What is the object of your work? If you were asked this question, you would probably hesitate awhile before answering. You might demand that I tell you first what I mean by object. You might ask whether I am interested in the objective – or goal – of your work. In general, you would have a hard time formulating an answer.
Let us take a simple example. The blacksmith (subject) uses a hammer (instrument) to mold a piece of iron (object). So the piece of iron is the object. But at one moment the piece of iron is a shapeless chunk, at another moment it is an identifiable, socially meaningful entity. Object is both “anything presented to the mind or senses” and “an end or aim” (Webster’s Dictionary, 1987, p. 257). So the object is both something given and something projected or anticipated. This very duality of the meaning of the term indicates that the concept of object carries in it the processual, temporal, and historical nature of all objects. Objects are objects by virtue of being constructed in time by human subjects. This in no way diminishes their reality and materiality. But despite its materiality, an unknown particle or a mineral in a rock is not an object for us before we somehow make it our object – by imagining, by hypothesizing, by perceiving, naming, and acting on it (Smith, Reference Smith1996).
The construction of objects is more complicated than it seems. The blacksmith cannot mold his or her object without tools. And the use of tools already implies the creation and use of secondary instruments: signs and models for representing, storing, guiding, transmitting, and communicating the procedures of tool use – what Rabardel and Waern (Reference Rabardel and Waern2003) call “instrumental genesis.” Lektorsky (Reference Lektorsky1984) observes:
In the objects cognized, man singles out those properties that prove to be essential for developing social practice, and that becomes possible precisely with the aid of mediating objects carrying in themselves reified socio-historical experiences of practical and cognitive activity.... In other words, the instrumental man-made objects function as objective forms of expression of cognitive norms, standards, and object-hypotheses existing outside the given individual. (p. 137)
In other words, objects are not constructed individually and arbitrarily. They are constructed with the help of and under the influence of historically accumulated collective experience, fixated and embodied in mediating artifacts.
The basic paradox of object construction has to do with the creation of the new. lf we construct objects only by looking through and working with artifacts made by our predecessors, how can we ever see and make anything truly new, qualitatively different from the inherited standards? “By creating novel mediating artifacts,” one might answer. As Lektorsky (Reference Lektorsky1984, p. 142) points out, this means that the mediating artifacts are taken as objects themselves, and “in this case they cease to be mediators and assume the construction of a new system of mediator objects, embodying the knowledge about them.” So the result is a circular argument, not a solution to the paradox.
All this has practical relevance in today’s expert work activities. As Leont’ev (Reference Leont’ev1978; Reference Leont’ev1981) emphasizes, the true motive of activity is its object. The motive of the blacksmith’s work activity resides in the iron – in the societal meanings and relations embodied and molded in each piece of iron the blacksmith makes his or her object. The notion of alienation implies that the workers, the subjects of work activity, cannot construct the object of their work as a meaningful motive.
The separation of ownership and the practical productive use of the means of production, interwoven with an intricate division of labor and the increasing abstractness of the object, make motive construction exceedingly difficult in many complex work organizations. And it is seldom possible to revitalize traditional motives simply because the object of work – what is actually produced and for what kind of uses – must be continuously questioned and redesigned under market, technological, and legislative pressures.
ln the following pages, I examine the construction of the object in the work activity of general practitioners in a health center. The research on which this chapter is based was conducted in the municipal health center of the city of Espoo in Finland. The health stations of the center served the population as providers of primary health care services, which were at the time of the data collection free of charge, and presently are for a small fee. At the time of the collection of our data, the services were organized so that each inhabitant of the city could in principle use any of the ten stations and any of the physicians working at those stations. We videotaped 85 randomly chosen patient consultations at two stations, one employing 10 general practitioners, the other employing 6. Together these two stations formed a service district of the municipal health center. After the videotaping, the patient and the doctor separately viewed the videotape and gave a stimulated recall interview, interpreting the events of the consultation and commenting upon them.
The Dual Viewpoints of the Doctor and the Patient
From the point of view of the physician, the object of activity is connected to the patient. The patient is the initial physical carrier and embodiment of the object, in whatever way the object is subsequently delineated and conceptualized. The patient is the raw material, the perceptual-concrete immediate appearance of the object. In every encounter, this raw material is first transformed into a meaningful pattern of important features, selected and arranged with the help of a more or less consciously used mediating model. This selective meaningful pattern is subsequently used as the basis for choosing examinations and therapeutic measures, leading to a temporary or relatively permanent outcome – supposedly some sort of an improvement in the health of the patient. This cycle may be repeated at varying intervals and within different time scales, as Zerubavel (Reference Zerubavel1979) has shown.
For the patient, the object is different. The perceptual-concrete raw material is pain: a feeling of ill health, worry, or more generally, sensuously experienced problems or symptoms. The doctor looks at the patient from the outside; the patient senses and experiences problems inside herself or himself. Both have quite different raw materials to start with. The patient also transforms the raw material into some kind of a meaningful pattern. She or he tries to make sense of the problem by using internalized or otherwise available culturally accumulated models. These are seldom similar to those used by the doctor. Finally, the meaningful pattern functions as the basis of the patient’s practical actions upon the problem.
