Marc Berg

The construction of medical disposals

Medical sociology and medical problem
solving in clinical practice

Abstract How do physicians construct medical disposals? In this paper it

is argued that insights developed in the sociology of science (in
particular so-called laboratory studies) can be of help in
addressing this relatively unexplored question. At the level of
clinical action, medical sociologists have until recently generally
separated the 'content' of medical action from the 'social'
aspects, the former constituting a domain inaccessible to
sociological investigation. This asymmetrical treatment of
'cognitive' and 'social' elements is stated to be based on two
assumptions: (i) historical and examination data are seen as
'facts' which the physician only needs to 'reveal' and (ii) medical
criteria and disposal options are regarded as scientific, fixed
'givens'. A 'laboratory study' of medical problem solving in
clinical practice, however, shows that these assumptions do not
hold. It is argued that the physician, in transforming a patient's
problem to a solvable problem, does not just combine some
'cognitive' items together, but actively articulates an array of
heterogeneous elements with the transformation. In this
construction process, both the elements and the transformation
take shape. Finally, the importance of the concept of 'routines'
for a sociological answer to the main question of this paper is
shown.

Introduction

In recent years the rapid developments within the sociological study of

science have been a source of inspiration for medical sociology. For a long
time, the study of science had been focussed on the social processes
constituting science as a professional knowledge-producing enterprise (eg
institutionalisation, normative regulation), without including scientific
knowledge itself as a possible object of study. Kuhn's The Structure
Sociology of Health & Illness voL 14 No. 2 1992 ISSN 0141-9889
152 Marc Berg
of Scientific Revolutions (1962), however, opened this sanctuary: by
introducing the term 'paradigm' and showing that paradigm-shifts cannot
be accounted for solely in 'cognitive' terms, sociological scrutiny of
scientific knowledge itself became possible. One influential and important
way in which this challenge was taken up is the so called Strong Programme
of the sociology of scientific knowledge (D. Bloor 1976). This programme
aims at the explanation of scientific development in terms of social and
historical factors: professional and political interests, available equipment
and skills, etcetera. Nicolson and McLaughlin (1988) provide an example
of this enterprise applied to a medical topic: they showed how the
possession of specific intellectual and technical skills in different research
groups structured the development of distinctive theories of the patho-
genesis of multiple sclerosis. Together with Foucauldian and 'critical
theory' research (which are primarily interested in the social and political
ramifications of medical knowledge) these studies have been labeled 'social
constructionist' approaches and have been the subject of some debate as to
their value for medical sociology.'
Another path taken by sociologists of science which, so far, has received
less attention from medical sociologists is the laboratory study (eg Latour
and Woolgar 1986; Knorr-Cetina 1981; Fujimura 1987). These studies,
which, as I will argue, can benefit the sociology of medicine in a specific
way, investigate scientific knowledge in the making (Latour 1987), using
anthropological and micro-sociological research techniques. In contrast to
the 'Strong Programme', these authors do not so much want to search for
social factors determining scientific beliefs as to study how scientific
belief takes shape in the day-to-day life in the laboratory. In their view, the
Strong Programme subordinates the 'cognitive' to the 'social'.
Contrarily, laboratory studies show how the shaping of scientific
knowledge results from continuous 'negotiations' between scientists,
funding agencies, instruments, materials etc. Scientists are trying to 'make
things work', which involves interactionally establishing what it means for
a certain thing to work, the constant modification of the experimental set-
up, etc. They do not follow Universal rules in this process. Rather, they can
be seen as practical reasoners (Knorr-Cetina 1981) who, in the process of
knowledge-construction, interweave 'cognitive', 'social' and 'material'
elements on an ad hoc, opportunistic basis.
The negotiations do take place in a highly preconstructed reality,
however {cf. Knorr-Cetina 1983:119). The laboratory setting, the scientific
literature that is used, the funding agencies and also the materials worked
upon are all elaborate constructions: measuring instruments are ingenuously
designed, laboratory animals selectively bred, funding procedures intricately
structured, chemicals thoroughly purified. Earlier choices (in the selection
of a certain instrument, grant organisation, laboratory animal) delineate
the space of further choices. In other words: the setting in which the
negotiations occur pre-structures their course towards the production of a
 The construction of medical disposals 153
'scientific fact'. The contingent, locally dependent character of these
earlier choices implies that scientists' construction work can only be
understood by referring to this situated, contextual nature.
How can the sodology of medicine profit from these insights? My
proposal is not simply to direct this perspective to scientific developments
on medical topics (Latour and Woolgar (1986), studying the 'discovery' of
Thyrotropin Releasing Factor did just that) but to apply these insights to
medical problem solving in clinical practice. The question I am interested
in is: how do physicians construct medical disposals? How is the problem of
a patient complaining of sharp chest pains or bloody stools 'solved'?
Although this endeavor constitutes the heart of the medical enterprise, this
question is rarely thematisised as an issue for sociological investigation.^
As stated above, at the level of medical theory medical sociologists have
recently begun to regard the domain of medical knowledge as an object of
study in itself. In the next section, I will briefly mention some different
approaches to the study of medical practice which have equally started to
incorporate the 'content' of medical action in their research. Here also, the
asymmetrical treatment of the 'cognitive' and 'social' aspects of medical
action is being abandoned. Subsequently, this development is furthered by
presenting results from a 'laboratory study' of physicians constructing
medical disposals.

