Medicine in advanced modernity: marketization, expertise and the problem of trust

This thesis is an analysis of doctors' understandings of, and responses to, changes to medicine and the doctor-patient relationship that locates them within a broader framework of socio-historical transformation. In the context of advanced modernity, adaptation to change is a key challenge facing orthodox medicine. Data on changes in the nature and context of medicine are drawn from a sample of editorials of the Australian Medical Journal, the Lancet, the Journal of the American Medical Association and the New England Journal of Medicine over the period 1965-1995. Data on the perceptions and experiences of individual doctors are drawn from semi-structured, in-depth interviews of general practitioners and specialist practitioners working in metropolitan, rural and remote regions of Tasmania and South Australia. Data from both sources are analyzed with the assistance of the qualitative analysis software package ATLAS/ti. The thesis demonstrates linkages between commodification, differentiation and rationalisation and the emergence of social processes and phenomena relevant to changing doctor-patient relationships, including the marketization of medicine and the rise of consumerism, the proliferation of knowledge and the specialisation of expertise. In contemporary social contexts (and most noticeably in metropolitan practice settings), doctor-patient relationships increasingly take the form of short-lived, 'restricted exchanges' in a market setting. Trust is becoming more problematic just as it simultaneously becomes more necessary as a mechanism for dealing with complexity and uncertainty. Five factors contribute to the 'problematization' of trust in medicine as an expert system: 1) increasing public knowledge of and access to healing systems and philosophies other than Western biomedicine, known collectively as complementary or alternative therapies; 2) growing emphasis on medicine as a 'business' and patients as 'consumers' of medical care; 3) the large and growing number of specialties and the dominance of 'high-tech' medical care; 4) greater 'visibility' of medical and scientific knowledge and particularly of the 'disputes that divide experts'; and 5) the increasingly litigious nature of wider society resulting in the new centrality of contracts, informed consent, the disclosure of diagnoses and risks and the practice of 'defensive medicine'. These factors all have implications for trust at the interpersonal level. The project indicates that, by virtue of its growing relevance to points 1) and 4), in particular, the Internet has the potential to impact upon, or even transform lay-expert relationships in a way that has only been partially realized to date. The project also finds evidence of role confusion among doctors associated with rapid social change and the diminishing public acceptance of 'paternalistic' doctor-patient relationships. It reveals considerable tension between high levels of marketization and the service-orientation and altruism central to traditional notions of professionalism. Doctors (particularly general practitioners) find themselves at the centre of a complex web of contradictory pressures and their individual and collective efforts to build and maintain trust can inadvertently contribute to its further erosion.