Legitimating the illegitimate: How doctors manage their knowledge of the prestige of diseases

Health 1 –19

© The Author(s) 2015Reprints and permissions:

sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1363459315596798

hea.sagepub.com

Legitimating the illegitimate: How doctors manage their knowledge of the prestige of diseases

Marit HaldarOslo and Akershus University College of Applied Sciences, Norway

Eivind Engebretsen and Dag AlbumUniversity of Oslo, Norway

AbstractAlthough the sociology of medicine has developed a rich body of research on patients’ experiences and how they handle their illnesses, few analyses have examined doctors’ concepts of disease. Building on previous research findings that doctors consider some diseases to be more worthy than others, this article focuses on how these differences in disease prestige are articulated and made logical. We presented a focus group panel of doctors a table of 38 diseases rank-ordered by prestige according to the results of a previous quantitative study of doctors. We prompted a lively discussion among the doctors by asking them whether they were familiar with this rank order. In analysing how they managed the prestige knowledge presented to them, we focused on how they handled the value conflict between this informal rank order and the formal value of equality of treatment. Using positioning theory as a theoretical premise and a methodological tool, we found that the focus group participants created positions in their conversations that allowed them to present and discuss views on disease prestige that would be considered illegitimate if they were declared directly. However, they were able to do so without being forced to take a personal stand. Thus, we demonstrate how informal disease rankings can be produced and reproduced.

Keywordsdiscourse analysis, health policy, issues in research methodology, organization of health services

Corresponding author:Marit Haldar, Faculty of Social Science, Oslo and Akershus University College of Applied Sciences, PO Box 4, St. Olavs plass, 0130 Oslo, Norway. Email: [email protected]

596798 HEA0010.1177/1363459315596798HealthHaldar et al.research-article2015

Article

by guest on August 5, 2015hea.sagepub.comDownloaded from

mailto:[email protected]

http://hea.sagepub.com/

2 Health

Introduction

There is a significant body of research on patients’ experiences, how they handle their illnesses and encounters with the health services, and the illness knowledge they develop based on such experiences (Nettleton, 2013). One main finding is that many help-seekers are met with stigmatizing reactions from healthcare personnel and others (Scambler, 2009). The new sociology of diagnoses (Jutel and Nettleton, 2011) has already made noteworthy contributions to this field of research.

Whereas the sociological knowledge about patients’ illnesses has expanded, very little has been reported about the sociological knowledge of doctors’ disease concepts. Disease has scarcely been opened to cultural analysis. To a large extent, sociology has accepted medicine’s own positivistic disease concept, without examining the meaning of medical classifications.

In this article, we wish to contribute to the sociology of medicine by making doctors’ understanding of disease and disease classification a subject for cultural analysis, in much the same way as has been done with patients’ understanding of illness. We concen-trate on the value-laden aspects of disease. As a parallel to illness stigma, we examine disease prestige, including the differences in honour, regard and esteem given to diseases in informal medical culture (Album and Westin, 2008).

It would be of great interest to know how disease rankings are produced, reproduced and circulated in health services that regard equality ideals highly. Ascertaining this is the main aim of this article. We investigate how doctors articulate differences in disease prestige and make these differences seem logical by analysing discussions of the disease prestige hierarchy between doctors in a focus group setting.

Theoretical background

Freidson (1970) introduces a constructivist view of disease and illness by importing the labelling theory model from the sociology of deviance. He maintains Parsons’ (1958) basic sociological view that ‘Health and illness are not only “conditions” or “states” of the human individual […]. They are also states evaluated and institutionally recognized in the culture and social structure of societies’ (p. 170). However, Freidson (1970) moves beyond the idea of diseases as discovered reality, arguing that ‘(i)llness as such may be biological disease, but the idea of illness is not, and neither is the way human beings respond to it’ (p. 209). Thus, biological deviance or disease is defined socially and is sur-rounded by social acts that condition it. Therefore, ‘naming something an illness has consequences independent of the biological state of the organism’ (Freidson, 1970: 208). Annemarie Mol (2002) agrees with Freidson: ‘Like patients, or so it is said, doctors have a perspective. They attribute meaning to what happens to bodies and lives’ (p. 10). In her view, doctors and patients have different perspectives. We follow this line of thinking in our empirical cultural analysis of doctors’ classifications of medical diagnoses. We con-tend that the upsurge of patient-centred medicine, ideals of patient empowerment, and administrative and economic constraints may have weakened doctors’ strong classifica-tory power. The authority of the medical profession undoubtedly is still strong, however, as is the social power of diagnostic classifications (Jutel and Nettleton, 2011).



Haldar et al. 3

Surprisingly, one of Freidson’s other contributions to the sociology of medicine is seldom mentioned. He introduces a sociological classification of diseases built on three elements: legitimacy (Parsons, 1951: Chapter 10), stigma (Goffman, 1963) and serious-ness. This classification is loaded with values. The diseases that come closest to the ideal sick role are serious, often acute, without stigma and (therefore) highly legitimate (Freidson, 1970: Chapter 11). His analysis of sociological types of illness, based on the conditions’ legitimacy, stigma, seriousness and permanence, brought the sociological analysis of disease further than has been acknowledged in subsequent literature.

Following Freidson, we study medical disease understandings by bringing in a clas-sification of diseases based on their informally determined value in medical culture. This classification forms a continuous variable expressing the relative prestige of a set of well-known diseases selected and ranked by physicians (Album and Westin, 2008). The studies that produced this classification were empirically based on survey data from samples of both hospital-affiliated and other doctors and medical students, as well as from participant observation in hospital doctors’ break rooms, and they indicate that members of the medical culture have a shared knowledge of a rank order of diseases (Album and Westin, 2008).

This understanding of prestige is consistent with that of sociological studies on the prestige of occupations (Treiman, 1977; Zhou, 2005) and medical specialties (Nørredam and Album, 2007) and with studies of prestige in social psychology (Ridgeway, 2014).