Sociological research on medical problem staving in practice

Analogous to the sociology of science, for a long time medical sociology

maintained a profound distinction between the 'social' and 'cognitive'
aspects of medicine. The latter were seen to be the unique domain of the
medical profession: medical knowledge could be analysed only in its own
terms. It could be compared and judged by epidemiology and scrutinized
by philosophy, but sodology stood with its back towards the heart of
medicine and studied the social phenomena encircling it. Tlius, medical
sociologists had imposed scientifically and politically important constraints
on themselves: by splitting the 'cognitive' from the 'social', medical
sociology deprived itself of a research domain and, maybe more con-
sequentially, curtailed its critical potential (Wright and Treacher 1982;
Gaines and Hahn 1985).
In studies of medical practice, this asymmetrical treatment of 'cognitive'
and 'social' aspects was equally paramount. It was generally presumed that
it is 'simply' biomedical knowledge that directs the physician, through
logical steps, from individual findings towards the right diagnostic and
therapeutic decisions. The 'cognitive' domain of medical action was thus
regarded as self-explanatory, not needing and defying sociological scrutiny.
This self-explanatory character can be split up into two assumptions which
were generally (im- or explicitly) maintained: first, historical information
154 Marc Berg
and examination results are seen as 'facts' which the physician only needs to
'lay bare'. Second, medical criteria and disposal options are seen as
scientifically constituted, fixed 'givens' against which the obtained data
have to be matched.
The opening-up of the 'cognitive' domain on the level of medical theory
has been briefly mentioned: here social constnictionist accounts have
started to show their value. On the level of medical action, a similar
development is occurring. Here, medical problem solving processes have
been the subject of a growing body of empirical research. For example, the
role of clinical problem solving processes in practice has been investigated.
Studies of professional socialisation show how leaming to perform and
leaming to revere clinical judgement is crucial for doctors-to-be entering
the clinic (eg Becker 1%1; Mizrahi 1985). Since clinical judgement is
inherently linked to experience, the high esteem of this 'unanswerable and
unanalysable' ability thus serves to legitimate the authority of those higher
in rank in the medical hierarchy (Bosk 1979: 93). These studies put the
medical problem solving process in the spotlight, and show its effects upon,
the ftinction it has for, the social reality of medical practice.^
Complementing the study of the impact of problem solving practices on
clinical reality, many authors have investigated the influence of social
factors on the construction of medical disposals. Several studies have
demonstrated that the outcome of medical problem solving processes is
partly dependent on patient- and physician characteristics and environ-
mental factors (see Eisenberg 1979 and Clark et al. 1991 for reviews).
Remaining at a distance from actual medical practice, however, these
studies do not inform us how these social factors interfere with the
construction of medical disposals. Social factors are shown to assert
influence upon the problem solving process and the outcome corres-
pondingly varies; the process itself, however, remains a black box:
[W]e have yet to account for how physicians collect infomiation and
arrive at decisions in the course of interacting with real patients in actual
clinical encounters. We know little about how decision making is
affected by the real life contingencies of clinical practice [...] (Clark etal
1991: 854, cf. Freidson 1970; Eisenberg 1979).
Essentially, the question how medical disposals are constructed by
physicians, immersed in the 'real life contingencies of actual practice', has
only been addressed by two approaches. First, clinical situations in which
the question 'to treat or not to treat' is paramount (eg decisions conceming
terminal patients or premature infants) have been investigated. The
medical decision process, according to these studies, is 'not entirely
rational or scientific' (Crane 1975: 19; Fox and Swazey 1978); treatment
decisions are the 'outcomes of protracted negotiations between physicians
and parents' (Frohock 1986: 91). The importance of the social context is
illustrated; Guillemin and Holmstrom convincingly demonstrate how the
 The construction of medical disposals 155
sodal practices in the neonatology department all work towards 'more
aggressive intervention rather than limiting, withdrawing or withholding it'
(1986: 118). Equally, Crane (1975) illustrates how medical considerations
for dedsion making are supplemented by social considerations, of which an
evaluation of the extent to which the patient will be able to communicate
with others is of prime importance.
Second, ethnomethodologically inspired researchers have shown clearly
how historical data are being constructed in the doctor-patient interaction.
Here, the analysis is concentrated upon the way a patient's problem is
transformed in the discourse between doctor and patient (eg Fisher and
Todd 1983; Cicourel 1981, 1986; Mishler 1984; Davis 1986, see the next
section).
All these approaches have contributed to the abandonment of the
delineation between accessible and inaccessible territory in the sociological
study of medical practice. In this paper, I want to further this attempt to
realise a fully symmetrical treatment of the 'cognitive' and 'social' aspects
of medical practice. In order to do so, this 'laboratory study' will join the
two approaches mentioned last and focus upon the question of how
a physician constructs medical disposals. Contrarily to the studies of
situations where the dilemma between aggressive, potentially iatrogenic
curative treatment and palliative care is prominent, the focus will be on
'ordinary' medical problem solving.* Also, I will expand the scope of the
discourse analysts (admittingly losing some of their impressive sense for
detail) by incorporating 'hard data' like laboratory investigations and X-
rays, 'concrete' actions like surgery, physical constituents like blood, etc.^
It will be shown that the two assumptions mentioned above (i.e. (i)
historical and examination data are seen as 'facts' which the physician only
needs to 'reveal' and (ii) medical criteria and disposal options are regarded
as sdentific, fixed 'givens') do not hold. Concurrently, a step will be taken
towards a fully sodological understanding of the construction of medical
disposals.

The construction of medical disposals

This paper is focussed on the physician who transforms patient problems

into solvable problems. A patient problem is defined as whatever a person
and/or his environment perceives to be a problem for which a doctor
should be consulted: a headache, red urine, questions concerning
contraception. The term 'transformation' implies a process in which the
patient problem is not simply translated but is remoulded. A problem is
solvable when the doctor is able to propose a disposal: a limited set of
actions which she perceives to be a sufficient answer (at this time and
place) to a spedfic patient problem ('a prescription of aspirin', 'referral to a
urologist' or 'advice'). This does not necessarily imply that the patient's
156 Marc Berg
problem is relieved: what matters is that the physician knows what to do
next. The physician makes a patient problem solvable by reducing the
infinite array of possible actions to just one disposal.
The results presented here were obtained in a participant observation
study of medical action in practice. Almost two years were spent working
as a houseman (I was, at the time, also fininishing my medical studies)
within different specialities in three clinics. Analogous to the laboratory
studies, I studied the taking shape of medical disposals in action. I took
notes of events which appeared to deal with the construction of medical
disposals: during patient meetings, after outpatient sessions, operations,
etc. Following each housemanship, some members of the team were
interviewed. General questions were asked, and the opportunity was taken
to discuss certain incidents that took place.^ Naturally, all the names of
physicians and patients in this paper are fictitious.