Both the doctor and the patient use models as mediating artifacts in relating to the object. In medical sociology and anthropology, the notion of mediating models was pioneered by Kleinman (Reference Kleinman1980). He differentiated between “general beliefs about sickness and health care” and “explanatory models” that are “marshaled in response to particular illness episodes” (p. 106). This roughly corresponds to a distinction between a general model and a case-specific meaningful pattern. Helman’s (Reference Helman1985) analysis of the differences and interplay of the explanatory models of five physicians with diverse backgrounds who treated the same patient is an elegant example of the power of the notion of mediating models.
But the model notion is not unproblematic (Wartofsky, Reference Wartofsky1978). Hunt, Jordan and lrwin (Reference Hunt, Jordan and Irwin1989) criticized the notion of “explanatory models” of illness:
This concept suffers from the same limitations of more general uses of cognitive models in anthropology: it produces a prevalent notion that people hold essentially static mental templates (modifiable as they may be) that provide a pattern for action in the world.... We avoid the “explanatory model” terminology and instead focus on the process by which illness explanations are constructed.... Thus what we refer to as “explanation” should be seen not as a structure or model but as a process in which current formulations become interactional objects in a social environment, which are molded in and by the circumstances in which they are employed. (p. 946)
As support to their criticism, Hunt, Jordan, and Irwin (Reference Hunt, Jordan and Irwin1989) point out that there were substantial fluctuations over time in the explanations of illness constructed by their subjects. At different points in time, a subject could consider a number of different causes of her symptoms.
It is indeed probably futile to seek specific models that would connect a given symptom to a fixed cause or illness in a stable manner. Actually, Kleinman (Reference Kleinman1980, p. 107) himself emphasized that “vagueness, multiplicity of meanings, frequent changes, and lack of sharp boundaries” are characteristic of explanatory models.
The very fact that a patient may produce several different causes as explanations to her symptoms within a short period of time calls for an analysis of her more general model for constructing causes. Such a model cannot be reduced to a well-bounded individual cognitive map of clear-cut propositions and explicit causal connections. We are talking about a more elastic, socially distributed, culturally and historically rooted cognitive–motivational approach or orientation.
The techniques of describing such complex representations are presently inadequate, but there is a clear need to tackle the issue. Resources may be found for example in Jewson’s (Reference Jewson1976) analysis of medical cosmologies and in the debates on social representations (Farr & Moscovici, Reference Farr and Moscovici1984; Potter & Litton, Reference Potter and Litton1985; see also Cohen et al., Reference Cohen, Tripp-Reimer and Smith1994; Rich, Patashnick, & Chalfen, Reference Rich, Patashnick and Chalfen2002; Kleinman, Reference Kleinman2013).
I agree with the point that instead of assuming stable mental structures, we should direct more attention to how categories are actually used and constructed in everyday practices (Potter & Wetherell, 1987, p. 137). But I also agree with the following dialectical advice:
There is a real cognitive dissonance for most of us if we are told that a single event is both particle and wave, or both structure and process, or both mind and matter. Complementarity is not to be confused with tolerance of different views. It is not a resolution of a contradiction, as if you were to agree that we are simply “looking at the problem from different perspectives,” like the blind man and the elephant. Rather, it is a sharpening of the paradox. Both modes of description, though formally incompatible, must be a part of the theory, and truth is discovered by studying the interplay of the opposites.
As we have concluded that we need analyses of both models and discourse processes, understood in their dialectical interplay and complementarity, we may make a first attempt at depicting schematically the subject–object relationship in a medical encounter (Figure 2.1).
Figure 2.1. The subject–object relationship in a medical encounter.
The question marks in Figure 2.1 imply that the problem is located in the transformation of the raw material into a meaningful pattern. This focus differs from that adopted by Hunt, Jordan, and Irwin (Reference Hunt, Jordan and Irwin1989), among many others. They sought explanations or diagnoses of particular symptoms. I do not think that the formation of meaningful patterns of doctors’ and patients’ objects can be understood purely at the level of particular symptoms and diagnoses. Diagnoses are always saturated and constrained by notions of how to contextualize and make sense of the problem. I am interested in how doctors frame and construct patients and how patients frame and construct themselves as totalities.
In the following pages, I first examine interview data containing health center doctors’ accounts of the object of their work. This section focuses on models gleaned from interview data. After that, I analyze the subject–object relationship in two specific consultations. This analysis focuses on discourse recorded in consultations and on postconsultation stimulated-recall interviews.
Physicians’ Dominant Models of the Object
We conducted an extensive interview with each of the 16 participating physicians. The interview contained, among other themes, a cluster of questions concerning the physician’s conception of the object of his or her work. The questions in this cluster required the subject to describe and justify his or her reactions in hypothetical difficult situations (e.g., a patient visit that the physician considers medically unnecessary; a patient with unclear or incomprehensible symptoms; a patient with psychic symptoms; a patient with a self-made diagnosis; a patient with multiple simultaneous problems).
