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Introduction
The first fragment shows how medical criteria are intimately related to
institutional features: when a change occurs in the latter, the former often
change accordingly. In the second fragment. Burton finds himself in a
situation where organisational limitations (the neonatal 'medium care' is
full) direct the transformation to the disposal 'stay in obstetric department
in incubator'. The examination data, however, suggest the disposal
'admission to neonatal medium care'. By requesting another temperature
measurement after one hour. Burton tries to adjust the examination result
'hypothermia' to the former transformation (note that this second
The construction of medical disposals 167
investigation is directively performed by placing the infant in a warm
incubator!). Also, Burton reconstmcts disposal options: in this situation,
the incubator on the obstetdcs department and hisfinalvisit are a sufficient
response to the meatnium-containing amniotic fluid and the hypothermia.
Just as in the previous section, however, 'social' factors do not
necessarily prevail: conversely, they can be reconstmcted in the light of
disposal options and medical cdteda. In the following fragment, Hodges
intervenes in organisational pattems in order to secure a specific disposal
option:
In hospital Z, Hodges, a gynaecologist, would refer premature infants of
less than 32 weeks of gestational age to another hospital whenever the
pediatdcian X was on duty. ^X, Hodges states, 'doesn't do what he
should be doing. In that other hospital they know what such a child
needs'.
Similarly, financial constraints can be adjusted in view of medical cdteda
and disposal options. So, the entdes on insurance forms arefilledin in such
a fashion so as to secure smooth payment:
While Dr. Bames, gynaecologist and younger colleague of Hodges, is
taking his outpatients' clinic he is called by the Patients' Fund^-'. The call
concems Ms. Stone, who has no house, lives in a caravan and, for this
reason, wants a clinical delivery. Bames has wdtten the Patients' Fund a
letter asking to pay these expenses because of this 'social indication'.
The Patients' Fund now informs him that this social indication is not
completely acceptable to them. They propose another location to
Bames, the midwife school, where Ms. Stone can have her baby at less
expense to the Fund. This school, however, is located 20 miles from the
hospital, while Ms. Stone's caravan lies next-door to Barnes' clinic.
After this phone call, Bames, who has become very irdtated, calls Hodges,
who shakes his head while Barnes relates his story. 'I though we'd told
you that asking for social indications gives you nothing but trouble. Why
do you try? [...] When somebody wants to have her baby in the
hospital, you just make up a medical indication. They won't know and
won't hassle you for that.' Barnes nods and agrees: 'Well, fortunately
her blood pressure has gone up somewhat, so FU make an 'imminent
toxaemia' out of it'. Hodges laughs and adds: 'with this warm weather
she'll probably have some oedema in her legs, so thatfitsin very well
too'. ['Oedematous legs' is an innocent symptom in pregnant women,
although in certain instances it can be a sign of toxemia.]
In the previous sections, I have argued that the assumptions concerning the
nature of the 'contents' of medical action do not hold. Histodcal and
168 Marc Berg
examination data as well as medical criteria and disposal options are not
'givens' which unidirectionally lead the physician towards a disposal. The
physidan does not pa^ively solve a puzzle with pre-set pieces: in
articulating elements to the transformation, they are actively moulded and
reconstructed. Furthermore, it has been demonstrated how these elements
intermix with other prevailing 'cross-cutting systems of relevance' (Bosk
1979: 57) in medical practice, such as time, organisation, the image of the
patient and financial considerations.
Finances Medical
criteria Historical
The patient infomiation
Organisation ^ CvaminaH
Tima Examination
Disposal ""^^ results
options
Fig. 1 Elements involved in transforming the patient's problem to a solvable
problem.