Historical information and examination results

As stated above, historical information and examination results were
generally seen as standing outside of the realm of sociological investigation.
These entities supposedly only needed to be 'revealed' by medical
techniques; presumptively, there was nothing 'social' about them.
As researchers of medical discourse have shown with regard to
historical data, however, both historical and examination data are not so
much 'uncovered' but are (re)constructed in the transformation process
from patient's problem to solvable problem. This can be illustrated by
some fragments from the empirical material:
Dr. Daton, a general practictioner, is called in by his patient Mr. Porter,
who, as Daton knows, suffers from chronic bronchitis and low back pain.
This time Porter is complaining of 'attacks of lung pain' (he rubs his
hands against his chest) which come up unexpectedly and disappear
promptly upon taking the 'pills from the specialist'.
D. When you've got that pain, do you want to lie still or move about?
P. No, doctor, I can't lie still.
D. Does the pain start when you exert yourself, or when you leave the
house when it's cold out?
P. No.
D. Do you tire quickly when you exert yourself?
P. Yes.
D. Does the pain start in your low back?
P. Yes.
D. When you're in bed, or at other times too, for example when you
make a wrong movement?
P. Well, doctor, I'm mostly in bed or in my chair when the pain comes,
but yes, I do sometimes make a wrong movement.
 The construction of medical disposals 157
D. And the pain stops when you take the pills I gave you? (Daton had
given him Feldene)
P. Yes, doctor, but the pills of the specialist do work better, more
rapidly.
These 'pills' appear to be Nitrostat [an anti-angina pectoris drug
which reduces the workload of the heart by dilating the vascular
system]. Driving back to his office, Daton remarks that Porter is
actually suttering from atypical low back pains. Nitrostat, he claims,
only 'works' because of a placebo effect.
According to the letter from Dr. Beatty, a cardiologist to whom
Porter had been referred by a fellow general practitioner, the
electrocardiogram and the cardial enzymes were normal. According
to Beatty the pain started generally in the left side of the chest. His
diagnosis: 'atypical angina pectoris'.
Dr. Brown, a vascular surgeon, is visited by a patient who, according to
the general practitioner's referral letter, suffers from intermittent
claudication [pain and tension in the legs, which is relieved by rest and
seen in ocdusive arterial disease]. A fragment of the conversation
(which took four minutes):
P. I can only walk for three minutes, doctor.
B. Then your calfs hurt?
P. Yes, and then I often walk crookedly.
B. What do you do when the pain starts. You stop walking?
P. Yes, doctor.
B. Do your legs ever hurt at night?
P. No, doctor, but sometimes they tremble a lot. (Brown pauses for a
moment and writes something in the patient record. The she looks
up.)
B. Do you smoke a lot?
The type of questions a physician asks, the way she asks them and her
interpretation of the answers shape the symptoms of the patient. Brown
only pursues her questioning on items and patient's remarks she considers
to be relevant to intermittent claudication ('then your calfs hurt?' 'do you
smoke a lot?'). In this way, the type of questions a physician asks selects the
information which corresponds with the transformation she has in mind: in
these questions, the typical historical intermittent claudication pattern is
already embodied. Similarly, the cardiologist Beatty does not ask any
questions concerning Porter's backaches: not considering this solution (he
is not familiar with Porter's medical history) he constructs entirely different
historical results.
Also, the way the physician poses her questions shapes the historical
data. Questions like 'then your calfs hurt?' and 'then you stand still?'
(instead of 'and then what happens?') already contain the expected
answer. This is illustrated in the first fragment: the reactions to the
158 Marc Berg
questions 'the pain starts in the low back?' (Daton) and 'the pain starts in
the left side of the chest?' (Beatty) are both affimiative. The very dissimilar
transformations these two doctors are considering are both confirmed {cf.
Macintyre 1978).'
Likewise, the physician selects certain examination procedures and
omits others, thus prestructuring the 'pathological reality' she will want to
counteract. Furthermore, the way the examination is performed equally
shapes the outcome. When the physician does not expect crackles or
wheezes, she will listen to the lungs more hastily and hear less; when she
does expect added lung sounds, she will auscultate more thoroughly and,
accordingly, hear more.*
By directively interpreting the information obtained the patient's
symptoms and complaints are further recast into pattems which conform to
the considered transformation. To Beatty, for example, the attacks of 'lung
pain' signify angina pectods, which is often felt outside of the heart area.
Contrarily, to Daton the vague designation of the pain indicates referred
back pain. Similarly, the normal ECG and cardiac enzymes are interpreted
by both physicians as sustaining their divergent proposed disposals: these
findings can be seen as compatible with both angina pectods and low back
pain. Also, Brown interprets her patient's remarks about his 'trembling
legs' and 'standing crooked' as irrelevant and, consequently, ignores them.
The process in which histodcal and examination data are constmcted
does not stop when the doctor-patient contact is over. When findings are
contradictory, the physician can attempt to regain alignment in several
ways. First, data can be put aside as a separate problem for which a
different solvable problem has to be found. Brown, for example, could try
to put aside the complaint 'trembling legs at night' as the solvable problem
'restless legs [unexplained nightly unrest of the legs] requidng medication'.
Similarly, concerning the fatigue Porter felt when exerting himself, Daton
later remarked: 'Well, he also has chronic bronchitis'. He thus put aside a
piece of information which contradicted the transformation he proposed:
rapid tidng dudng exercise is not a symptom of low backaches.
More fundamentally, when obtained data do not conform to a proposed
transformation, they can be recortstructed in vadous Ways. See, for
example, how the weight of a patient's statement in the patient record
varies with several ways of putting it down:
Anamnesis: never been sick. Now stomach ache for two years.
Anamnesis: stomach ache for two years
Anamnesis: according to the patient he has had 'stomach aches' dudng
the last two years (?).'
Adding quotation- or question marks, wdting 'according to the patient. . .',
etc., downgrades the importance of the recorded data. On the other hand,
underlining words, using exclamation marks or adding 'intelligent patient'
or 'rarely visits physician' upgrades the data. Similarly, during case
 The construction of medical disposals 159
meetings the weight of data can be up- or downgraded by referring to eg
the patient's story as 'typical' or 'classical' or, respectively, 'atypical' or
'incoherent'. Equally, the weight of examination data can be modified by
referring to the excellent or poor quality of the performer of the
examination, the worth of the examination technique, etc.
In the following fragment, the physician reconstructs historical data so as
to adjust them to the transformation he proposes:
At a surgical case meeting. Dr. Martin, a surgeon, presents his patient
Peterson, suffering from intermittent claudication, for surgery.
According to blood pressure measurements. X-ray and doppler
investigations, Peterson has a severely limited arterial circulation in his
legs. When his history was taken, however, he had stated that he could
easily walk more than half a mile. 'He overestimates himself, Martin
states. 'He moves at a snail's pace.'
Martin reconstructs the historical finding 'I can walk more than half a mile'
by adding that the patient moves 'at a snail's pace'. This extra information
changes the meaning of this finding: being able to walk more than half a
mile does not agree with severe intermittent claudication, but when
'walking' means moving slowly, step by step, the finding no longer
contradicts the solvable problem.
In the previous fragment, historical data were reconstructed so as to align
them with a transformation which was based primarily upon blood pressure
measurements and X-rays. It would be erroneous, however, to conclude
from this fragment that examination data form the 'rockbottom' to which
the historical data are adjusted. In the following fragment, just the
opposite occurs:
At a surgical case meeting Ms. Snow is discussed. Dr. Bally, the surgeon
who has been seeing her, states that her sigmoid needs to be resected
since she has had recurrent episodes of diverticulitis. 'I understand that
her complaints are severe', says Martin, 'but she doesn't bleed much
during attacks, nor have we ever found a significant leucocytosis [a raise
in white blood cell count - a sign of inflammation] or fever.' 'that may be
so,' Bally replies, 'but her complaints are so typical that surgery is
definitely indicated. Anyway, those examination results are highly
indeterminate.'
Here, the examination results do not support the transformation Bally
proposes: in this hospital, a resection of the sigmoid for chronic
diverticulitis was normally performed only when positive examination
results were found. By emphasising the severity and typicality of her
complaints and downgrading the value of the examination results he
modifies the data so that they support the transformation he proposes.'"
Just as examination data cannot be considered to constitute a solid
ground upon which the historical data are adjusted, there are no types of
160 Marc Berg
examination data which are on pdnciple 'more fundamental' than others.
In the following fragment, 'clinical judgement' is given priority over
'objective', 'precise', technologically based data:
Dr. Johnson, a surgical registrar, notes at a case meeting that according
to the blood pressure and doppler investigations Mr. Thompson is
suffedng from occlusive arterial disease and should be operated upon.
Baker, a surgeon, asks for the clinical picture. 'That's not too bad',
Johnson replies 'in any case it's better than you would expect with such
laboratory results.' Baker: 'These examinations give us only numbers,
that is something you should always remember'. The operation is
cancelled."
Here, Baker rejects the results from the vascular laboratory by stating that
these are 'only numbers'. 'Clinical judgement is what counts' he teaches
{cf. Daly 1989). Contradly, in the next fragment Fisher rebukes the
cardiologists for relying upon their clinical judgement:
The cardiologists often conclude that after investigation, no heart failure
was found. Lately it happened again: this patient was short of breath and
had an ejection fraction of 20 per cent [very low value]. You always have
to examine these patients yourself as well. The cardiologists don't look
well enough at the thorax X-rays, they only look at the patient, at the
clinical picture. But just that can be so treacherous (remark by Fisher,
lung specialist in hospital X).