In this way, as with studies of stigma, this study concentrates on informal evaluations of medical conditions. However, whereas stigma researchers are concerned with the dichotomy between normal and stigmatized diseases, we are concerned with a continu-ous variable in which, in principle, all recognized diseases are evaluated and ranked rela-tive to each other. Our study, then, focuses on shared evaluations of contested (Brown, 1995) as well as ‘unambiguously medical disease’ (Freidson, 1970: 213).

Positioning theory

To investigate how doctors talk informally about disease evaluations, we use the concept of positioning as our main analytical tool. This concept belongs to post-structuralist social science and is derived from discourse theory (Davies and Harré, 1990; Hollway, 1984). It was originally inspired by Foucault’s discourse theory, as formulated in ‘The Order of Discourse’ (Foucault, 1981). One of Foucault’s basic thoughts is that the subject is created or positioned through language, not the other way around. Through conversa-tions, we participate in narratives that pertain to us and we are offered ways of being in the world. In this case, language or discourse is the bearer of established images or ste-reotypical conceptions of doctors and patients, women and men, or heroes and villains (Langenhove and Harré, 1999).

There are several versions of the subject position concept (Davies and Harré, 1990). We use a conversation-oriented version rather than a macro-oriented one, thereby drawing on positioning rather than subject position as the main concept (Harré and Langenhove, 1999). This micro-oriented, conversation-directed version views discussions as action-oriented and situational. Based on a wide range of templates that are available through the discourse, the participants actively negotiate their positions. Various cultural templates are



4 Health

activated, combined or modified during the conversation and, in this sense, spoken into existence (Davies and Harré, 1990).

According to our view, positioning takes place in a conversation when a participant raises a point and receives a reaction. This participant’s point and the other participants’ reactions serve to position the participants in relation to each other in that phase of the conversation. Such multiple positionings are far from uniform or permanent; instead, they are episodic and fleeting in the settings where they are produced, although the same kind of position may appear in several settings (Harré and Langenhove, 1999). Positions are places from which to consider something and act upon it, and they provide a frame-work to explain one’s own and others’ thoughts, attitudes and actions (Søndergaard, 2002). In this way, each participant in a talk can occupy a series of different positions that they may talk from and talk to. When the participants in a conversation are part of (and familiar with) the same culture, they can use hints or subtle references to encourage the others to consciously or subconsciously imagine what is being suggested, such as by recognizing story-lines (Frigeiro, Montali and Fine, 2013). When doing positioning anal-ysis, it is necessary to focus on the discourse particles being employed as well as words referring to content. Words such as ‘anyway’, ‘you know’, ‘well’, ‘we’, ‘them’, ‘there’, ‘here’, as well as the use of the active and passive forms constitute an important part in recognizing positionings.

This form of suggestion, which stirs associations to well-known types, figures, and situations, has an effect. It causes the participants to detect other figures, including opposing figures. Understood in this way, conversation is a constant process of negotia-tion in which there are positions and positionings that provide participants with opportu-nities to adopt tentative stances. It is important to keep in mind that such stances are not necessarily associated with the people who express them. People can make statements that are attributed to a position from which they distance themselves. The acts of contest-ing, protesting, and agreeing allow for the effective positioning of oneself and others, including others that are not present. Also, such stances are not necessarily tied to per-sons. They might, for example, be ‘the past’, as we will see later. Thus, the positioning concept is a suitable tool for analysing which positions allow one to talk about prestige, and which do not.

From our theoretical perspective, we always speak from a position and always con-struct positions to talk to and talk against. In this way, positioning is a premise for our analysis, not a result. However, what we assert about how they use positioning, and which positions they adopt, is a result of our analysis.

Our analysis is consistent with Harré and Langenhove’s (1999: 6) model with regard to three basic features: (1) the moral positions of the participants, and the rights and duties they have to say certain things; (2) the conversational history and sequence of things that have been said; and (3) the actual comments with their power to shape certain aspects of the social world.

Inspired by these basic features, we will analyse how doctors manage to draw on moral positions in their conversation without those positions becoming attached to them as persons, how they draw on accepted knowledge in medicine and how they speak of some positions into existence in their conversations by presuming that the positions are true or real.



Haldar et al. 5

To reveal how doctors manage their knowledge about differences in prestige between diseases and how such differences can be discussed and made defensible, even when they collide with the norm of equality in treatment, we analyse data from a focus group interview with doctors.

Material and methods

Focus group methodology

A focus group interview is a group conversation in which a moderator directs group discussion towards specific topics that are relevant to the research questions (Kvale and Brinkmann, 2009). In ordinary group interviews, there is active dialogue between the interviewer and the group participants, whereas in the focus group, the dialogue between participants is meant to dominate the interaction (Halkier, 2002; Kitzinger, 1994), which implies that the individual is not the appropriate unit of analysis (Wilkinson, 1999).

The focus group interview is a unique and compact way of eliciting the co-construction of meaning in action (Wilkinson, 1998). It also reveals different understandings, opinions and descriptions, and it is especially well suited for examining how such statements are expressed and managed by speakers and responders. Thus, the focus group interview is suitable not only for revealing taken-for-granted notions but also for examining attitudes that participants find illegitimate. Data from focus groups come from group interactions (Morgan, 1996), and such interactions are better suited than individual or group inter-views for studying the dynamic between participants and how they position themselves relative to the other group members, and the positions they adopt, refer to or distance themselves from.

Nevertheless, data on interactions have allegedly been underutilized in focus group research (Duggleby, 2005), and such research has been criticized for failing to analyse conversational processes (Hydén and Bülow, 2003; Smithson, 2000). However, recent con-tributions have demonstrated analytical advances in combining content and interaction analyses (Halkier, 2010). In the words of Holstein and Gubrium (2004), there should be room for the ‘whats’ as well as the ‘hows’, and room for the analysis of substantive issues as well as discourse (Morgan, 2010). We use a focus group interview to analyse substantive questions (whats) concerning how a group of doctors view the prestige hierarchy of dis-eases presented to them. We further analyse how the focus group members react to the hierarchy; how they construct agreements, avoid conflicts and describe rankings without taking responsibility for them; and how, in this way, they express ‘whats’ through their ‘hows’.