Schematically, the transformation process is summarised in Fig. 1 (the
listing of elements is strictly heuristic). In transforming a patient's problem
to a solvable problem, the physician has to deal with an array of
heterogeneous elements which constitute her micro-environment. The
double-pointed arrows illustrate that these elements reciprocally shape the
transformation and are moulded themselves in this process: historical data
take shape or are forgotten and the image of the patient is altered; a
patient has backaches which necessitate Feldene or angina pectoris
requiring Nitrostat. What counts as the solution of the patient's problem is
a result of the outcome of the transformation; and, equally, what counts as
the original problem is redefined during this process. Also, the articulation
processes mutually interact: disposal options are modified in the light of
time pressure, organisational patterns are reconstructed in view of
examination data, etc. There is no essential disparity between 'cognitive'
and 'sodal' elements which would justify an asymmetrical treatment in a
sociology of medical practice; there is no such thing as a secluded, self-
explanatory domain in medical action. On the contrary, in medical practice
itself no a priori distinction between 'content' and 'context' or between a
'social' and a 'cognitive' domain is made. As the fragments have shown,
the physician, as a 'heterogeneous engineer' (Law 1987), smoothly
interconnects and interweaves the diversity of elements in constructing a
The construction of medical disposals 169
medical disposal, disregarding any absolute distinction ever made by
outside investigators.'*
The terms 'solvable problem' and 'disposal' are not equivalent to the
'textbook' duality 'diagnosis' and 'treatment', which is adopted without
question in almost all sociological studies of medical action. A logical gap
divides the latter two terms. They are independent entities: for one
diagnosis X there may be several different therapies. This independence,
as Bloor (1978) already stated, is lacking in medical practice. A solvable
problem inherently contains a disposal: they are two sides of the same coin.
Physicians do not first search for a diagnosis and then, subsequently,
decide upon a therapy. This phased, two-step motion does not characterize
medical problem solving. On the contrary, from the outset, the trans-
formation process is unidirectionaliy geared towards the constmction of a
disposal. 'Diagnosis' and 'therapy' are terms which can be applied to this
process in retrospect, but in an 'in situ' study of medical practice the usage
of these terms creates an artefactual distinction.
These routines are essential in two related ways. They facilitate medical
action: the physician is not continuously deliberating on the steps she
should take next. Rather, the articulation processes are realized 'on her
spinal marrow' (statement of a surgical registrar). By learning the routines,
the physician learns to see 'in a single flash' what is essential in a given
situation and how this situation should be dealt with (Bloor 1978: 39-40,
Gordon 1988). In this way, routines realize an 'economy of effort' (Berger
and Luckmann 1%7: 71). Furthermore, the physicians' routines do not
stand on their own. They interconnect with routines of other people in the
organisation, thus creating ot^anisatiorud routines: laboratory investigations
are applied for on standard forms and routinely dealt with in the
laboratory; printed results from emergency cases are directly available at
the intensive care through an on-line connection {cf. Fujimura 1987; Rees
1981).
Second, routines constitute, in Konner's terms, ^the safety of the norm':
'you feel safe because you do what everybody else is doing' (1988: 366).
Following the time-tested, trodden path has the important function that
the physician and her environment know that she acts properly {cf.
Garfinkel 1967; Giddens 1984: 30). When articulation processes are
realised by routine, the elements support the transformation in a self-
evident fashion: it is then a 'replica' of a transformation which has been
performed in a similar fashion many times before.
The locally situated routines constitute the frame of reference sought
for: they encompass the unwritten rules which define whether historical
data and the image of the patient fit a transformation or not, whether
examination data or medical criteria are adequately reconstructed or not,
etc. {cf. Atkinson 1988: 200). In daily practice, routines define what counts
as a good articulation and how to articulate:
The construction of medical disposals 171
You don't need all the 1500 pieces of the puzzle for your diagnosis, but
you'll need 1378 of them (remark of Dr. Flores, an internist in hospital
X).
The fact that it is actually the routines determining whether the 1378 pieces
are sufficient or not, instead of 'biomedical knowledge' is illustrated
further when we compare two different practices:
In Hospital PI always used that drug, but my bosses would shoot me if I
used it here (Stokes, neurological registrar in hospital Yon the use of an
anti-psychotic drug).
In hospital Y the cardiologists state that a proper physical examination of
the heart requires the meticulous palpation of this organ's vibrations in
the chest. Percussion of the heart, they say, is senseless. Contrarily, the
cardiologists in hospital X refer to the palpation of the heart as 'a
meaningless investigation'. They, in their turn, attach great importance
to the percussion of the heart.
In these hospitals different routines exist; in these two sites, what counts as
'adequate' or 'sufficient' is different.
It is important to note that routines are not confined to singular
articulation processes. Rather, routines are characterised by their irtclusive-
ness (Bloor 1978: 42): their coinciding extension into several articulation
processes emphasizes the heterogeneous engineering of the physician.
While articulating historical and examination data with the transformation,
the cooperation of the patient and the education of the onlooking
houseman is 'managed' simultaneously. The physician's expertise stretches
out into the diversity of elements which constitute her micro-environment.