Here, in contrast to the previous fragment, examination results based upon

physical examination and clinical judgement are stated to be of less value
than information gathered through meticulous technological means.
In the transformation process, histodcal information and examination
results are constmcted and reconstructed in light of each other. These
findings direct the transformation and, concurrently, they are shaped by it.
In transforming a patient's problem to a solvable problem, however, the
physician is not only dealing with these 'cognitive' aspects. In a similar
fashion, histodcal and examination data are moulded and remoulded
because of 'social' factors. Time is one such factor which interferes with the
transformation process. Duty rosters, office hours, deadlines for X-ray and
laboratory requests, create a rigid structure of 'interlocking timetables' in
which the unpredictable flow of patients has to be fitted (Atkinson 1981:
51; Zerubavel 1979; Armstrong 1985). When time runs short dudng
consulting hours, potentially time-consuming historical or examination
cues are often (re)moulded in favour of a more timesaving transformation.
The physician, for example, can interpret a patient's complaints about
recurrent 'stomach aches' as 'due to stress' instead of 'requidng thorough
examination' {cf. Horobin and Mclntosh 1983). In the next fragment, a
similar phenomenon occurs:
 The construction of medical disposals 161
In a neurological case meeting in hospital y patients are discussed which
will be presented to the neurosurgeon of hospital Z (who h ^ not arrived
yet) for surgery. The patients all suffer severely from a herniation of the
nucleus pulposus (HNP) [here the nucleus of a intervertebral disc
protrudes into the spinal cord, sometimes leading to the compression of
a nerve, causing pain and/or lameness]. Hanson, a neurologist, asks
Connor (neurological registrar): 'Are your cases sound? When there's
something wrong or unclear they're wiped out in no time [from the
surgery schedule]. We've got lot's of them, they'll be busy, which makes
that even easier.'
Here patients are presented whose historical and examination data direct
the transformation towards the solvable problem 'HNP requiring urgent
surgery'. However, when the surgeon's time becomes sparser, this
transformation becomes harder to accomplish. The increasing time
pressure directs the transformation to 'HNP treated conservatively'.
Time, of course, is not the only 'social' element which pervades the
medical problem solving process in clinical practice. The image of the
patient is also, in Eisenberg's terms, 'an important socio-cultural influence'
(1979: 957).'2
In a case meetings of internists Mr. Forsyth, 70 years old, is discussed.
At endoscopy and X-ray investigation, this patient was found to have a
large malignant stomach tumour. The CT-scan and other additional
investigations have not shown signs of tumourous growth outside of the
stomach. The decision would have been easy if metastases had have
been found: then no surgery would have been performed, only palliative
treatment. The patient would have been declared incurable. Now that
the cancer seems to be limited to the stomach, however, Forsyth is
eligible for curative, surgical treatment which involves the resection of
the entire stomach. Dr. Austin, Forsyth's internist, however, states that
his patient is 'already in his seventies' and 'probably not very happy with
all this surgery'. Moreover, 'his vitality is wanting' and 'his carotid
arteries are occluded'. The latterfindingimplies that before Forsyth can
be operated on his cancer, his carotids will have to be operated on first:
in hospital A^such carotids are a contraindication for surgery. With a
carcinoma of this size, Austin argues, there is a considerable chance that
some tumourous material, as yet not traceable with a CT-scan and other
such methods, has in fact already left the stomach. The discussion in the
case meeting goes on for half an hour before it is decided that further
diagnostic tests are necessary. They will puncture the abdominal cavity
and rinse it: using this technique they yet hope tofindtumour cells
indicating the presence of malignant growth outside the stomach so that
surgery could be cancelled.
The routine search for metastases or evidence of tumourous growth
outside of the stomach yields negative results: all the examination data
162 Marc Berg
support the transformation to the solvable problem 'stomach cancer
requiring curative surgery'. Austin's image of the patient ('already in his
seventies'; 'not happy with surgery'), however, leads him to suggest an
alternative disposal: 'palliative treatment'. In order to realign the
examination data to this transformation they are reconstructed: 'negative
results do not imply that there are actually no metastases or tumour cells
outside of the stomach'. Finally, new examination procedures are selected
(the abdominal flush) which raise the chances of obtaining positive results.
Again, to conclude that one type of element apparently weighs more
than other elements would be mistaken. Historical and examination data
are not necessarily adjusted to 'social' restraints: equally, the reverse can
occur. In the following fragment, for example, the image of the patient is
reconstructed so as to support a transformation:
Mr. Dorland, who drinks and smokes heavily, suffers from intermittent
claudication due to an occlusion in his groin artery. His surgeon, Martin,
wants to dilate this occlusion by means of the PTA technique
[percutaneous transluminal angioplasty, in which the occlusion is dilated
by means of a little 'balloon' connected to a catheter]. Other surgeons
present at the case meeting, however, oppose to this suggestion. 'You
should not operate on such a man, you should kick him in the ass! If he
doesn't stop smoking I'd refuse to operate on him' states Rope, his
colleague. The sentiment in the case meeting inclines toward refusal,
until Martin remarks: 'Actually, I can only see him as a pitiful person'.
This works: the discussion settles in his favour.
Also, when the physician does want to pursue some time-consuming cues
in the data, she can 'create' time by introducing a 'time out' and break
through the pre-set 'ten-minutes-per-patient' boundary (Richman and
Goldthorp 1977: 173-9). In constructing a medical disposal, 'cognitive' as
well as 'social' elements direct and are adjusted to the transformation.