The analysis of the transcribed interviews resulted in a classification of the physicians’ models of the object of their work, summarized in Table 2.1. The models are simplified ideal types, constructed by highlighting dominant notions expressed by the subjects and by eliminating nondominant and ambiguous notions. The five models found among the physicians of this organization correspond to five historically distinct and culturally deep-seated conceptual patterns of thinking about and dealing with illness. These cannot be conceived in terms of stages along a one-dimensional path from novice to expert. There is no unproblematic way to categorize some of these models as “more advanced” or “better” than others.
Table 2.1. Primary Care Physicians’ Conceptions of the Object of Their Work
| Object of Work | Number of Respondents | Corresponding Theory of Illness | Key Expressions in the Interview |
|---|---|---|---|
| 1. Somatic diseases | 4 | Ontological–biomedical | Old-fashioned diseases; small medically unnecessary problems; clear-cut causes; psychic problems are difficult; self-made diagnoses are aggravating; care is under control; patient is honest and compliant |
| 2. Consumers of health care services | 4 | Administrative–economic | Types of visits and patients; misuse of services; referrals; self-made diagnoses are aggravating; relationship between patient and organization; patient should observe the agreed-upon appointment |
| 3. Patient as a psychosomatic whole | 1 | Psychiatric | Mental-health problems; there are no unnecessary visits; deeper psychic causes revealed through interviewing; patient must be guided to talk; give patient time |
| 4. Patient’s social life situation | 2 | Socio-medical | Social problems and multiple illnesses; there are no unnecessary visits; psychic problems have social origins; patient’s own diagnosis is important |
| 5. Patient as collaborator | 5 | Systemic-interactive | Active thinking patients; unnecessary visits caused by lack of knowledge and bureaucracy; make patient reflect upon his/her own situation and alternative actions; make patient take health into his/her own hands; patients are more critical and informed than they used to be; equal collaboration |
The first model in Table 2.1 sees the object as a physical lesion, as a biomedical disease. This view is the core of the professionalism of medical craftsmen, possessing the secrets of disease. Armstrong (Reference Armstrong1984) observes:
At the beginning of this century, the patient’s view was, in essence, the unformed words of the disease. The interrogation was concerned with the characteristics and “life history” of the symptom. ... To get a clear picture of the symptom so that it stands out as if it had a personality is the ideal to be sought for. Beyond the disease, the patient only had existence as a good, bad or indifferent historian. (p. 738)... Under the old regime the patient was no more and no less than the body which enclosed the lesion. (p. 740)
The second model in Table 2.1 basically sees the object as a flow of input-output units, measured by the amount of time and work they require. This model represents the rationalized and bureaucratic type of physicians’ work, which has gradually replaced the autonomous professionals (see e.g., Mechanic, Reference Mechanic1976; Mizrahi, Reference Mizrahi1986).
The third model in Table 2.1 sees the object as the patient’s psychosomatic problems. This model represents the humanized type of physicians’ work, which exists parallel with the rationalized type. Armstrong (Reference Armstrong1984) noted, “By the 1930s many doctors were well aware of the ubiquity of the neuroses and the need for a general mental hygiene. ln consequence patient anxieties and personalities together with notions of psycho-somatic unity began to become important features of much clinical practice” (p. 739).
The fourth model in Table 2.1 is closely related to the third one. While the psychiatric model seeks to extend the notion of illness along the dimension of psychic depth, the socio-medical model extends it horizontally, along the dimension of socioeconomic space. Arney and Bergen (Reference Arney and Bergen1984) observe: “The roots of changes in medicine lie in the 1920s and 1930s when concern over the incidence of chronic diseases in non-institutional populations first surfaced. ... At the conceptual level, the problem was to locate disease in the socio-economic parts of the holon hierarchy of systems” (pp. 80–81). Contradictions of both the rationalized and the humanized types of work seem to push forward elements of an emerging new model that regards the object as a relatively autonomous decision-maker and contributing partner in health-related assessment, planning, and execution of therapy (e.g., Speedling & Rose, Reference Speedling and Rose1985). The rise of consumerism in medicine (Van den Heuvel, Reference Van den Heuvel1980; Haug & Lavin, Reference Haug and Lavin1983) is one aspect of this trend. The rise of the search for patients’ subjective interpretations and explanations of their symptoms is another. Arney and Bergen (Reference Arney and Bergen1984) went so far as to claim that a full transformation has already happened: “The object medicine practices on today is different from the object nineteenth and early twentieth century medical doctors practiced on. Medicine practices on a subjective object, and subjectivity has been captured by medicine’s new mode of objectification” (p. 50).