Routines can be considered as the micro-sociological correlative of the
concept 'paradigm'.*' They facilitate medical action by embodying routes
to take and to avoid in the transformation processes and, at the same time,
supply a framework which delineates what is proper action and what is not.
Like a paradigm, routines are not just a 'social' category {cf Latour in
press). As mentioned shortly above, routines can be materialised in on-line
connections or standard forms. Routines do not simply dictate the usage of
an instrument or form: the form itself structures the contact between
physician and laboratory and delineates which tests are relevant, which are
expensive, etc. Equally, in the stethoscope conceptions of the doctor-
patient relation and the relevancy of certain examination data are
embedded (see note 14). Thus pre-stnicturing the articulation processes,
the stethoscope, the form and the on-line connection themselves are
integral parts of the routines.*
In this way, the concept of 'routines' supplies a structure in medical
action. This structuring role of routines does not imply that physicians
continuously act in a routine fashion. Stepping out of a routine, however,
implies that the correctness of the action needs to be explicitly renegotiated:
172 Marc Berg
the legitimacy which comes as a matter of course with a routine articulation
is now absent. In these continuous renegotiations (many examples of which
can be seen in the empidcal fragments in this paper) the possibility of
changing routines is contained."
This leads me to a final point that needs to be mentioned. Most of the
examples discussed here were taken from hospital settings, where routines
are shared by groups of physicians and negotiations take place within these
groups. However, many physicians (eg family practitioners) work in
relatively isolated settings. The question may arise if the notion of
'routines' suits these situations as well. I would answer affirmatively: when
there is little interference with colleagues and a low dependency of
organisational facilities and instruments, highly individualised routines can
develop {cf. M. Bloor's (1976) study of ENT specialists). In these
situations routines also fulfill the role of frame of reference, and,
correspondingly, stepping out of the routine implies a deviation from the
'safety of the norm', psychologically necessitating an explicit legitimation
for doing so.
Conclusion
Acknowiedgements
I want to thank the anonymous referee, Wiebe Bijker, Michael Bloor, Jessica
Mesman, Gerard de Vries, Wies Weijts, Rein de Wilde, and especially Annemarie
Mol for helpful comments on earlier versions of this paper.
Notes
1 See for example the work of Armstrong (1983, 1985), Amey and Bergen
(1983), and the essays in Wright and Treacher (1982). The relevance of the
social constructionist approach for the sociology of medicine has been debated
in eg Bartley (1990), Bury (1986, 1987), King (1987) Nicolson and McLaughlin
(1987, 1988) and Wright (1979). As Nicolson and McLaughlin (1987) have
noted, medical sociologists tend to use the word 'constructionism' while
sociologists of science speak of 'constructivism'. With Nicolson and McLaughlin, I
see no fundamental difference in meaning lying behind this different usage.
2 Since I am interested here in a sociological study of medical problem solving in
practice, I will not discuss the medical decision making literature that tries to
describe the decision process of the individual physician in cognitive-
psychological terms (eg Elstein et al 1978, Denig et al 1988, cf. Scheff 1972).
This has been done elsewhere (Berg and de Vries 1991, in Dutch; cf. Gordon
1988, MSseide 1983).
3 Showing how medical problem solving processes mediate relations between
doctors is not the only way in which medical sociologists have focussed upon the
role of these processes in clinical practice. The studies of 'the social construction
of medical reality' (Atkinson 1981), undertaken in the tradition of Berger and
Luckmann (1%7) and Garfinkel (1%7), are all very detailed in spelling out this
role in the interactional constitution of medical reality in the doctor-patient
relationship (e.g. Emerson 1970; Strong 1979, cf. Silverman 1987).
4 By centring on situations of which the 'ethicality' is explicitly acknowledged by
all participants, it may appear as if the existence of a distinctive, 'non-objective'
category, different from 'ordinary' medical problem solving, is suggested.
Indeed the 'not so rational or scientific' decision making process which Crane
discusses is explicitly linked to decisions about critically ill patients. Doing so,
she seems to imply that in ordinary cases the process might be entirely different
(1975: 19); it might, in fact, be completely rational and scientific.
5 Also, in clinical practice in particular the medical problem solving process
stretches out far beyond the setting in which the doctor-patient interaction takes
174 Marc Berg
References