Focus group interview in our study

Our analysis is part of a larger project studying priority settings in the health sector, in which participant observation, document analysis, surveys, qualitative interviews and focus group interviews are brought to use.

The participants in the focus group were six Norwegian doctors with extensive expe-rience in medical practice, primarily in large specialized hospitals. They were all



6 Health

specialists, and although they did not work together, they had met previously and knew each other to some extent. The doctors joined the focus group in 2010 during a training course. The interviews were conducted in one of the rooms of the building where the training course took place.

At the beginning of the interview, we gave the informants a table showing the prestige ranking of 38 diseases. The ranking was based on data from a questionnaire given to a separate group of doctors in a previous study. This set of 38 diseases was selected by a group of experienced doctors to cover a wide range of disease types (Album and Westin, 2008) (see Appendix 1). In this study, the moderator used this table of ranked diseases as a device to evoke discussion going with the following statement: ‘My initial question will be broad and open. Is this ranking something you are familiar with?’ During discus-sions, the moderator played a passive role which afforded us the opportunity to analyse the interaction between the participants.

Our basic strategy was to analyse closely the interaction between participants in one focus group interview only. We wanted to scrutinize the positioning of the participants during an entire conversation. Such a ‘close reading’ approach necessitated attention to a rather restricted selection of data. Given our analytical aims, we did not place emphasis on matching individual participants with their statements and we did not consider the participants’ expressions to be isolated from each other; instead, they were seen as evoked by other utterances. Our aim was to study how the conversation produced and sorted legitimate and illegitimate views. We were interested in the positioning work within one group of doctors. Our emphasis was on the statements themselves and how they related to other statements made in the session.

Informal rankings of diseases analysed here were discovered during fieldwork in doc-tors’ lunch room. This fieldwork took place in an early phase of the study. We con-structed a situation which replicated doctors’ conversations about diseases in order to study this in a controlled setting.

We considered the focus group to be a laboratory of conversation. As we wish to understand and categorize different views about disease prestige, we purposely created a situation in which doctors were forced to talk about how diseases are value-laden and by observing how the group reacted to a list of ranked diseases.

While reading and discussing the transcripts, we soon became aware of how the group participants negotiated legitimate and illegitimate positions towards prestige. This led us to positioning theory, which we then chose as our theoretical premise and analytical tool.

Data and results

Experts acknowledging and correcting a prestige hierarchy

When the moderator gave the participants the disease prestige rank table and asked them whether they were familiar with the hierarchy, they took the position as experts at once by immediately addressing whether the disease rankings presented to them were correct or not:

P(articipant) 1: It is certainly reflected in the priorities of the health service; you know, that heart disease is highly prioritized, and that heart disease is dominated by men with power and money.



Haldar et al. 7

P 2: I want to offer a small comment here, because I think perhaps the high priority there was more relevant 20 years ago … Yet, it’s still, you know, I would think it was a bit lower …

P 3: I actually think that heart attacks have lost a bit of their status, because they are now linked to lifestyle and being overweight …

Interestingly enough, they questioned the rank order and disagreed with it, but they did not question the existence of such an order. Their statements must be interpreted in light of their assignment, which was to comment on the table they received. The way they talked about the table, never calling the idea of a prestige ranking into question or offering any doubts or judgements about whether or not it existed, must mean that they acknowledged the existence of the hierarchy, although they disagreed with the specific ranks. The passive forms ‘is reflected’, ‘is prioritized’ and ‘is dominated’ emphasize the de facto nature of the phenomenon. Disease prestige and prioritization did not originate with them; they are an external reality to which they relate with analytical distance.

We also see in the above quotes that prestige is mirrored by prioritizing, and prioritiz-ing follows from prestige in an obvious manner. What is obvious and unproblematic in this context is conveyed in the expressions ‘certainly’ and ‘you know’.

A statement by Participant 5 referred to the disease prestige scale by underlining that it is different from the scale of diseases receiving more or less money from the public:

P 5: I think one has to distinguish a bit between the prestige assigned to diseases by doctors and others who participate in treatment, and what receives money from the public. If you look a bit at what disease groups receive money, that is, from the public, then it is cancers and children that are on top. Children and cancer are an unbeatable combination; it is indisputable, then the money pours in … But that is not the same as a disease having high prestige among doctors and others who participate in treatment that they have a special desire to work with. So there are two different scales, I think.

The following conversation, which was somewhat incoherent, became a negotiation in which the doctors argued for moving diseases up or down the hierarchy relative to their original positions. They took the existence of a hierarchy for granted, but doubted its specifics. The doctors hardly ever pursued each other’s lines of reasoning. Instead, additional comments moved the discussion in many directions, apparently based on a situation-oriented, implied understanding. Quite disparate characteristics of the diseases were raised, and every disease was a metonym for a reservoir of knowledge that was taken for granted as shared. It was unnecessary to elaborate, as if everyone immediately understood everyone else’s intimations and could freely associate in new directions with-out anyone falling behind.

All diseases have a complex set of characteristics that can raise or lower their prestige. The doctors did not argue over different assessments of the same characteristics; they focused on different characteristics that suggested different rankings for the disease. This enabled them to have strong opinions about the placement of a particular disease, even in partial opposition to colleagues, without their disagreements being socially problem-atic. They did not correct each other; they corrected the list, thus allowing each other to remain valid commentators. At the beginning of the interview, they spoke from a joint



8 Health

expert position, not only knowing the prestige of diseases but also the reasons behind the degree of prestige. In relation to one another, they behaved as mutually acknowledged authorities.

The first two statements indicate that there have been changes, but they do not explain them:

P 1: But this [cancer] is an example of a disease that has risen in status. Because previously it was like the surgeons did, yeah yeah, we take it in between, now it has become a specialty in itself … In general, many cancers have moved up …

P 4: But it is not as prestigious among doctors. It is difficult to recruit radiologists, surgeons, and oncologists to work with breast cancer …

Then, the group made a series of comments on different diagnoses and their ranks, explaining why the diagnoses are ranked where they are, or why they should have been ranked higher or lower. They discussed each disease rank with reference to a special criterion:

P 2: I want to return to heart attack … it has something to do with the technical side for doctors … the more technical it is, the more status it has. But then, for exam-ple, how do you explain appendicitis being so high up on the list?