The situation may look like that at the level of proclamations and theoretical discourse. But empirical evidence from medical practice suggests that corporatization and rationalization have so far had much more pervasive effects than the ideas Arney and Bergen refer to (McKinlay & Stoeckle, Reference McKinlay and Stoeckle1988). In this light, Armstrong’s (Reference Armstrong1984) conclusion seems better balanced:
This does not mean that the discourse which is the vehicle for this new perception necessarily has immediate or real effects on clinical practice. Despite the widespread endorsement of an extended patient’s view in the literature ... , most clinical practice today ... probably relies on an older scheme of interpretation. ... Nevertheless the “conditions of possibility” for an extended patient’s view, whatever its empirical support, have begun to occur over the last few decades and this of itself ... signifies a change in the status of patienthood. (p. 743)
Armstrong’s notion of “conditions of possibility” resembles – if only at a metaphorical level – my reinterpretation of Vygotsky’s concept of the zone of proximal development (Engeström, Reference Engeström2015, p. 138). This “gray zone” of construction of a newly expanded object – we might call it the zone of subjectification of the object – is where interesting and important failures, innovations, and learning occur.
This kind of learning cannot be measured by the acquisition of preexisting well-defined skills and knowledge, not even by an individual’s ability to “participate fully in the community of practitioners.” In fact, the community hesitates and does not know what should be learned because it is facing an uncertain and contradictory field of demands and possibilities. Learning in the zone of proximal development is simultaneously creation and acquisition of the object and instruments to be learned.
I argue that the paradox of constructing new objects by old means, or the inertia of practice, is broken by virtue of the contradictions evolving within the dominant type of work, and within the corresponding dominant models of the object. These contradictions nurture various forms of spontaneous subjectification of the object patient. How does this manifest itself in everyday practice? In the following pages, I take a closer look at two patient cases.
Dealing with the Patient’s Life Context in Consultations
In a Swedish study, Larsson, Saljö, and Aronsson (Reference Larsson, Säljö and Aronsson1987) found that physicians fairly often asked in consultations about their patient’s smoking and drinking habits. However, physicians seemed to be satisfied with very shallow information on these topics, mostly answers of the type of “yes” or “no.” The authors suggest that this was partly due to the biomedical view, according to which smoking and drinking habits, although perhaps generally related to ill health, do not as such qualify as specific organic causes of particular illnesses. This interpretation indicates that the doctors were still primarily constructing their meaningful patterns on the basis of the craft–professional model of patient as physical lesion, as biomedical disease.
My data seems to support this finding. In our 85 videotaped consultations, social aspects of the patient’s life context were brought up relatively seldom (Table 2.2). The two aspects that were discussed relatively often, work and lifestyle habits (the latter include smoking and drinking), were typically dealt with in a very brief and shallow manner, much as in the data of Larsson, Säljö, and Aronsson (Reference Larsson, Säljö and Aronsson1987). Work, especially its physical hazards, and lifestyle habits are nowadays accepted at a general level as legitimate health factors, even within the classic lesion and disease model. Family, housing, economy, and personal relations – the aspects quite seldom brought up in our consultations – are much more suspicious from the viewpoint of the classic model.
Table 2.2. Aspects of the Patient’s Social Life Context Brought Up in Consultations (N = 85)
| Aspect | % |
|---|---|
| Work, occupation | 37.6 |
| Family | 17.7 |
| Housing | 17.7 |
| Economy | 3.5 |
| Personal relations | 5.9 |
| Lifestyle habits | 30.6 |
This general picture is broken, however, as we enter the texture of particular consultations. My first example is patient number 24, Anna, a 40-year-old female kitchen helper who had an appointment with a male doctor. The duration of her consultation was 7 minutes and 20 seconds, clearly below the average of 13 minutes and 6 seconds in our data.
Anna had experienced what she described as heart pains for two nights. The consultation took place about two weeks after the patient had experienced the pain, was seen by doctor, and had had laboratory tests. The consultation began with the doctor informing the patient that the test results were good and everything was OK according to them. The doctor subsequently asked the patient about the nightmares and the pressing feeling she had had.
Excerpt 2.1, consultation with Anna, patient VIII/24
Doctor: Well, what do you think about it now afterwards? Do you have some explanation to add to it, what is your view?
Patient: Well, I only have the work as explanation. I’ve been really under pressure and the work is heavy. I have slept badly because I’ve had pain in my shoulders, so ...
Doctor: So you’ve been in something like a spin ...
Patient: Yes, a little like a spin. A long time, really heavy kind of work. And the workplace doctor actually promised to come to the spot, already next week. He’ll make a job assessment of my work.
Doctor: What do you actually do in your work?
Patient: I wash dishes in the kitchen, and I do all kinds of odd jobs. But it’s such an old-fashioned, small dishwasher, in which I must kind of elevate the dish tray with my hands. It’s occasionally awfully heavy when there are plates and such stuff, so it strains just these shoulders very much. So when we are in hurry. We must really hurry, and we work by contract [a Finnish idiom for very intensive working]. It strains others, too; if someone else has been replacing me, they are exhausted also.
Doctor: How is it then, the comp ..., I mean ... the employer, or the workplace physician will come there?
Patient: Yes, they’ll come to make a job assessment.
Doctor: Will you then assess the situation together?
Patient: Yes. And then they were supposed to have the kitchen renovated already this summer, but that will be postponed to next summer. So it will be renovated and it will get modern machines. So I hope l’ll have enough strength to stay there for one more year. And if I won’t, then I’ll try to get ... if they’ll have a chance to transfer me somewhere else.