Medical criteria and disposal options

In the previous section it was shown that historical information and

examination results are not 'sources' of data which the physidan only
needs to 'reveal' (the first assumption). The relation between data and the
transformation is not a one-way affair: the transformation is directed by
the data and, concurrently, the data are (re)constructed so as to fit a
certain transformation. In thus articulating data with the transformation,
they are selected, interpreted, remoulded and, when necessary, modified
in view of other data and 'social' factors such as time and the image of the
patient. In these fundamentally redprocal processes no fixed hierarchy
exists: examination results do not necessarily count more than historical
 The construction of medical disposals 163
information, data do not in pdnciple overmle interfering social factors,
etc.
The second assumption stated that medical cdteda and disposal options
constituted the 'scientifically constituted framework' against which histodcal
and examination data are matched. However, in medical practice these
elements are dealt with in a similar fashion as the data. They also cannot be
considered to be 'pre-fixed givens': in the transformation process, data as
well as medical cdteda and disposal options can be reconstmcted. In the
following fragment, for example. Miller reconstmcts the cdteda for
adenotonsillectomy [ATE]:
Dr. Miller, an ENT specialist, is taking his out-patient clinic together
with a houseman, who has just examined a new patient: a child whom he
suspects to suffer from adenoiditis. Miller asks him what the adenoiditis
tdad consists of. Since the houseman remains silent. Miller prompts:
'Open mouth, snodng and obligatory mouth respiration, caused by
obstmction of nasal respiration by the swollen tonsil. Don't forget'. The
child enters. 'No, he doesn't snore, but breathing seems to be difficult',
says the father. Both nostdls appear unobstmcted on examination:
obligatory mouth respiration is absent. In the child's throat 'kissing'
tonsils are visible who appear to be quiet [you can't see the nose tonsil
without special instmments]. The child does not have a cold and does
not have chronic nose symptoms. Miller wdtes in the patient record that
the child should have an ATE and comments to the houseman: 'This is
adenoiditis: note the typically adenoid appearance' (referdng to the
somewhat pallid face of the child and its op>en mouth).
Of the 'diagnostic tdad' of adenoitis, only one component is found (the
open mouth), but. Miller says, the child has a 'typically adenoid
appearance'. Here, the lack of fit between findings and cdteda is
compensated through the introduction of a new cdtedon, which the child
meets completely: note the word 'typically'. Similarly, Beatty (see the first
fragment in the previous section) is able to align all the negative answers
and examination results (the ECG and the cardial enzymes were normal,
the pain started when resting) to his transformation by stating that the
patient has atypical angina pectods.
Comparably, disposal options can be reconstructed to fit the trans-
formation:
Fields, a surgical houseman, presents Mr. Cowan (diagnosis: groin
mpture) at a case meeting in hospital Y. At the end of his presentation
he says: 'The proposal is to perform a Geer repair'. Some of the staff
members look up. 'Do you know what that is?' Martin asks. Fields, who
has expected this question, nods: 'The Geer repair prevents the groin
hernia from recurdng by putting a little synthetic mat over the defect.'
'Who is the responsible surgeon of this patient?' Martin asks. 'I am', says
164 Marc Berg
Richards, who has so far remained silent. 'Why do you want to do a
Geer? It's the first time this patient has a hernia! WTiy would you put in
foreign material with which we have hardly any experience? Why don't
you perform a regular operation?' Martin asks. Richards answers: 'Well,
this is an elderly patient, who probably has a weak abdominal wall.
When I'd do the conventional technique, we'd definitely get a recurrence
of the hernia. Moreover, the preliminary results of the research on the
Geer repair are favourable.' Although not all of the surgeons present
seem to be convinced, the meeting carries on with the next patient.
Somewhat later, however, a conventional technique is proposed with
regards to another patient with the same type of groin rupture. Now the
discussion starts all over again. 'Why don't we do a Geer here also? Why
do we treat similar patients differently?' Martin asks. 'Well, it's a
different physician'. Turner remarks dryly. The surgeons laugh. 'Well,
maybe I feel too strongly about foreign material in the abdomen', Martin
says finally. 'Maybe it's all a matter of taste'.
In this fragment, the examination and historical data direct the transforma-
tion towards a 'conventional therapy'. By questioning this option ('you'd
definitely get a recurrence') and, at the same time, underscoring his
alternative ('the results of the research on the Geer repair are favourable')
Richards tries to reconstruct the value of both therapies in order to pursue
the transformation he proposes.
Medical criteria and disposal options are involved in the transformation
process in an essentially similar matter as the other elements mentioned
above. So, historical and examination data can be reconstructed in view of
medical criteria, as was shown in the fragment presented earlier involving
the intermittent claudication patient who could walk more than half a mile.
The opposite also occurs as in the fragment where Daton prescribes
Nitrostat to his patient who, in his view, is suffering from backaches.
Likewise, in the next fragments, additional data lead to the reconstruction
of medical criteria:
Mr. Hughes, aged 66, has been admitted to the hospital because he
spitted blood. He was known to suffer from chronic bronchitis and
pulmonary emphysema. The extensive physical and laboratory
examination which was performed after admission did not yield new
information, except for a positive sputum smear. An attempt to culture
the sputum fails, and a second sputum smear is negative. The tuberculin
skin test also remains negative [a positive test indicates a (past)
infection]. Conclusion (from the discharge letter from the lung
specialist): 'active tuberculosis'. An antibiotic treatment (lasting nine
months) is prescribed and the patient is discharged.
So far, nothing special happened. A patient, known to suffer from a
chronic lung disease, develops a new symptom (the spitting of blood)
 The construction of medical disposals 165
which is extensively investigated. This results in a positive sputum smear
which could explain this symptom. The development of tuberculosis in the
elderly occurs quite frequently, as does the phenomenon that other
tuberculosis tests remain negative. Here, since no clues leading to other
causes (eg cancer) were found, the positive sputum smear directs the
transformation to the solvable problem 'tuberculosis requidng antibiotic
treatment'.
The case does not stop here, however:
Four months later Hughes is admitted, severely ill, to the department of
intemai medicine. He is suffedng from an acute kidney dysfunction,
requidng dialysis. The antibiotic treatment against tuberculosis is
stopped (while he still hasfivemonths to go), because one of the dmgs
involved is known to potentially affect the kidneys. The dmg could, in
fact, have caused the kidney failure, but the precise aetiology remains
unclear. Because Hughes is being treated by the lung specialists. Dr.
Fisher, a pulmonologist, is called for consultation. After questioning and
examining the patient and reading the information conceming the
previous admission, he wdtes in his report: 'Emphysema and
tuberculosis. Therapy: recommence antibiotic treatment as soon as
possible. Repeat sputum smear and culture.' After reading the report.
Dr. Stubbs, an intemist, calls Fisher. Two days later Stubbs wdtes below
Fisher's report: 'Consultation with Dr. Fisher: no recommencement
antibiotics since smear and culture are negative.'
On seeing the patient now. Fisher reaches the same conclusion as his
colleagues did four months previously: Hughes suffers from tuberculosis
and needs to continue his antibiotic treatment in order to kill all the
bacteda. He repeats the sputum culture and smear, although he does not
expect these to yield positive results: the patient is, at this time, not
coughing. After the consultation with Stubbs, however, the situation
changes radically. The negative culture and smear, which at first did not
lead to a rejection of the diagnosis tuberculosis, now does lead to that
decision: after being informed by Stubbs of the potentially harmful
consequences of the antibiotic medication for this patient. Fisher decides
to restrict the medical criteria for 'tuberculosis'. The negative results now
contradict the disposal 'tuberculosis requidng antibiotic treatment'. Now,
Hughes suddenly no longer suffers from this disease.
Medical cdteda and disposal options are, thus, modified in view of
histodcal and examination data in the same way that these data can be
adjusted in view of disposal options and cdteda. Also, like the data,
medical cdteda and disposal options can be reconstmcted in the light of
'social' factors. Such an element which has not so far been mentioned is
finances: a transformation has to be paid for, and in many situations, the
physician's earnings are related to this payment. This factor also is
interwoven in the medical problem solving process. In hospital X, for
166 Marc Berg
example, the decreasing number of obstetric patients on the obstetrical
wards did not lead to a substantial decline in admitted patients. The criteria
for admission of eg pregnancy toxemia patients concurrently changed:
patients were now admitted in earlier stages of this disease {cf. Katz 1985;
Freidson 1970: 92).
Also, the organisation of clinical practice is an important element in the
construction of medical disposals. The following fragments show how
organisational limitations can lead to the reconstruction of medical criteria
and disposal options:
During the vacation of Dr. Eron, an internist-oncologist in hospital X,
Edwards, a registrar in internal medicine, takes over his duties. The
diagnosis 'leukaemia' is normally made by microscopical examination of
bone marrow, obtained by puncturing the rim of the pelvis. Since
Edwards is not familiar with this procedure, the diagnosis is temporarily
made by puncturing the breastbone [here, a bone marrow puncture
yields less and qualitatively inferior cells, which makes the microscopical
investigation less dependable].
Maxwell, a gynaecological registrar in hospital X, is called to a delivery
during his night duty. The parturition is somewhat difficult: the amniotic
fluid contains meconium [this indicates fetal distress] and the child
appears to be hypothermic. After the child is bom it is investigated by
Maxwell, who does not find other problems. He aspirates the mucus out
of the nose and throat [especially important since the meconium may
clog the airways] and calls the pediatrician. Burton. Since in this hospital
both hypothermia and meconium-containing amnioticfluidare criteria
for transferral to the neonatal 'medium care'. Maxwell wants him to
transfer the child. The neonatal medium care, however, is full at the
moment. 'Put the child in your incubator and measure the temperature
again after an hour or so' Burton says. After one hour in the warm
incubator, the temperature has indeed become normal. The child's chest
is still retracting on inspiration, however [this suggests an impeded
respiration; due to the meconium?] and Maxwell calls Burton again. 'I'll
come over and aspirate myself he replies. So it happens, and the infant
remains on the obstetrics department.

The first fragment shows how medical criteria are intimately related to
institutional features: when a change occurs in the latter, the former often
change accordingly. In the second fragment. Burton finds himself in a
situation where organisational limitations (the neonatal 'medium care' is
full) direct the transformation to the disposal 'stay in obstetric department
in incubator'. The examination data, however, suggest the disposal
'admission to neonatal medium care'. By requesting another temperature
measurement after one hour. Burton tries to adjust the examination result
'hypothermia' to the former transformation (note that this second
 The construction of medical disposals 167
investigation is directively performed by placing the infant in a warm
incubator!). Also, Burton reconstmcts disposal options: in this situation,
the incubator on the obstetdcs department and hisfinalvisit are a sufficient
response to the meatnium-containing amniotic fluid and the hypothermia.
Just as in the previous section, however, 'social' factors do not
necessarily prevail: conversely, they can be reconstmcted in the light of
disposal options and medical cdteda. In the following fragment, Hodges
intervenes in organisational pattems in order to secure a specific disposal
option:
In hospital Z, Hodges, a gynaecologist, would refer premature infants of
less than 32 weeks of gestational age to another hospital whenever the
pediatdcian X was on duty. ^X, Hodges states, 'doesn't do what he
should be doing. In that other hospital they know what such a child
needs'.
Similarly, financial constraints can be adjusted in view of medical cdteda
and disposal options. So, the entdes on insurance forms arefilledin in such
a fashion so as to secure smooth payment:
While Dr. Bames, gynaecologist and younger colleague of Hodges, is
taking his outpatients' clinic he is called by the Patients' Fund^-'. The call
concems Ms. Stone, who has no house, lives in a caravan and, for this
reason, wants a clinical delivery. Bames has wdtten the Patients' Fund a
letter asking to pay these expenses because of this 'social indication'.
The Patients' Fund now informs him that this social indication is not
completely acceptable to them. They propose another location to
Bames, the midwife school, where Ms. Stone can have her baby at less
expense to the Fund. This school, however, is located 20 miles from the
hospital, while Ms. Stone's caravan lies next-door to Barnes' clinic.
After this phone call, Bames, who has become very irdtated, calls Hodges,
who shakes his head while Barnes relates his story. 'I though we'd told
you that asking for social indications gives you nothing but trouble. Why
do you try? [...] When somebody wants to have her baby in the
hospital, you just make up a medical indication. They won't know and
won't hassle you for that.' Barnes nods and agrees: 'Well, fortunately
her blood pressure has gone up somewhat, so FU make an 'imminent
toxaemia' out of it'. Hodges laughs and adds: 'with this warm weather
she'll probably have some oedema in her legs, so thatfitsin very well
too'. ['Oedematous legs' is an innocent symptom in pregnant women,
although in certain instances it can be a sign of toxemia.]