P 3: I think I can explain that, because appendicitis is still a clinical diagnosis. It is, nevertheless, the doctor’s skill as a clinician that decides whether a patient has appendicitis or not.

P 6: I have, in any case, no problem understanding why fibromyalgia is at the bot-tom. I immediately get that … Of course, it’s a prejudice, you know. It’s not a genuine … I think there is psychiatry behind it.

P 1: But it is lower than schizophrenia …P 3: AIDS is another disease I reacted to in terms of how low it was on the list.P 2: … The same with cirrhosis. That is surely linked with alcohol …P 3: Another thing that struck me is how high ruptured spleen is. Super high –

ruptured spleen is so cool.P 5: It is ideal to work with things where the patients go in sick and come out healthy

…P 1: But then pancreatic cancer certainly comes out surprisingly high on the list.

Experts positioning ‘the others’: a public service, the past and media

At one point further in the conversation, Participant 4 said, ‘I don’t understand this list’, and all of the other participants agreed. Then, Participant 2 said,

I totally get why the items at the bottom of the list are at the bottom, that is, below apoplexy. I understand that, but the ones at the top, I don’t entirely understand those, you know. For example, a torn meniscus, is that very cool?

Everyone laughed.



Haldar et al. 9

Participant 4’s explicit statement that she or he did not understand the list constituted a break in the conversation. Three other participants supported the critical remark, with the third ending the critique with a question about who had made the list. In this way, the group adopted an active outside positioning. The disease rankings were made relative, and responsibility for the rank order in the table was determinedly transferred to posi-tions other than theirs.

As the following excerpt shows, this was particularly obvious when they asked the moderator who made the disease list, and the moderator’s answer did not stop the criti-cisms. Their continuing scepticism was first directed at the choice of diseases included and then at the rank order presented, concluding with the characterization that it was ‘very odd’. In this passage, the focus group participants turned themselves into a ‘we’ of experts, in total agreement against an old-fashioned or even ignorant position:

P 2: I think there was actually a lot of strange stuff on that list.P 3: Yes, very much so. I also reacted because …P 6: Just apropos, who made the list? It lacks a bunch of diagnoses.Moderator: Yes, well this is just a selection of diseases that I chose together with

doctors, for the most part specialists in hospitals. What is strange about the list? What is it you all are missing?

P 5: We are quite simply reacting to the selection, to the fact that, for us, it seems a bit arbitrary. … We are unable to determine much logic in it. Possibly that’s what makes it a bit strange, because I think we are … We do not strongly disagree with what is on the top and what is on the bot-tom, but we think a lot of the other stuff is a bit of a grab-bag.

P 6: It lacks dizziness, tinnitus, head and throat cancer.P 2: I learned that this is from a study that was done in 2008. And I thought

that this was a list that perhaps could have been relevant twenty years ago, that we now have other operation techniques, another result of treating some of them, and that some would be driven down and others up.

P 1: For example, I would have pushed heart down and cirrhosis up. And then I am surprised that, for example … stroke is up … Yes, and that appendicitis is so high up. I don’t understand that either.

P 5: Very odd. Very odd.

They still talked about disease prestige as something that existed as a matter of course, but they pointed to faults and oddities in the list. The selection of diseases was arbitrary, important diagnoses were lacking and the rank order was incorrect. It might have been correct 20 years ago, but not now. They distanced themselves further from responsibility; the prestige rank order presented to them was not theirs. In this way, they made them-selves even greater experts, closer to knowledge about disease prestige, because they claimed to know what a list that reflected the current prestige order would look like.

Another noteworthy aspect of their discussion is that they reached internal agreement by attributing the list to positions that is not assigned to anyone present, which is an example of how disease prestige is produced and maintained. Disease prestige is



10 Health

produced and reproduced through suggestions, as something they themselves are not part of, but which is undoubtedly real. It is something they know about but do not control. Such informal processes and forms of production, which everyone speaks into existence by making others responsible for them, are based outside of formal arrangements. Because everyone evades responsibility and there are no formal arrangements, there is nothing to terminate the process of production.

The ranking of diseases, especially the high status of heart disease, was first attributed to prioritization by the health services. The reason for the ranking is thereby placed out-side of the doctor group; instead, it is placed on a public service. When ranking is attrib-uted to entities outside the group, there is clearly more freedom to describe the entity’s motives. The health services, an external institution, can be blamed precisely because no specific people are identified. This kind of positioning is powerful because it evades specificity and genuine responsibility.

The positioning may be made even more unassailable by attributing the ranking to the past, as when Participant 2 said, ‘I want to offer a small comment here, because I think perhaps that the high priority there was more relevant twenty years ago’. The use of ‘there’ also creates vagueness about who held the position in the past, the doctors or a political agency. Regardless of the referent, the past excuses the present. Placing respon-sibility on the past allows discussion of the existence of a phenomenon that is difficult to eliminate because its origins no longer exist. The formulation is somewhat ambiguous because it suggests that although high priority does not exist now, it did at some time in the past.

High social rank among people affected by a particular disease also explains its pres-tige, at least when decided by the public through media. This is demonstrated in the fol-lowing excerpt:

P 6: And then Bechterew’s disease is going to go up since we discovered that Stoltenberg … [Norwegian prime minister]. That, you know, it is going to go up now.

P 2: Next year?P 6: Stoltenberg has it, you know.P 1: Lung embolism?P 6: No, Bechterew’s.P 1: He does?P 6: Yes, it was in the paper.