Doctor: (inaudible)
My second example is patient number 49, a 37-year-old male roofer named Paavo who came as an acute case without appointment and was seen by a female doctor. The duration of his consultation was 6 minutes and 30 seconds. Paavo had a pain in his eye. The consultation began with the doctor asking what the problem was. The question of work came up almost immediately.
Excerpt 2.2, consultation with Paavo, patient VII/49
Doctor: Well, what kind of work do you do?
Patient: I do outdoor work now.
Doctor: All outdoors?
Patient: Yes, on the roof.
The doctor continued the physical examination. She concluded that the problem was not serious and recommended an ointment. There was a final brief allusion to work.
Excerpt 2.3, consultation with Paavo, patient VII/49
Doctor: Yes, you could use the ointment tonight. lf it’s clearly better tomorrow morning, then it’s worth using for a few nights. You won’t really get sick leave for that, though.
Patient: Well, no.
Here we have two quite different cases. Anna (patient 24) actually drew the doctor into an unusually detailed and complex discussion of her work and housing conditions. The consultation with Paavo (patient 49) was a more typical case. Work was briefly touched upon, and other aspects of the patient’s social life context were not mentioned at all.
Viewing the videotape of her consultation in the stimulated recall interview, Anna extended her account of her life context with further details. She also brought up the family aspect in the interview.
Excerpt 2.4, stimulated recall interview after consultation with Anna, patient VIII/24
Interviewer: Here [in the videotape] you are going through the test results. When you came for your first visit, did you have yourself some kind of an assumption of what could be the cause of this?
Patient: Well, I did have a feeling that it must be caused by the work, so I did guess the cause ... I don’t have any psychic [psychological] disturbances and there has been no pressure at home. I don’t have small children anymore, only a 12-year-old girl and an 8-year-old boy. So I felt right away that it’s work, it’s strain from the work.
Paavo also provided some further details of his work in the stimulated recall interview. He mentioned that he welded a lot in his work and several times had had particles in his eyes.
Excerpt 2.5, stimulated recall interview after consultation with Paavo, patient VII/49
Patient: I’ve had to get eye medicine quite often because I have a job where I am a bit careless, prone to accidents.
Excerpt 2.6 is from later in the same interview.
Excerpt 2.6, stimulated recall interview after consultation with Paavo, patient VII/49
Interviewer: It didn’t come up there [in the videotape] that you’ve had eye troubles before?
Patient: No, I was not asked. I would have said right away that I have had kilos of rubbish there [in my eyes].
This was indicative of Paavo’s approach. He had a history of eye troubles. He was very conscious of this history, but the doctor never became aware of it. Paavo did not bring it up, since he was not asked.
Subjectification in Doctor–Patient Discourse
Above I argued that the current contradictions of medical practice nurture various forms of spontaneous subjectification of the object patient. The occurrence of patient-initiated therapies and referrals might be a possible indicator of the prevalence of spontaneous subjectification. Again, this kind of quantitative overview does not look very impressive. In 9.4% of our videotaped consultations, the doctor gave a prescription on the patient’s initiative. The doctor gave a sick leave on the patient’s initiative in 4.7% of the cases, and some other form of therapy on the patient’s initiative in 2.4% of the cases. Similarly, the doctor gave some kind of a referral on the patient’s initiative only in 9.4% of the consultations.
It must be emphasized that manifestations and symptoms of the contradictions that define the zone of proximal development of the activity system do not appear in the majority or in routine forms of practice. They appear as exceptions and disturbances. The consultation of Anna (patient 24) demonstrates the emergence of spontaneous subjectification in an instructive fashion.
Excerpt 2.7, consultation with Anna, patient VIII/24
Patient: What tests were taken, after all?
Doctor: There are quite a few here ...
Patient: Yes, and did it include white blood cells, too?
Doctor: Yes, it did.
Patient: And was cholesterol also included?
Doctor: That was within the normal range, but maybe a little bit high. It is not alarming, it’s 6.8. It should be, the ideal would be perhaps under 6.
Patient: Aha, we get such greasy food at work. Very often it’s deep-fried and that sort of greasy food. I have tried salads at such meals, less greasy, and to start eating salad.
Doctor: Well, it is within the given normal limits, so it’s not at all so high. It’s between the recommended values. But it could be a bit lower ... And the test on the thyroid gland was ...
Patient: Oh, there was such a test, too?
Doctor: The heart film was quite normal, yes, it looks pretty good.
Patient: Yes, it feels better, too, now. Rest is the best medicine, I must say.
Doctor: Yes, when it is ...
Patient: .. needed.
Doctor: The situation ...
Patient: ... it did even affect my mental state then, so that I was very sensitive and everything made me cry. And now it does not feel anymore like that ...
Doctor: ... different.
Patient: Right.
Doctor: Let’s do so that if you could occasionally get your blood pressure measured.
Patient: Yes, I can come and do that.
Doctor: You don’t need to do it very often.
Patient: For example when I go to vacation, and ...