The constmctioii of raedical disposals: intermediate conclusion

In the previous sections, I have argued that the assumptions concerning the
nature of the 'contents' of medical action do not hold. Histodcal and
168 Marc Berg
examination data as well as medical criteria and disposal options are not
'givens' which unidirectionally lead the physician towards a disposal. The
physidan does not pa^ively solve a puzzle with pre-set pieces: in
articulating elements to the transformation, they are actively moulded and
reconstructed. Furthermore, it has been demonstrated how these elements
intermix with other prevailing 'cross-cutting systems of relevance' (Bosk
1979: 57) in medical practice, such as time, organisation, the image of the
patient and financial considerations.

Finances Medical
criteria Historical
The patient infomiation

Patienf s problem Solvable problem/disposal

Organisation ^ CvaminaH
Tima Examination
Disposal ""^^ results
options
Fig. 1 Elements involved in transforming the patient's problem to a solvable
problem.
Schematically, the transformation process is summarised in Fig. 1 (the
listing of elements is strictly heuristic). In transforming a patient's problem
to a solvable problem, the physician has to deal with an array of
heterogeneous elements which constitute her micro-environment. The
double-pointed arrows illustrate that these elements reciprocally shape the
transformation and are moulded themselves in this process: historical data
take shape or are forgotten and the image of the patient is altered; a
patient has backaches which necessitate Feldene or angina pectoris
requiring Nitrostat. What counts as the solution of the patient's problem is
a result of the outcome of the transformation; and, equally, what counts as
the original problem is redefined during this process. Also, the articulation
processes mutually interact: disposal options are modified in the light of
time pressure, organisational patterns are reconstructed in view of
examination data, etc. There is no essential disparity between 'cognitive'
and 'sodal' elements which would justify an asymmetrical treatment in a
sociology of medical practice; there is no such thing as a secluded, self-
explanatory domain in medical action. On the contrary, in medical practice
itself no a priori distinction between 'content' and 'context' or between a
'social' and a 'cognitive' domain is made. As the fragments have shown,
the physician, as a 'heterogeneous engineer' (Law 1987), smoothly
interconnects and interweaves the diversity of elements in constructing a
 The construction of medical disposals 169
medical disposal, disregarding any absolute distinction ever made by
outside investigators.'*
The terms 'solvable problem' and 'disposal' are not equivalent to the
'textbook' duality 'diagnosis' and 'treatment', which is adopted without
question in almost all sociological studies of medical action. A logical gap
divides the latter two terms. They are independent entities: for one
diagnosis X there may be several different therapies. This independence,
as Bloor (1978) already stated, is lacking in medical practice. A solvable
problem inherently contains a disposal: they are two sides of the same coin.
Physicians do not first search for a diagnosis and then, subsequently,
decide upon a therapy. This phased, two-step motion does not characterize
medical problem solving. On the contrary, from the outset, the trans-
formation process is unidirectionaliy geared towards the constmction of a
disposal. 'Diagnosis' and 'therapy' are terms which can be applied to this
process in retrospect, but in an 'in situ' study of medical practice the usage
of these terms creates an artefactual distinction.

The construction ot medical disposals: the role ot routines

The results outlined here offer a further step towards a sociological

approach to the medical problem solving process in practice: the focus of
the acount has been on the constmction of medical disposals itself.
Moreover, since the articulation processes are reciprocal, this account can
be designated as essentially combining some approaches to the medical
problem solving process discussed earlier. That is, the study of the impact
of certain elements (like patient- and physician characteristics) on the
medical problem solving processes and the study of the impact of these
processes upon the elements (eg upon the intercoUegial relations; the 'role'
approach) are here 'collapsed' into one approach, which highlights the
interdependency of the two.'^
There is, however, an important point that needs further cladfication. If
'biomedical knowledge' does not appear to be the beacon it is thought to
be and 'pragmatic' action is paramount, medical practice could be seen to
be utter chaos. Do we have to resort to the image of a physician who,
unbound by rules, adjusts the elements at will in order to construct the
disposal she pleases? Also, in this paper, terms like 'fitting' elements and
'directing' data were used. These adjectives imply that a physician has a
frame of reference which allows for these judgements. What is this frame of
reference? 'Biomedical knowledge' would be the traditional answer. But,
as is clear from the fragments presented earlier, medical practice does not
adhere to universal decision rules and categories. Medical cdteda and
disposal options themselves are modified and reconstructed in order to
align them with the transformation.'^ Then what is this frame of reference
in clinical practice?
170 Marc Berg
In this last section I want to argue tentatively that the concept of rotitines
can lead us toward an answer to these questions. A routine designates a set
of actions which is repetitively carried out with a certain 'automatism':
habitually, without explicitly reflecting on or legitimating the actions
involved. In the medical problem solving process, routines are of major
importance. The type of questions a physician asks, the way she asks them,
the kind of examination she performs, the interpretation of the answers
and the results, the completion of insurance forms: all these actions are
routinely performed.

These routine assessment practices are the means by which specialists

render unproblematic their decisions on patient disposal: by following
these time-tested routines in clinic a)nsultations specialists are able to
construct images of the clinical signs, symptoms and circumstances of
each patient which make the disposal-decisions 'obvious' to the
specialists (M. Bloor 1976:45).

