Elsevier

Social Science & Medicine

Volume 62, Issue 4, February 2006, Pages 1022-1030
Social Science & Medicine

Technogovernance: Evidence, subjectivity, and the clinical encounter in primary care medicine

https://doi.org/10.1016/j.socscimed.2005.07.003Get rights and content

Abstract

Technological solutions to problems of knowledge and practice in health care are routinely advocated. This paper explores the ways that new systems of practice are being deployed as intermediaries in interactions between clinicians and their patients. Central to this analysis is the apparent conflict between two important ways of organizing ideas about practice in primary care. First, a shift away from the medical objectification of the patient, towards patient-centred clinical practice in which patients’ heterogeneous experiences and narratives of ill-health are qualitatively engaged and enrolled in decisions about the management of illness trajectories. Second the mobilization of evidence about large populations of experimental subjects revealed through an impetus towards evidence-based medicine, in which quantitative knowledge is engaged and enrolled to guide the management of illness, and is mediated through clinical guidelines. The tension between these two ways of organizing ideas about clinical practice is a strong one, but both impulses are embodied in new ‘technological’ solutions to the management of heterogeneity in the clinical encounter. Technological solutions themselves, we argue, embody and enact these tensions, but may also be opening up a new array of practices—technogovernance—in which the heterogeneous narratives of the patient-centred encounter can be resituated and guided.

Introduction

Recent sociological accounts of technological change in medicine—whether they review apparently global developments in the domain of technoscience (Clarke, Mamo, Fishman, Shim, & Fosket, 2003; Webster, 2002), or more specific developments in genetics (Franklin, 2001), visualisation (Waldby, 2000), or the internet (Nettleton, 2004)—have all been forced to struggle, in one way or another, with the problematic interactions between two kinds of medical knowledge. The first of these is experiential qualitative knowledge rooted in clinical experience and worked out in the everyday clinical encounter, and the second is experimental quantitative knowledge derived from population studies, randomised controlled trials and meta-analyses, and worked out through the production of different kinds of clinical guidelines for practice.

In the UK, the interaction between these two ways of thinking about the ways that medical knowledge informs practice has often been framed in terms of a contest between individual clinical autonomy and a new field of evidence based medicine, and this has been represented both in studies of experiences of clinical practice (Summerskill & Pope, 2002), and in studies of doctors’ perspectives on the interpolation of newly codified ‘evidence’ into their everyday work (Armstrong, 2002). At a macro-level the shift to evidence-based medicine has been understood in terms of the play of power through the intervention of the state and its relatively autonomous agencies to regulate medical practice (Harrison, 1996), which in turn acts as a key element of policies and practices around the ‘modernisation’ of the National Health Service (Harrison, 1999). This view parallels a growing recognition of the emergence of steadily more sophisticated and interventionist mechanisms of state intervention and regulation, what Moran (Moran, 2002) has termed the ‘transformation’ of the regulatory state from ‘government by command into uncoupled systems of self-steering’ (p.391). These ‘uncoupled systems’ themselves form mechanisms of self-surveillance and governance (Daly, 2003), in which regulatory authority is delegated downwards into different public sector bodies and responsibility for meeting the demands of new structures of governance is diffused through networks of active management rather than traditional patterns of bureaucratic administration (Kelly, Mulgan, & Muers, 2002).

Political struggles over the status of evidence-based medicine (EBM) are only one element of a complex arrangement of shifts that are currently taking place in the British health care system and which frame the production, mediation and effects of knowledge about health and health care in relation to individuals and groups. In this paper we argue that these struggles are about more than clinical autonomy and managerialism, but also represent struggles over what kinds of experiences and knowledge patients are authorised to bring to the clinical encounter, and how these are made to count.

Our analysis focuses on the apparently routine practices that surround the management of chronic illness in primary care, for this is the field in which contradictory tendencies of subjective engagement and aggregated abstraction are being worked out. We call upon a range of theoretical dispositions, from perspectives informed by interactionist (Strauss, Fagerhough, Suczek, & Wiener, 1997) and Mertonian ‘middle-range’ theories (Reiser, 1978) of the interaction between technologies and social practices, to more recent theoretical positions in which technologies and social practices are understood to be woven together in the most intimate way (Heath, Luff, & Svensson, 2003; Timmermans & Berg, 2003a), and theories of discourse and its production in critical psychology (Mather, 2000).

The paper is divided into four sections. We begin with the problem of patient-centredness—a crucial recent ideological move in medicine—and then explores its consequences in debates about informed and shared decision-making in the clinical encounter. The focus then shifts to practices of production of EBM and its mediation in the clinical encounter. Finally we point to the emergence of new technologies and systems of practice which mediate between patients and health care providers and which reconstruct the patient as a minimum data set. At the heart of our analysis is a set of problems about power, knowledge and subjectivity, and the ways that policies of modernisation bind new technologies into a new way of framing health care practice which we call technogovernance.

Section snippets

Problem of subjectivity

A problem for medicine as a general field is what to do with the patient's subjective experience of illness, and how to connect it with medical knowledge and practice. Since the 1800s, medicine has focused primarily on underlying organic pathology: shifting attention away from the patient's expressed symptoms and onto clinical signs—initially attending to organic processes and disease states, but moving steadily towards more microscopic analyses of the body (e.g. genetics). Jewson (Jewson, 1976

Negotiating medical knowledge

The shift to patient-centredness opens up heterogeneity: patients are no longer construed as specific instances of a disease to be locally negotiated, nor are they passive recipients of individualised and authoritative expertise. Instead they are now conceptually organised as local negotiators of a problem, able (and expected) to make choices about its management, express subjective experiences and wants, and to adjudicate on the quality of the care they receive. All of this is expected to take

Calculating and presenting risks

To the epistemological and practical challenges we have described above, we now need to add another problem. This is that much of what is now at issue and is not so much the prognostic calculation embedded in the management of a disease, but rather the calculation of risks and effects—deploying knowledge derived from large trials, or from systematic reviews and meta-analyses—and translating this knowledge about collectivities into an individual plan for a specific patient.

One of the possible

Technogovernance

A central feature of contemporary modes of governance is distributed accountability (Newman, Barnes, Sullivan, & Knops, 2004). In this context, the shift from doctor-centred to patient-centred individualizing approaches to the clinical encounter and to shared decision-making practices within it can be seen a political, as well as a clinical, move. But the shift to patient-centred practice brings with it a problem, this is found in the priority that is given within it to the patient's subjective

Acknowledgements

We gratefully acknowledge the financial support of the Alcohol Education Research Council (Grant APP41/2001); Department of Health (Grant ICT 2/032); Economic and Social Research Council (Grants L218 25 2067 and RES000270084); European Commission; National Institute of Clinical Excellence; and Wellcome Trust (Grant GR068380AIA-HSR). Many people have commented upon this paper or contributed to the empirical studies that have informed it. We thank especially, John Bond, Marie Campbell, Martin

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