Doctor: Yes, if it is at the level where it was the last time, it can be measured less often, like once ...
Patient: ... once a month.
Doctor: Even more seldom, or perhaps a couple of times with a one-month interval, and after that every three months.
Patient: Aha, yes.
Doctor: So no more often.
Patient: Yes.
Doctor: OK, so ...
Patient: Yes, thanks, good-bye.
Doctor: Bye, and have a good summer.
Patient: The same.
The transcript in Excerpt 2.7 at times resembles a verbal fencing match in which the patient and the doctor take turns to grab the initiative and determine the direction of the discourse. In several occasions, the doctor seemed to be surprised, puzzled, even troubled by the takeovers of the patient. In this respect, the consultation is an example of disturbances indicative of the zone of proximal development.
The resemblance to a fencing match is too superficial, however. Toward the end of the encounter, both the doctor and the patient actually pushed each other forward and literally finished each other’s sentences, somewhat in the manner jazz musicians complement and encourage each other in a band. This form of subjectification was clearly a jointly constructed achievement.
In the stimulated recall interview, Anna also continued taking initiatives. Perhaps the most illustrative moment came when she suddenly took over and began to question the interviewer.
Excerpt 2.8, stimulated recall interview after consultation with Anna, patient VIII/24
Patient: Have you had other patients interviewed today?
Interviewer: No, we were over there in K [the other health station] earlier this morning and came from there. We have here all the doctors participating, and the same in K.
Patient: Are you doing this in Espoo or all over the country?
Interviewer: In Espoo.
Patient: Ah, in Espoo?
Interviewer: And actually at these two health stations, since they form a service district.
How Patients Reconstruct Their Problems and Themselves
Most of the literature on medical cognition and problem-solving takes it for granted that the cognizing subject and creator of diagnosis is the physician. In some careful ethnographic analyses (notably Cicourel, Reference Cicourel, Galegher, Kraut and Egido1990), medical diagnosis is seen as a collaboration between professionals. Little attention has been paid to the contribution of the patient (for exceptions, see Tuckett et al., Reference Tuckett, Boulton, Olson and Williams1985; Hunt, Jordan, & Irwin, Reference Hunt, Jordan and Irwin1989; Cohen, Tripp-Reimer, Smith, et al., Reference Cohen, Tripp-Reimer and Smith1994; Charles, Gafni, & Whelan, Reference Charles, Gafni and Whelan1997; Loewe, Schwartzman, Freeman, et al., Reference Loewe, Schwartzman and Freeman1998). In recent literature, patients are mainly seen as entitled to contribute to advance-planning of their care during final stages of their life (e.g., You, Fowler, & Heyland, Reference You, Fowler and Heyland2014), entailing a switch from cognition and problem-solving to wishes and preferences.
If the patient does not accept the physician’s diagnosis or the prescribed therapy, there is in the end usually relatively little the physician can do to enforce his or her opinion. This is particularly true in primary care, where the patients are not hospitalized. The patient may and will interpret the physician’s conclusions in his or her own way. This prerogative operates during the actual diagnostic reasoning discourse, too.
In the final analysis, the subjectification of the object patient is dependent on how the model used by the patient and that used by the doctor are put into interplay with each other, if not partly merged. The patient’s model of herself or himself is, therefore, of great importance for the transformation of doctors’ work.
In the case of Anna, the patient’s model seemed to be quite straightforward. I have demonstrated that she had a very clear assessment of the work-related causes of her problem. She also had no difficulty in defining her diagnosis in the stimulated recall interview.
Excerpt 2.9, stimulated recall interview after consultation with Anna, patient VIII/24
Interviewer: Do you have a notion of the present diagnosis of your illness?
Patient: At this moment? Well, it was exhaustion, but at this very moment I would say that it’s tension neck.
Interviewer: What is exhaustion?
Patient: Exhaustion is a state of extreme fatigue. It can be caused by either mental or physical stress. In my case, it was caused by the physical. I’ve had such a heavy job, heavy work over a long period. I have found out for myself about these things because I am interested in medicine. I read medical books and I have worked in the field of health food products. I’m very interested and if I had had the opportunity I would surely have studied to become a doctor. But this tension neck is a kind of stiffness in the neck. This is the diagnosis made by the workplace doctor.
Here we see that the emergence of an emancipated model of oneself is not solely, probably not even primarily, an immediate product of the collaboration between the patient and the doctor. Certain mediating cultural artifacts play a central role – medical books, in this case. This was further emphasized later in Anna’s interview.
Excerpt 2.10, stimulated recall interview after consultation with Anna, patient VIII/24
Patient: Well, I went once to a doctor who got a little angry when I did not take a certain pain reliever. You see, I am interested in knowing what the book says about pain relievers, and I asked if I could see it. It’s the medicine called A, for back pain. I had had a bad pain in the neck for five days and he prescribed this medicine. And then I asked if I could see in the book what it said about the side effects. And he gave me the book and I read it, and there were quite some things. But then it said something in Latin that I did not understand. And I asked him to tell me what that end part meant. So he took the book and became quite red in the face and said that “Yes, well, it says that this can cause the growth of glaucoma, and difficulties to urinate, and sexual impotence.” And then I very politely said that could I please refuse to take this medicine because I am afraid of those side effects. And he got a little mad: “So what are we going to give you then?” I then said that I have once got L and that I had not found noticeable side effects. “Even that is not harmless,” he said. I said that I know that they are not harmless, so he does not have to prescribe it. But he wrote the L prescription.