What is interesting about this limited exchange of words is how a change in rank is made locally true. No one opposed the prediction that Bechterew’s disease would go up. In other passages, there is more of a professional discussion and style, and one disease usually quickly succeeds another. Here, they stick to Bechterew’s disease, and there is an almost naïve way of speaking, as phrases such as ‘have you heard’ and ‘that’s just how it is’ are used. The discussion was not about whether the prestige of a disease increases when a high-ranking person has it. The discussion was about whether Prime Minister Stoltenberg had this disease. Although they spoke about this in a somewhat playful and ironic tone, there seemed to be no doubt that the doctors immediately acknowledged that



Haldar et al. 11

when a person of high social standing has a particular disease, this will raise the disease’s prestige.

Internal positions: the technologically playful doctor, the research doctor, the healer–life-saver

After having accepted the existence of the prestige rank order and mentioning external positions from which it could become comprehensible, the group turned towards finding (legitimate) reasons for its logic, taking up positions internal to medicine.

Participant 4 introduced three possible positions in the same paragraph. Referring to a previous statement, she or he mentioned the technologically playful doctor, the research doctor, and the healer or life-saver. The first two were barely mentioned, and in an ironic tone at that. The final one she or he addressed more thoroughly as she or he elaborated the last position:

The list reflects the prestige it has among doctors. And there is nothing strange in cancer coming far down, because whatever we do, the patients die, …, while these more technology things, and – as you mention – leukemia and stem cell research. One can do something about it, and there are a lot of us, that is why we are doing what we’re doing. We want to see the results of what we are doing, and we want it to be useful and for people to become healthy. And if it turns out that we still can’t get people healthy by what we are doing, then it isn’t that strange that people don’t get involved.

The person who made these comments spoke himself or herself into the last of these positions through the use of ‘we’ and ‘us’ and through justificatory meta-commentaries such as ‘it isn’t that strange that …’. The same participant repeated the same formulation slightly later in the conversation, to achieve precisely the same objective: ‘And if you really … then it isn’t that strange that where we can do a lot with the help of a profes-sional effort, then that is what has a high status’.

The most important thing about these statements, however, is that they legitimate the ranking of the less prestigious diseases. By pointing out that the doctor’s most important duty is to cure diseases, it becomes legitimate (or, at least, understandable) not to engage with certain diseases – those where lives are not saved or people do not get better. Participant 5 later strongly advanced the same positioning:

But it is the case that we are pulled towards diseases where we feel we have something to offer. Indeed, most of us would really like to work with diseases where you feel that what you’re doing … it really makes a difference in a way that is possible to see. The ideal is to work with things where the patient comes in sick and leaves healthy. Having to comfort and carry the burden of a hopeless course, that demands a lot more, you know. And some seek out that kind of thing, but most of us would prefer doing something that makes a difference as well.

The ‘most of us’ versus ‘some of us’ construction in this passage can be read as an attempt to legitimate and explain the engagement with and prestige of some diseases. With the ‘comfort and carry the burden of a hopeless course’ formulation, treatment of certain diseases is relegated to a caregiver position, and thus the care that is provided less



12 Health

resembles what a doctor does. Others can do that job just as easily. Seen from this per-spective, a doctor who chooses diseases with a ‘hopeless course’ to some extent chooses to be less of a doctor. The healer position legitimates the desire not to engage with dis-eases that offer poor treatment results.

It is also from the healer or even life-saver position that this argumentation was allowed to become the most normative and persistent:

P 4: Then you have to remember that even though what you are saying is right, you have to think about nearly everything we have been taught throughout the years, like the Lønning committee [an official proposition on prioritization criteria (Priorities-I, 1987)], and this whole thing with prioritizing and stuff. So remem-ber, what lies at the bottom of prioritization is how serious it is, you know.

P 2: The degree of seriousness, yes.P 4: And there still is, as far as I know, no one who has died from fibromyalgia …

The imperative formulations ‘then you have to remember’, ‘then you have to con-sider’ and ‘so remember’ are demonstrative, direct and offensive; they are almost rebukes. This time, the ‘you’ is not directed towards a general other, but towards the person who had just spoken. This unusual way of speaking comes from the position of the life-saver. What is said from this position stands out as the most certain truth. From there, others can be openly corrected, and emphatically so. This position makes it legiti-mate to speak with rhetorical fervour. Again, minimizing the importance of previously low-ranked diseases (in this case fibromyalgia) is justified, and it is done with a strong degree of irony. In contrast to fatal diseases, diffuse pains can be trivialized, and right-fully so.

Later in the conversation, a new position emerged that seemed to be legitimate: the advanced artisan. This position was also raised in an indirect manner, as a critique of the great prestige of the brain surgeon:

P 6: No, well, brain surgery clearly, that is. Everyone says, you know, everyone says so. Colleagues, too: ‘This isn’t brain surgery, you know’. It’s an expression. Brain surgery, that’s like the top. He works the longest, and the most, and in the middle of the night.

P 4: I was also very fascinated by that and thought … until I read a description of an operation, and it just said, ‘Tumour easily extracted with suction’. Then I wasn’t so impressed any more.

P 6: Yes, there is a bit of carelessness.P 2: Yes, that was neurosurgery.P 4: That was neurosurgery. Then it sort of wasn’t that exciting. So for me, it jumped

down on the list a bit.

This expresses a clear ambivalence towards brain surgery. On the one hand, it is clear that it is a very prestigious activity and position. On the other hand, they cast doubt on whether it is as elevated and demanding as it is perceived to be. They question whether neurosurgery is such a difficult craft and therefore whether it deserves the prestige it has.



Haldar et al. 13

Consequently, the performance of an elevated and demanding craft (and the diseases treated by those who master it) is generally and mutually recognized as something that should have a high level of prestige.

A final legitimate position was implicated as an explanation of disease prestige, this time in the form of a justification. Participant 1 said,

… even though we are doctors, we are also regular people, and there is something about the heart and brain that is … if this is stable over time, then there is something about the idea that these are very central organs, and that has great emotional significance.

