Knowledge and ambiguity

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

Abstract

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.