Interviewer: Do doctors usually tell you about the side effects of medications?
Patient: No, I’ve never been told. I have started to find out for myself because I once got a medicine, it was called D, and I got such terrible stomach pains from it that I had to walk in a bent-down position when I took it. So I really did not dare take that medicine. And so I became interested myself. And I bought that book which you can get in the pharmacy, the one which tells about those side effects. Now that I have read it, I don’t like taking medications.
What Anna was recollecting here was a fairly severe disturbance or discoordination from the viewpoint of the doctor involved. Books as mediating artifacts became means for breaking out of the professional and/or bureaucratic dominance.
In the case of Paavo (patient 49), the subjectification came to the surface only in the interview and in much more dilemmatic ways. At the beginning of the interview, Paavo expressed his conviction that he was very healthy.
Excerpt 2.11, stimulated recall interview after consultation with Paavo, patient VII/49
Interviewer: Have you used the services of the health center previously? Have you for example visited here in L?
Patient: I think this is my first visit. I am so healthy.
Almost in the next sentence, he contradicted himself (Excerpt 2.12).
Boasting about healthiness and simultaneously having quite a few medical problems seems to be an example of a deep-seated cultural dilemma, closely related to traditional male notions of capacity and achievement. Billig et al. (Reference Billig, Condor, Edwards, Gane, Middleton and Radley1988) note:
For most people in Western culture being ill means not being able to work, so that what defines their condition is not so much a bodily condition but an incapacity. To be healthy is to be “fit for” social duties; to be ill is to be unable to satisfy them. Determining which of these situations one is in is often fraught with uncertainty. (p. 87)
Parallel to this, there was another discrepancy in Paavo’s approach. When asked about the criteria of a good relationship between the doctor and the patient, he emphasized equality and mutuality.
Excerpt 2.13, stimulated recall interview after consultation with Paavo, patient VII/49
Patient: So that she comes like a pal comes to a pal, even if she is a doctor. This makes an impression on me, when I come to a doctor who immediately gives up formalities, discusses with me like people discuss with one another.
In spite of this emphasis, and in spite of his explicit satisfaction with the consultation just finished, the patient did not take a single discussion initiative during the actual consultation. So his ideal of symmetric discussion was hampered by his own behavior.
These two inhibiting discrepancies – boasting of healthiness while having health problems, and demanding symmetric discussion while remaining mute – explain why the subjectification of this patient became manifest only toward the end of the stimulated recall interview, quite unexpectedly. Paavo started to tell about a medical problem he had had for quite some time.
Excerpt 2.14, stimulated recall interview after consultation with Paavo, patient VII/49
Patient: I have such a lump in my throat. I still feel it. They say there is nothing. He [a doctor] asked me if I am a tense type. I said that sure I sometimes lose my temper. He said that can be the cause, that I think about it too much, and I feel it even though it’s not there. I don’t believe that. But I will wait till winter. If nothing happens, I will go to get a laryngoscopy.
Interviewer: Did you visit the health center because of that throat?
Patient: Yes, I’ve visited the doctor because of it, I guess two or three times. I’ve been in for throat culture and blood tests. I’ve not been in for laryngoscopy.
Interviewer: And they have not been able to do anything, so that you have not been given any diagnosis?
Patient: Well, no. But I have something of a diagnosis of my own. I looked in the doctor book, on the basis of my symptoms. There was this polyp in the vocal cord. You see, when I have to do like this, I feel like something is coming up, and when I swallow, it goes back down.
Interviewer: Is the polyp some sort of a tumor?
Patient: It’s kind of a mucous tumor, or something. It’s on the side of the vocal cord.
Interviewer: Has some doctor told you that it could be that?
Patient: No. I read it in the book myself.
Interviewer: You diagnosed it yourself?
Patient: Yes. I just swallow and on that basis I looked it up in the book.
Interviewer: Have you told any doctor that you have thought that it’s a polyp?
Patient: No, I have not. But if I now go to get a laryngoscopy, I will tell [the doctor] that I’ve thought that it could be that. But there, you see, I’ll face this relationship between the doctor and the patient, so if I go and tell the doctor that I have a polyp in the vocal cord, he will ask me which one of us is the doctor. ...
Interviewer: Has some doctor suggested to you that you should go to laryngoscopy?
Patient: No. I’ve talked about it and seen it in the television. I think it’s such a good instrument for that purpose. And also it doesn’t cost anything when you go through the health center or through the workplace doctor.
Interviewer: It must have bothered you a long time?
Patient: I guess five years. I asked [a doctor] if it could be throat cancer. He said no. He asked when it started, and I said three, four years ago. He said it’s not throat cancer.
Interviewer: Why did you think it could be throat cancer?