These routines are essential in two related ways. They facilitate medical
action: the physician is not continuously deliberating on the steps she
should take next. Rather, the articulation processes are realized 'on her
spinal marrow' (statement of a surgical registrar). By learning the routines,
the physician learns to see 'in a single flash' what is essential in a given
situation and how this situation should be dealt with (Bloor 1978: 39-40,
Gordon 1988). In this way, routines realize an 'economy of effort' (Berger
and Luckmann 1%7: 71). Furthermore, the physicians' routines do not
stand on their own. They interconnect with routines of other people in the
organisation, thus creating ot^anisatiorud routines: laboratory investigations
are applied for on standard forms and routinely dealt with in the
laboratory; printed results from emergency cases are directly available at
the intensive care through an on-line connection {cf. Fujimura 1987; Rees
1981).
Second, routines constitute, in Konner's terms, ^the safety of the norm':
'you feel safe because you do what everybody else is doing' (1988: 366).
Following the time-tested, trodden path has the important function that
the physician and her environment know that she acts properly {cf.
Garfinkel 1967; Giddens 1984: 30). When articulation processes are
realised by routine, the elements support the transformation in a self-
evident fashion: it is then a 'replica' of a transformation which has been
performed in a similar fashion many times before.
The locally situated routines constitute the frame of reference sought
for: they encompass the unwritten rules which define whether historical
data and the image of the patient fit a transformation or not, whether
examination data or medical criteria are adequately reconstructed or not,
etc. {cf. Atkinson 1988: 200). In daily practice, routines define what counts
as a good articulation and how to articulate:
 The construction of medical disposals 171
You don't need all the 1500 pieces of the puzzle for your diagnosis, but
you'll need 1378 of them (remark of Dr. Flores, an internist in hospital
X).
The fact that it is actually the routines determining whether the 1378 pieces
are sufficient or not, instead of 'biomedical knowledge' is illustrated
further when we compare two different practices:
In Hospital PI always used that drug, but my bosses would shoot me if I
used it here (Stokes, neurological registrar in hospital Yon the use of an
anti-psychotic drug).
In hospital Y the cardiologists state that a proper physical examination of
the heart requires the meticulous palpation of this organ's vibrations in
the chest. Percussion of the heart, they say, is senseless. Contrarily, the
cardiologists in hospital X refer to the palpation of the heart as 'a
meaningless investigation'. They, in their turn, attach great importance
to the percussion of the heart.
In these hospitals different routines exist; in these two sites, what counts as
'adequate' or 'sufficient' is different.
It is important to note that routines are not confined to singular
articulation processes. Rather, routines are characterised by their irtclusive-
ness (Bloor 1978: 42): their coinciding extension into several articulation
processes emphasizes the heterogeneous engineering of the physician.
While articulating historical and examination data with the transformation,
the cooperation of the patient and the education of the onlooking
houseman is 'managed' simultaneously. The physician's expertise stretches
out into the diversity of elements which constitute her micro-environment.
Routines can be considered as the micro-sociological correlative of the
concept 'paradigm'.*' They facilitate medical action by embodying routes
to take and to avoid in the transformation processes and, at the same time,
supply a framework which delineates what is proper action and what is not.
Like a paradigm, routines are not just a 'social' category {cf Latour in
press). As mentioned shortly above, routines can be materialised in on-line
connections or standard forms. Routines do not simply dictate the usage of
an instrument or form: the form itself structures the contact between
physician and laboratory and delineates which tests are relevant, which are
expensive, etc. Equally, in the stethoscope conceptions of the doctor-
patient relation and the relevancy of certain examination data are
embedded (see note 14). Thus pre-stnicturing the articulation processes,
the stethoscope, the form and the on-line connection themselves are
integral parts of the routines.*
In this way, the concept of 'routines' supplies a structure in medical
action. This structuring role of routines does not imply that physicians
continuously act in a routine fashion. Stepping out of a routine, however,
implies that the correctness of the action needs to be explicitly renegotiated:
172 Marc Berg
the legitimacy which comes as a matter of course with a routine articulation
is now absent. In these continuous renegotiations (many examples of which
can be seen in the empidcal fragments in this paper) the possibility of
changing routines is contained."
This leads me to a final point that needs to be mentioned. Most of the
examples discussed here were taken from hospital settings, where routines
are shared by groups of physicians and negotiations take place within these
groups. However, many physicians (eg family practitioners) work in
relatively isolated settings. The question may arise if the notion of
'routines' suits these situations as well. I would answer affirmatively: when
there is little interference with colleagues and a low dependency of
organisational facilities and instruments, highly individualised routines can
develop {cf. M. Bloor's (1976) study of ENT specialists). In these
situations routines also fulfill the role of frame of reference, and,
correspondingly, stepping out of the routine implies a deviation from the
'safety of the norm', psychologically necessitating an explicit legitimation
for doing so.

Conclusion

In this paper, it is argued that the sociology of medical action could

enhance its scientific and political potential by employing insights
developed in the sociology of science (in particular 'laboratory studies').
Until recently, medical sociologists studying medical practice generally
seperated the 'content' of medical action from the 'social aspects', the
former constituting a domain inaccessible to sociological investigation.
This asymmetdcal treatment of 'cognitive' and 'social' elements was stated
to be based on two assumptions: (i) histodcal and examination data are
generally seen as 'facts' which the physician only needs to 'reveal' and (ii)
medical cdteda and disposal options are regarded as scientific, fixed
'givens'. It is argued that the abandonment of this asymmetry will be
furthered through a 'laboratory study' of medical problem solving^" in
clinical practice.
The results of this study show that neither histodcal and examination
data, nor medical cdteda and disposal options, can be seen as 'givens'
which unidirectionaliy lead the physician towards a solvable problem.
These elements as well as 'social factors' such as the image of the patient,
financial considerations, etc., direct the transformation and, reciprocally,
are adapted to it. The physician, in transforming a patient's problem to a
solvable problem, does not passively combine some 'cognitive' items
together, but actively articulates an array of heterogeneous elements with
the transformation. Consequently, 'biomedical knowledge' cannot be
considered to be the beacon which guides the construction of medical
disposals in clinical practice. This does not imply that anything goes: it is
 The construction of medical disposals 173
not 'biomedical knowledge' which forms the frame of reference for medical
action, however, but the locally situated routines. These facilitate medical
action by allowing the articulation processes to be performed 'by rote' and,
simultaneously, they define what is proper action and what is not.
Department of Health Ethics and Philosophy,
State University of Limburg,
Maastricht, The Netherlands.

Acknowiedgements

I want to thank the anonymous referee, Wiebe Bijker, Michael Bloor, Jessica
Mesman, Gerard de Vries, Wies Weijts, Rein de Wilde, and especially Annemarie
Mol for helpful comments on earlier versions of this paper.

Notes

1 See for example the work of Armstrong (1983, 1985), Amey and Bergen
(1983), and the essays in Wright and Treacher (1982). The relevance of the
social constructionist approach for the sociology of medicine has been debated
in eg Bartley (1990), Bury (1986, 1987), King (1987) Nicolson and McLaughlin
(1987, 1988) and Wright (1979). As Nicolson and McLaughlin (1987) have
noted, medical sociologists tend to use the word 'constructionism' while
sociologists of science speak of 'constructivism'. With Nicolson and McLaughlin, I
see no fundamental difference in meaning lying behind this different usage.
2 Since I am interested here in a sociological study of medical problem solving in
practice, I will not discuss the medical decision making literature that tries to
describe the decision process of the individual physician in cognitive-
psychological terms (eg Elstein et al 1978, Denig et al 1988, cf. Scheff 1972).
This has been done elsewhere (Berg and de Vries 1991, in Dutch; cf. Gordon
1988, MSseide 1983).
3 Showing how medical problem solving processes mediate relations between
doctors is not the only way in which medical sociologists have focussed upon the
role of these processes in clinical practice. The studies of 'the social construction
of medical reality' (Atkinson 1981), undertaken in the tradition of Berger and
Luckmann (1%7) and Garfinkel (1%7), are all very detailed in spelling out this
role in the interactional constitution of medical reality in the doctor-patient
relationship (e.g. Emerson 1970; Strong 1979, cf. Silverman 1987).
4 By centring on situations of which the 'ethicality' is explicitly acknowledged by
all participants, it may appear as if the existence of a distinctive, 'non-objective'
category, different from 'ordinary' medical problem solving, is suggested.
Indeed the 'not so rational or scientific' decision making process which Crane
discusses is explicitly linked to decisions about critically ill patients. Doing so,
she seems to imply that in ordinary cases the process might be entirely different
(1975: 19); it might, in fact, be completely rational and scientific.
5 Also, in clinical practice in particular the medical problem solving process
stretches out far beyond the setting in which the doctor-patient interaction takes
174 Marc Berg

