The convivial and the pastoral in patient–doctor relationships: a multi‐country study of patient stories of care, choice and medical authority in cancer diagnostic processes

Abstract

Experiences of cancer diagnosis are changing in light of both the increasingly technological-clinical diagnostic processes and the socio-political context in which interpersonal relations take place. This has raised questions about how we might understand patient-doctor relationship marked by asymmetries of knowledge and social capital, but that emphasise patients' empowered choices and individualised care. As part of an interview study of 155 participants with bowel or lung cancer across Denmark, England and Sweden, we explored participants' stories of the decisions made during their cancer diagnostic process. By focusing on the intersections of care, choice and medical authoritya convivial pastoral dynamic we provide a conceptual analysis of the normative ambivalences in people's stories of their cancer diagnosis. We found that participants drew from care, choice and medical authority to emphasise their relationality and interdependence with their doctors in their stories of their diagnosis. Importantly negotiations of an asymmetrical patient-doctor relationship were part of an on-going realisation of the healthcare processes as a human endeavour. We were therefore able to draw attention to the limitations of dichotomising emancipatory-empowerment discourses and argue for a theorisation of the patient-doctor relationship as a contextually bounded and relationally ambivalent humanity. Notes1 The authors recognise the potential rupture of using conviviality outside of the studies of race and racism studies and considered developing alternative conceptualisations. However, it was felt this would be both academically inappropriate and an injustice to the inspiration and work of those cited as well as the wider field of cultural studies from which it was drawn.

From loyalty to resignation: Patient–doctor figurations in type 1 diabetes

“…For instance, Greener ( 2008 ) stressed the co‐existence of the logics of caring and empowering, whereas Phillips and Scheffmann‐Petersen ( 2020 ) stressed the co‐existence of both models of doctor‐ and patient‐centredness and considered the relationship as the unstable product of dialogic meaning‐making processes that are inherently complex and full of tensions. By the same token, MacArtney ( 2020 : 855) underlined the ‘limitation of dichotomised framings of the patient–doctor relationship’, by stressing both the asymmetries of knowledge and social capital, on one side, and patients' empowered choices and individualised care, on the other side. Our findings corroborate the need to go beyond ‘dichotomised framings’.…”

“…Among techno‐critics, Lupton ( 2014 ) highlighted the extension of the panoptical gaze of health professionals by means of technologies: since they create more ways of entering into people's private and intimate worlds, the role and power of physicians results to be strengthened. Another issue is the ambivalence often showed by patients as to whether they want to participate in their clinical decision‐making in addition to wanting to trust and rely on their doctors, and to be guided by them in medical decision‐making (MacArtney et al, 2020 ; Nettleton, 2013 ). In these contexts, scholars tend to stress the uncertain affective and digital atmospheres triggered by devices that are worn constantly, such as pumps or sensors, which might stimulate both sentiments of happiness or apprehension (Lupton, 2017 ).…”

“…Actually, some authors stressed more nuanced patient–doctor frameworks that go beyond such static representations. For example, the dynamic tensions underlying the practice of goal‐setting have been highlighted (Murdoch et al, 2020 ); or the ongoing conflict over power and control (Greenfield et al, 2012 ); or the ambivalence between logics of ‘being cared for’, or even ‘strongly guided’, and empowerment (Greener, 2008 ; MacArtney et al, 2020 ; Nettleton, 2013 ). In line with this more nuanced and dynamic analysis, we think that a relational perspective, which focuses on processes and flows of action (Powell & Dépelteau, 2013 ), as well as on transaction (Emirbayer, 1997 ), could be helpful in describing actual day‐to‐day patient–doctor relationships.…”

“…Increasing patient competence both on clinical and technological grounds within a framework of self‐management and shared doctoring creates high expectations regarding the figurations with their diabetologists. They are required to have clinical competence, technological skills and also the capacity to share the doctoring, which entails relational traits such as exchanging knowledge, suggestions and experiences, as well as giving words of comfort (Mol, 2008 ) and empathy (Brown et al, 2015 ; MacArtney et al, 2020 ). These requirements reject asymmetrical and paternalistic relationships, as well as seeing patients as independent figures sublimated by concepts of empowerment and patient‐centredness.…”

“…This excerpt confirms the importance of trust for the quality of the figuration, because it affects self‐management, among other things (White et al, 2013 ). Moreover, it is intertwined with clinical‐technical competence and interpersonal skills, such as exchange and empathy (Brown et al, 2015 ; MacArtney et al, 2020 ; Mol, 2008 ; Peek et al, 2013 ). Besides, we also see the relevance of technological skills, as patients have bridged the gap with the diabetologists, or even know more than them, and they demand these TDs (Bos et al, 2008 ).…”