Patient: Well, for example because my voice gets hoarse. But it is temporary. And it feels dry, but it’s temporary. Perhaps just these symptoms in the book indicated a polyp in the vocal cord. And then we’ve had a similar case at my workplace. He swallowed for a long time, too, and the lump was always there. They took such a mucuous tumor out of his throat. And it was taken to analysis. The said they’ll let him know; if not, then it’s a benign one.
Interviewer: And he heard nothing?
Patient: No.
Paavo had used the book, the television, and peer experiences to construct his own diagnosis. He was aware of the offensive nature of such a construction in the eyes of doctors and expected to create trouble: “He will ask which one of us is the doctor.” The fear of cancer seemed to loom large behind his problem. At the end of his account, Paavo told the interviewer that he smoked a pack of cigarettes every day.
Instead of a conscious and consistent model of himself, the patient’s model was saturated by discrepancies, or internal contradictions. But he was working through them, determined to bring his throat problem into a satisfactory solution no matter what doctors might say. In that determination, he would pose a challenge to the object construction of his doctors.
Concluding Remarks
In various contemporary forms of radical constructivism, the object of activity and cognition often becomes something to be constructed purely by the actors, not having any identity and dynamics of its own. Even Bruno Latour in his book Science in Action (1987) ridiculed the idea that “nature speaks to us” when we study it. In critical sociological inquiries of medicine, the professional dominance of doctors is commonly pictured as constructing patients and illnesses as if they were passive material. Patients are seen as being silenced, molded, and turned into abstract categories of medical jargon.
My own data and analyses do not support this one-dimensional notion of object construction. The object is not only constructed by the subjects, it also constructs itself. The patients’ life activities have tremendous momentum and dynamics of their own.
This self-construction of the object is not, however, something that can be understood outside the broader activity of the subject. Otherwise it would not be a question of an object in the first place. Patients construct themselves and are constructed by doctors within a complex system of two interacting activities.
In the two cases discussed in this chapter, the doctors’ general models of the object did not mechanically determine the actual interaction. In his stimulated recall interview, Anna’s doctor represented a rationalized type 2 model (object as consumers of health care services, see Table 2.1). However, in the consultation, Anna was certainly not handled as an anonymous input–output unit. Her own initiatives – the dynamics of the object – precluded such a possibility.
Paavo’s doctor represented a type 4 model (object as patient’s social life situation). In the consultation, Paavo’s social life situation was handled in a superficial, routine manner. Here the rules of the activity system of the health center were probably a decisive factor. This patient came in as an urgent case without an appointment. Both doctors and patients had well internalized the rule that such consultations were supposed to be quick and superficial, focusing on the immediate chief somatic complaint only. In the case of Anna, the rule was more elastic since the patient had a reserved appointment. Although Anna’s consultation was not dramatically longer in duration than that of Paavo, the contents of the discourse were allowed to evolve much more flexibly.
In other words, the transitions from raw material to meaningful pattern to outcome in the construction of the object are not straightforward and algorithmic in any simple sense. The doctor’s model alone does not determine the outcome. Neither does the patient’s model. The encounter takes place in the activity system of a clinic and it is shaped by the contradictions within this activity system. Moreover, if we want to understand what happens to the patient before and after the encounter – which is necessary for any realistic assessment of the outcomes – we must realize that the patient’s actions are shaped in one or more complex activity systems that make up the patient’s lifeworld (family life, work, hobbies, etc.). For the sake of simplicity, I shall here treat these activities as if they were one single activity system – the life activity of the patient.
Thus, Figure 2.1, presented earlier in this chapter, depicts only the disembedded visible tips of the icebergs of two activity systems: the work actions of the doctor and the life actions of the patient. When the actions are embedded in the respective activity systems, we get the model depicted in Figure 2.2.
Figure 2.2. The embedded subject–object relationship in a medical encounter.
There is no way to merge the two activities depicted in Figure 2.2, to melt them into one. That would be the vision of “tyranny of harmony” feared by Arney and Bergen (Reference Arney and Bergen1984). No institution can control the totality of human life activities.
Instead of fantasies of merger, the key question of expansive object construction in medical work is rather how to enable the doctor and the patient to engage in working out partially shared models or representations of the object – i.e., of the patient’s health problem in its context. In other words, instead of trying to eliminate the difference between the doctor and the patient, we might try and create instruments with which they can take advantage of their differences. This requires new mediating artifacts. The forms of spontaneous subjectification analyzed above demonstrate that such mediating artifacts are in fact “in the process of becoming.” Too little attention has been paid to these artifacts (see Stoeckle, Reference Stoeckle1984, for an early opening). A recent study by Jowsey et al. (Reference Jowsey, Dennis, Yen, Mofizul Islam, Parkinson and Dawda2016) is a rare exception. The authors found that people with chronic illnesses respond agentively to absences of continuity and coordination in their care by means of keeping personal up-to-date medication lists and generating their own specific management plans. These artifacts are not only cognitive supports; they also support volitional action in the face of often paralyzing structures of institutional and professional dominance.
