaction, and not a property of the individual. Power is omnipresent and dynamic. For example, power is inherent in the medical gaze that serves to shape the patient’s symptoms, behaviours and diagnoses.
The patients whom I interviewed described illness talk as boring, and as «something the other women keep doing» (1). They distanced themselves from stereotypes of women as preoccupied with illness or as weak and crazy. In a social-constructivist perspective, the patients’ strategies can be conceived as attempts to counter the moral control and disciplining that they experience. The patients and doctors both related to a bio-medical discourse on illness (1). Foucault regards the use of diagnoses as an expression of social control, and the diagnoses as reflections of current medical discourses (13).
Måseide shows how the expert model has been replaced by a cooperation model as an ideal for the medical consultation (14). The cooperation model, however, does not take into account that medical treatment presupposes inequalities in knowledge and power (14). The medical consultation is not an encounter between equal parties with equal opportunities to enforce their definition of reality. The doctor cannot choose to exceed the professional framework without incurring grave consequences (14). Måseide argues that the medical consultation must be analysed on the basis of a perspective on power and control, including the notion that power is necessary for good practices in spite of the risk of violations.
Are sociological considerations of any help to the doctor?
The presentation of chronic and disabling symptoms without any so-called objective indications of disease challenge the doctor’s notions of what constitutes «real» diseases. The patient risks being categorised as troublesome, and the doctor risks appearing incompetent or unable to understand the patient’s perspective. The patients may have to struggle to maintain their credibility and dignity (1).
In a sociological perspective, the challenges involved in difficult consultations can be conceived of as relational and structural, rather than as being associated with troublesome patients or unaccommodating doctors. The meta-language of sociology provides analytical tools for reflection. This could help elevate the perspective and see medicine, one’s own practice and role from a new angle. An understanding of the roles and power structures in which both parties are embedded could help us better understand the matters that may be at stake.