The doctor as a regular person is ascribed a dual role. In contrast to the healer, the artisan and the researcher, this is not a position that can be inferred from an ideal, ele-vated or exemplary doctor role. She or he is not saying: I am not human because I am a doctor. The position seems to be more of a ‘despite’ rather than ‘because of’ situation: I cannot stop being human, although I am a doctor. Humanity is a crack in the polished, superficial veneer of the doctor, but it is a necessary crack. A good doctor cannot just be a doctor. The positioning of the doctor as a regular person, therefore, is consistent with the exemplary doctor figure, but it is legitimate precisely by virtue of its being an excep-tion to the rule. The regular person must appear in a roundabout way. That which is represented as a break from the doctor role (we are not merely professionals, we are also people) is legitimated through a kind of rhetoric of authenticity. The reference to a regu-lar and emotional human being renders possible the position from which the heart and brain and their diseases are given prestige. However, it is through this justificatory rheto-ric that the doctor role indirectly becomes exemplary. First, the doctor role must be understood as purely professional: under no circumstances can a doctor give herself or himself over to the emotional side of things. Those holding such a role are exemplary by being able to set their own feelings aside. Next, when it becomes obvious that one can do this, one becomes an exemplary doctor by breaking with the professional doctor role. An inhumane doctor is an illegitimate position. In this way, diseases linked to the heart and brain are raised in rank in a credible manner.

Legitimate articulation of the illegitimate by confession

This justificatory and credible rhetoric is an example of a phenomenon that was common in the conversation: the illegitimate is articulated in a legitimate manner.

In a previously cited comment, Participant 6 said that she or he has no problem under-standing why fibromyalgia is at the bottom of the prestige table, and then she or he declared, ‘I immediately get that. … Of course, it’s a prejudice, you know. It’s not a genuine … I think there is psychiatry behind it’. With this statement, the participant says what is not supposed to be said by adding, ‘Of course, it’s a prejudice, you know’.

Participant 4 began one of his or her comments with the hesitating introduction, ‘That may be it then’, thus warning that she or he is about to say something illegitimate, which thereby makes it legitimate to continue: ‘So, maybe that’s the case, that we don’t like it because we don’t know anything about it?’ Slightly later, the same participant said, ‘So you all think that this list perhaps better reflects which people we like?’ Formulating the



14 Health

question with ‘so you all think’ and toning it down with ‘perhaps better’ allows him or her to say something about himself or herself and the others while at the same time dem-onstrating that it is not a statement she or he personally supports.

This is a different type of positioning from the ones previously identified. The previ-ously analysed positions can be characterized as points of view assigned to unspecific others. With this new type, the speakers opt out of the meaning they state by means of a confession or other kind of meta-commentary.

Participant 5 was able to say something illegitimate by means of a similar type of positioning:

Most patients with cirrhosis of the liver, they die a slow death in a medical ward, as foul-smelling, unpleasant … yes … that’s how we are. I think we are like that. We gravitate towards what’s pleasant, and this is unpleasant business.

In this passage, the expressions ‘that’s how we are’ and ‘this is unpleasant business’ turn an inappropriate statement into something more appropriate because it is already acknowledged as being inappropriate. In saying that it is bad to make a particular state-ment, it immediately becomes less bad to say it. Participant 1 expressed something ille-gitimate in the following way:

If there is something you in a way have been in part inflicting on yourself, or if there is something you got sick from through no fault of your own, I think that we are actually affected by those kinds of things when we are working, whether we want to stand by it or not.

In this passage, the phrases ‘actually’ and ‘whether we want to stand by it or not’ envelop the illegitimate in a legitimate manner. It is the confession that makes the state-ment more appropriate at the time. Through self-recognition, the statement becomes more morally acceptable. Participant 5 also used the rhetoric of confession:

I think there is something there as well, which also is not too pleasant to be reminded of. But it is clear there are people who are verbal, who are educated, who are eloquent, with whom you can conduct a reciprocal conversation and discussion with … you know. That is preferable.

By starting with the confession ‘which also is not too pleasant to be reminded of’, the participant is able to mitigate his or her statement. This self-scrutinizing makes his or her statement credible. ‘You know’ is an interpolation. The participant does not let his or her statement go without comment. She or he is self-reflective and at the same time acquires support from the other participants. By saying, ‘you know, she or he implies that the oth-ers agree, unless they explicitly contest it. Thus, the illegitimate utterance is normalized.

In a sense, this legitimation of ranking through justifications and confessions is related to a rhetoric that generalizes the ranking by attributing an anonymous and general posi-tion to it, such as the public health system and ‘the past’. The justifications and admis-sions also have a generalizing and universalizing function. There is a kind of ‘general self’ that is expressed and that confers legitimacy to the position. The speaker asserts the right to be this way because ‘that is how we all are’. A kind of general personal position is established to legitimate the illegitimate statements.



Haldar et al. 15

Discussion

The main aim of this study has been to illuminate how informal disease prestige rankings in medicine are produced, maintained and circulated among health personnel, when it collides with bio-ethical values. We have analysed experienced doctors’ talk in a focus group setting, in which they had been asked to reflect on findings from a previous study of the prestige rank of diseases.

The focus group setting was intended to approximate the informal talks between col-leagues during breaks in daily work or other occasions. The high level of participation from all the doctors in the group indicates that they were familiar with and interested in the theme of the discussion.

We used positioning theory as a methodological tool to scrutinize the systematic ele-ments in their talk. This was important in our strategy for understanding how doctors handle value-laden views on diseases. In our judgement, this approach made it possible to elicit an important two-sidedness in their discussion, that is, how they can recognize the reasonableness of differences in the prestige of diseases without acknowledging these views as their own.

The positioning approach requires interaction data, which is why we chosen to ana-lyse focus group data by examining relatively long sequences of discussion in detail. Such a detailed approach meant that we were only able to examine one interview session for this article. A series of analyses of differently composed focus groups who are given the same assignment would be of interest. These could include groups comprised solely of general practitioners or hospital doctors and groups from different types of hospitals with varying medical specialties, ranks, age groups and gender.

Three women and three men, all of them experienced specialists with an average age of around 40 years, participated in the session analysed here. Our examination of discus-sions and interaction in the focus group revealed a democratic pattern. Female partici-pants spoke almost twice as often as male participants, but the males spoke for a longer time on average, such that the women and men spoke for an almost equal amount of time overall. It would be interesting to analyse this pattern further. There was no connection between gender and individual statements made in the group discussions.