place. A comprehensive sociological approach to medical problem solving in

practice should thus 'follow the physician' {cf. Latour 1987) and observe case
meetings, ward rounds, etc. as well.
6 The (assistant) housemanships consisted of: surgery, internal medicine, family
medicine (each lasting three months), gynaecology and psychiatry (two months
each), pediatrics (six weeks), neurology (four weeks), ear, nose and throat
medicine, dermatology and ophtalmology (three weeks each). My status as
houseman had the advantage of being unproblematically accepted in all the
aspects of the medical practice {cf. Atkinson 1981:126-9). At the same time, of
course, this position implicated that several duties interfered with the time
available for making and working on research notes (with the exception of the
interviews it was not possible to use a cassette recorder). Also, at times the dual
role was difficult to maintain. I can only hope that the considerable duration of
the fieidwork and the regular presence of 'time ofT periods between the
housemanships prevented these disadvantages from asserting a detrimental
effect upon the work.
7 One could object that these physicians 'do no listen well' or 'are biased towards
a presupposed diagnosis'. Such an objection, however, still assumes that
historical data are 'there to be found' for the physician who listens properly. As
stated, however, historical data are not 'givens' but constructions which come
about during the doctor-patient contact. In that setting, the historical data take
shape for both physician and patient {cf. Young 1981; Helman 1988; Wynne
1988). After the consultation, the pattern of symptoms has crystallised in a new
form for both participants. Also, one could say that the patient's part in the
interactive realisation of historical data is neglected. Since I am intersted in the
way physicians construct medical disposals, however, I focus primarily upon
them. Furthermore, such is the structure of the doctor-patient contact that the
patient's influence is in fact relatively small {cf. Strong 1979; Silverman 1987;
Fisher 1984).
8 See Atkinson (1981, 1988) who shows how, through bedside teaching, medical
students learn to construct 'sense' out of the seemingly meaningless chaos of
possibly important signs and symptoms.
9 This example is a compilation of several statements, regarding different
complaints, found in patient's records.
10 In the end, the operation did not proceed: this was not a consequence of the
case meeting, however, but due to a sudden refusal of the patient. The will of
the patient is also an element which has to support the transformation for it to
succeed.
11 The operation would have been performed if Baker had not made this
objection.
12 Several studies have shown how patients are categorised by medical personnel,
using a mix of medical knowledge and everyday typifications, as 'good' or 'bad',
'responsible', or 'not responsible', 'more' or 'less urgent', 'legitimate' or
'illegitimate' (eg Roth 1972; Hughes 1977, 1980; Dingwall and Murray 1983).
13 The Patient's Fund ('Ziekenfonds') is a Dutch institution which covers the
medical expenses of citizens earning less than a certain income. Participation in
the Fund is obligatory. People earning more than this income can insure
themselves by private insurance companies. The medical care system, however,
is not thus divided: there are, in general, no specific hospitals or other facilities
 The construction of medical disposals 175
which are only accessible to privately insured patients. Since the problem of
skyrocketing medical expenses has also hit the Netherlands, the Fund has tried
to reduce its spending by scrutinising more closely the medical criteria
involved. In the case of deliveries, for example, the Fund uses a list of
'Indications' which necessitate clinical delivery, such as hypertension, previous
complications, etc. When these indications are not met, the Patients' Fund will
only cover the costs of a delivery at home.
14 As stated, the listing of elements has only a heuristic basis. There is no claim for
completeness: many 'contextual' elements could be added, such as the need to
'cover' oneself in view of the possibility of 'malpractice claims', the will of the
patient {cf note 10), regulations, the physician's involvement with scientific
research and education, etcetera {cf Konner 1988: 46; Freidson 1975: l&~n;
Bosk 1979,1980; Atkinson 1981; Silverman 1987). More importantly, the listing
is strictly heudstical on principle. A stringent categorisation of elements would
blind us to the mutual interwovenness of the elements (Hughes 1986). It is
imftortant to remain sensible to the fact that the different 'elements' develop
interactively and that the 'borders' between 'cognitive' and 'contextual'
elements are not given but constructed - which is why I constantly use inverted
commas in assigning these labels. Medical criteria, prescriptions, organisational
arrangements are embedded in disposal options, {cf. Bijker, Hughes and Pinch
1987; Bijker and Law in press); disease definitions encompass therapeutic
|X)ssibilities, organisational configurations and professional interests {cf. the
sodal constructionist studies mentioned in the introduction); the organisation of
the hospital is again interwoven with medical criteria, professional interests and
therapeutic possibilities, etc.
15 I owe this point to Bijker et al, who make an analogous point regarding the
sociological study of technology ('Introduction' in Bijker, Hughes and Pinch
1987).
16 The way 'decision rules' do figure in medical practice underlines this
typification. Hiese rules do not function as solid precepts for action but as ad
hoc legitimations. For example, as mentioned in the paragraph on historical and
examination data, physicians often legitimate the reconstruction of an opposing
examination finding by referring to the importance of technical, sound data and
reliable scientific research. Thus, Fisher stated that cardiologists rely too much
on their clinical judgement: 'They don't look well enough at the thorax X-ray
[. . .] The clinical picture [. . .] can be so treacherous'. Equally, however, just
the opposite occurs. Baker, for example, (in the fragment preceding Fisher's
statement) stated 'these examinations give us only numbers'; 'the clinical
picture is what counts'. It is important to recognise that these statements do not
exemplify the fundamental viewpoint of these doctors: if this would be the case,
something of a 'universal decision rule' would be recognizable. Contrarily, in
interviews both physicians did not speak out in favour of either 'sound technical
data' or 'clinical judgement'. The statements made in the fragments were of a
very practical nature: dependent upon the situation (i.e. whether it is favourable
given the transformation they support) physicians appeal to their 'invaluable
clinical judgement' or to the 'need for scientifically based examination
techniques'. Richards, for instance, (see the second fragment in the section on
medical criteria and disposal options) refers, in two consecutive sentences, first
to his clinical experience ('when I'd do the conventional technique, we'd
176 Marc Berg
definitely get a recurrence') and subsequently to scientific research ('the
preliminary results [. . .] are favourable)'.
17 Here I draw especially upon Kuhn's clarifying elaboration of this concept in his
postscript to the second edition of The Structure of Scientific RevolvUions (1970).
The word 'micro-sociological' is not meant to invoke a fundamental discussion
about methodolo^cal issues but is used only to indicate a close-to-the-actors
level of investigation.
18 Thus, the concept of routines is markedly different from Kleinman's 'Explanatory
Model' (eg Kleinman 1978; Helman 1985), which concerns primarily the
'cognitive' elements and does not incorporate objects.
19 By referring to the concept 'paradigm' I do not want to imply that routines
develop in a similar fashion to Kuhn's model of 'normal' science and
'revolutionary' science. As has been argued in the case of paradigms as well
(Nickles 1989), routines probably develop in a more gradual manner.
20 In this paper I have avoided the term 'decision making'. There are several
reasons for this caution; first, usage of the term 'decision' would disregard the
fact that very often it is unclear where and if a 'decision' is taken at all (cf.
Frohock 1986). Routinely performed transformations, for example, can hardly
be thought of as involving 'decisions': the case 'speaks for itself; the physician
works on her 'spinal marrow'. Furthermore, 'decisions' often come about
incrementally: in situations differing in time and place, small steps eire taken
which, in retrospect, appear to have led up to a 'decision' (ibid.). The double
meaning of the term 'decision' ('decision' as deliberate choice and 'decision' as
retrospectively applied term) easily leads to confusion. (As will be clear, this
point is a further argument for not using the duality 'diagnosis' and 'therapy' {cf.
Bloor 1976).) Second, the word 'decision' draws one back into a cognitive-
psychological framework, disregarding the constructive and heterogeneous
nature of medical problem solving.

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