As is usual in qualitative research, we had to choose between presenting a relatively detailed analysis of one conversation or a more cursory summary of several of the ses-sions. We found the first choice to be more fruitful, especially as this is the first time an analysis of this type has been done. We have not found other studies analysing how illegitimate issues are discussed in informal talk among professionals.

In our view, there is a more general aspect of this analysis that is also worth mention-ing. Using a positioning approach to analyse focus group interactions is suitable for studying how people discuss controversial issues on a broader basis. Observing how people speak (‘how’) when they discuss substantive matters (‘whats’) is important in this context.

A serious possible critique of our approach is that we forced the participating doc-tors to talk about illegitimate aspects of their own professional culture. In their daily life at work, they will more easily be able to leave situations where such topics are raised or stay silent. The participants in the focus groups had been told they could



16 Health

withdraw whenever they wished, but this may be socially difficult. When we, never-theless, found it ethically appropriate to do this, it is because we know from other interviews and from fieldwork that this kind of talk is common and done with ease in unofficial settings.

Conclusion

Understanding professional talk of the kind presented here can give a clearer view of how informal priorities based on shared culture are maintained. In times when diagnoses are closely connected to economic resources and incentives, this topic is important for policy-making in the healthcare sector.

Assessments made by professionals affect informal priority settings in the health sector along with pressure from the pharmaceutical industry, patient organizations and media, economic incentives for hospitals and so on. We know, however, that disease prestige cannot be discussed in formal settings, such as board meetings, because the notion that diseases have different levels of prestige contradicts firmly held values about providing equal treatment (Førde, 2012; Priorities-I, 1987; Priorities-II, 1997).

In this study, we attempted to make more transparent what people already know but have difficulty conveying: namely, that there are informal rank orders of basic categories of work in professions, such as doctors’ prestige ranking of diseases. To demonstrate how a group of doctors acknowledge the existence of this disease prestige hierarchy as a matter of course, we focused on their management of that knowledge, especially how they handled its informality, somewhat illegitimate nature and its conflict with the ethical values of their profession.

The existence and systematic nature of the prestige rank order have been identified previously. What this study adds is an analysis of how people discuss such information. By analysing doctors’ discussion in a focus group setting, we observed how negotiation processes in their conversations about positions and positioning allowed them to take positions on disease prestige rankings while avoiding personal responsibility for what they said because what was said did not have to be associated with the speaker. The speaker could attribute a statement to a position that was constructed as part of the dis-cussion and thereby distance himself or herself from the statement. By analysing the articulation and justification of disease prestige, we have shown how doctors position themselves when they discuss a topic that is loaded with unsanctioned values and how they are able to express illegitimate views. We emphasize that ‘illegitimate’ does not mean hidden or forbidden; instead, it refers to knowledge that is not formal and cannot be discussed in all contexts.

We regard this as an important step forward in the analysis of disease prestige in medical culture. By learning more about how this is discussed, we can get closer to understanding how differences in prestige may affect informal priorities in the health services.

Funding

This research was supported by the The Research Council of Norway.



Haldar et al. 17

References

Album D and Westin S (2008) Do diseases have a prestige hierarchy? A survey among physicians and medical students. Social Science and Medicine 66(1): 182–188.

Brown P (1995) Naming and framing: The social construction of diagnosis and illness. Journal of Health and Social Behavior 35: 34–52.

Davies B and Harré R (1990) Positioning: The discursive production of selves. Journal for the Theory of Social Behavior 20(1): 43–63.

Duggleby W (2005) What about focus group interaction data? Qualitative Health Research 15(6): 832–840.

Førde R (2012) How can empirical ethics improve medical practice? Cambridge Quarterly of Healthcare Ethics 21(4): 517–526.

Foucault M (1981) The order of discourse. In: Young RC (ed.) Untying the Text: A Post-Structuralist Reader. Boston, MA: Routledge.

Freidson E (1970) Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Dodd Mead & Co.

Frigeiro A, Montali L and Fine M (2013) Attention deficit/hyperactivity disorder blame game: A study on the positioning of professionals, teachers and parents. Health 17(6): 584–604.

Goffman E (1963) Stigma. Englewood Cliffs, NJ: Prentice Hall.Halkier B (2002) Fokusgrupper [Focus Groups]. København: Samfundslitteratur.Halkier B (2010) Focus groups as social enactments: Integrating interaction and content in the

analysis of focus group data. Qualitative Research 10(1): 71–89.Harré R and Langenhove L (1999) The dynamics of social episodes. In: Harré R and Van

Langenhove L (eds) Positioning Theory: The Moral Contexts of Intentional Action. Oxford: Blackwell Publishers Ltd., pp. 1–13.

Hollway W (1984) Gender difference and the production of subjectivity. In: Henriques J, Hollway W, Urwin C, et al. (eds) Changing the Subject: Psychology, Social Regulation and Subjectivity. London: Methuen, pp. 227–263.

Holstein JA and Gubrium JF (2004) The active interview. In: Silverman D (ed.) Qualitative Research: Theory, Method and Practice. London: SAGE.

Hydén LC and Bülow PH (2003) Who’s talking: Drawing conclusions from focus groups: Some methodological considerations. International Journal of Social Research Methodology 6(4): 305–321.

Jutel AG and Nettleton S (2011) Towards a sociology of diagnosis: Reflections and opportunities. Social Science and Medicine 73(6): 793–800.

Kitzinger J (1994) The methodology of focus groups: The importance of interaction between research participants. Sociology of Health and Illness 16(1): 103–121.

Kvale S and Brinkmann S (2009) Interviews: Learning the Craft of Qualitative Research Interviewing. London: SAGE.

Langenhove L and Harré R (1999) Positioning as the production and use of stereotypes. In: Harré R and Langenhove L (eds) Positioning Theory: The Moral Contexts of Intentional Action. Oxford: Blackwell Publishers Ltd., pp. 127–138.

Mol A (2002) The Body Multiple: Ontology in Medical Practice. Durham, NC: Duke University Press.

Morgan DL (1996) Focus groups. Annual Review of Sociology 22: 129–152.Morgan DL (2010) Reconsidering the role of interaction in analyzing and reporting focus groups.

Qualitative Health Research 20(5): 718–722.Nettleton S (2013) The Sociology of Health and Illness. Cambridge: Polity Press.Nørredam M and Album D (2007) Prestige and its significance for medical specialties and dis-

eases. Scandinavian Journal of Public Health 35(6): 655–661.



18 Health

Parsons T (1951) The Social System. New York: The Free Press of Glencoe.Parsons T (1958) Definitions of health and illness in the light of American values. In: Jaco EG

(ed.) Patients, Physicians and Illness: Sourcebook in Behavioural Science and Medicine. Glencoe, IL: The Free Press.

Priorities-I (1987) Retningslinjer for prioritering innen norsk helsetjeneste [Guidelines for Priority Settings in Norwegian Health Services]. Oslo: Statens forvaltningstjeneste.

Priorities-II (1997) Prioritering på ny [Priorities a New]. Oslo: Statens forvaltningstjeneste.Ridgeway C (2014) Why status matters for inequality. American Sociological Review 70: 1–16.Scambler G (2009) Review article: Health-related stigma. Sociology of Health and Illness 31:

441–455.Smithson J (2000) Using and analysing focus groups: Limitations and possibilities. International

Journal of Social Research Methodology 3(2): 103–119.Søndergaard DM (2002) Poststructuralist approaches to empirical analysis. International Journal

of Qualitative Studies in Education 15(2): 187–204.Treiman DJ (1977) Occupational Prestige in Comparative Perspective. New York: Academic

Press.Wilkinson S (1998) Focus groups in health research: Exploring the meanings of health and illness.

Journal of Health Psychology 3(3): 329–348.Wilkinson S (1999) How useful are focus groups in feminist research? In: Barbour R and Kitzinger

J (eds) Developing Focus Group Research: Politics, Theory and Practice. London: SAGE.Zhou X (2005) The institutional logic of occupational prestige ranking: Reconceptualization and

reanalyses. American Journal of Sociology 111(1): 90–140.

Author biographies

Marit Haldar is a Professor of sociology at the Department of Social Work, Child Welfare and Social Policy at the Oslo and Akershus University College of Applied Sciences. She has done extensive qualitative research, mostly analysing gender relations, childhood and family. She is now involved in a project analysing informal aspects of medical culture.

Eivind Engebretsen is an intellectual Historian and a Professor at the Faculty of Medicine at the University of Oslo, where he is responsible for the phd-programme. He has done research on knowledge cultures within health and social work and has mainly worked on text and discourse analysis.

Dag Album is a Professor of sociology at the University of Oslo. He has done ethnographic studies in hospitals, analysing patient-patient interaction and culture. One of his main interests has for a long time been informal evaluations of diagnoses among doctors and other health personell.



Haldar et al. 19

Appendix 1Disease prestige: rank and mean scores (95 per cent confidence intervals) in senior doctor, general practitioner and senior student samples.a

Samples Senior doctors

General practitioners

Senior students

N = 242 N = 327 N = 317

Diseases Mean of all diseases 5.0 5.1 5.5 Myocardial infarction 1 6.9 1 7.2 2 7.1 Leukaemia 1 6.9 2 6.9 3 7.0 Spleen rupture 3 6.6 3 6.6 4 6.9 Brain tumour 3 6.6 3 6.6 1 7.2 Testicular cancer 5 6.5 6 6.5 6 6.5 Pulmonary embolism 6 6.3 3 6.6 5 6.6 Angina pectoris 7 6.0 6 6.5 7 6.5 Extra-uterine pregnancy 7 6.0 8 6.0 9 6.1 Thyroid cancer 9 5.9 10 5.9 16 5.5 Meniscus rupture 9 5.9 10 5.9 10 6.1 Colon cancer 11 5.7 12 5.8 14 5.7 Ovarian cancer 11 5.7 12 5.8 12 5.8 Kidney stone 13 5.6 15 5.6 15 5.6 Appendicitis 14 5.5 8 6.0 8 6.4 Ulcerative colitis 15 5.4 17 5.5 23 5.1 Kidney failure 15 5.4 19 5.3 19 5.3 Cataract 17 5.3 21 5.2 24 5.0 Duodenal ulcer 18 5.2 15 5.6 18 5.4 Asthma 18 5.2 12 5.8 17 5.5 Pancreatic cancer 18 5.2 18 5.4 11 5.8 Ankle fracture 21 5.1 19 5.3 13 5.7 Lung cancer 21 5.1 21 5.2 21 5.2 Sciatica 23 4.9 23 5.0 25 5.0 Bechterew’s disease 23 4.9 23 5.0 26 4.8 Femoral neck fracture 25 4.6 26 4.7 27 4.8 Multiple sclerosis 26 4.5 26 4.7 20 5.2 Arthritis 27 4.4 25 4.9 29 4.1 Inguinal hernia 28 4.2 29 4.3 28 4.5 Apoplexy 29 4.0 28 4.4 22 5.2 Psoriasis 30 3.8 30 4.2 33 3.7 Cerebral palsy 31 3.6 31 3.9 30 4.1 AIDS 32 3.5 32 3.8 31 4.0 Anorexia 32 3.5 33 3.5 32 3.7 Schizophrenia 34 3.2 35 3.3 34 3.4 Depressive neurosis 35 3.1 34 3.4 36 2.8 Hepatocirrhosis 35 3.1 36 3.0 35 3.1 Anxiety neurosis 38 2.8 36 3.0 37 2.5 Fibromyalgia 38 2.3 38 2.3 38 2.0

aThe diseases are listed in the rank order found in the senior doctor sample.



Legitimating the illegitimate: How doctors manage their knowledge of the prestige of diseases

Documents

Transcript of Legitimating the illegitimate: How doctors manage their knowledge of the prestige of diseases