Rhetorical work and medical authority: Constructing convincing cases in insurance medicine, 2020, Rasmussen

Andy · Sep 15, 2020

Highlights

• Absent but expected biomedical evidence cause problems of trust and credibility.
• General practitioners (GPs) face such problems as gatekeepers in health insurance.
• The study explores GPs' work to construct convincing cases for insurance benefits.
• Uses focus groups and follow-up interviews to unpack GPs' persuasive efforts.
• Proposes rhetorical work and insurance trajectories as conceptual innovations.

Abstract
This article explores general practitioners' (GPs) persuasive efforts in cases where biomedical evidence is absent but expected. Health insurance in Western countries is based on the biomedical ideal that legitimate complaints should have objective causes detectable by medical examination. For GPs responsible for assessing sickness and incapacity for work, the demand for objective evidence can be problematic: what if they as experts deem that a patient is in fact sick and eligible for benefits, but are unable to provide objective evidence to that fact? How can they convince bureaucrats in the insurance system to accept their judgment?

Taking ‘medically unexplained symptoms’ as my case, I draw on focus group and follow-up interviews with GPs in Norway to explore how GPs attempt to persuade bureaucrats to accept their professional judgment. Proposing the concept of ‘rhetorical work’, I reconstruct a typology of such work that doctors engage in to influence bureaucratic decision-making and provide long-term health benefits for patients. I then discuss the potential societal implications of GPs' rhetorical practices and the applications of the concept of rhetorical work in future research.
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Open access, https://www.sciencedirect.com/science/article/pii/S0277953620305438

Dolphin · Sep 15, 2020

This is more about disability insurance than health insurance. Health insurance is about paying for tests and treatments; disability insurance is about disability benefit payments.

Over the years, a failure to distinguish between the two has led to people talking about different things.

Dolphin · Sep 15, 2020

I sometimes have ended up writing letters of support for people for disability claims. I wonder has this any practical implications for that sort of activity.

rvallee · Sep 15, 2020

Not so sure that rhetorical work and medical authority is the solution to problems caused by rhetorical work and medical authority. MUS are purely rhetorical constructs used instead of their actual nature, in large part because of stubborn defiance against doing the actual work and research that would solve them. This is exactly the problem: rhetorical arguments are common in medicine. I'd rather have none than build upon a both sides thing that is ripe for abuse. We're already on the widespread abuse side of things. It's very bad.

Medicine is terrible at dealing with illness, it's built for disease and has a terrible grasp of object permanence. Let's fix that instead. No rhetoric required. Whether that goes through a distinct but formal specialty in medicine or by simply doing the work that has been rejected for decades because (*loud reverb*) THE MAGICAL POWERS OF THE MIND (*/loud reverb*) are so damn intoxicating is irrelevant, medicine can't function without accepting basic facts and MUS is precisely an area that exists on rejecting reality and substituting their own.

There is no tweaking a broken system. It's broken, nothing a bit of glue will fix. Or even all the glue.

Hutan · Sep 16, 2020

From the first paragraph of this paper:

In many cases, patients suffer from conditions for which doctors fail to provide evidence – at least of the type that is expected. Owing to the lack of objective ‘signs of disease’ (e.g. x-ray images or laboratory tests), such conditions are often characterized as subjective and they constitute the largest group of complaints in primary care
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I've looked at NZ data a few times now and the doctors manage to identify a straightforward problem to code almost all of the consultations to. I doubt that these doctors or the patients are particularly unusual.

https://www.moh.govt.nz/notebook/nb...748C007D64D8/$file/NatMedCaReport6Dec2005.pdf
From Table 8.4 of this (admittedly old) NZ study which was the first one to come up when I googled.
For example, for non-Maori patients, % of GP visits - by problem grouping for consultations

21.9% Respiratory (Acute respiratory infections,Chronic obstructive airways disease, Pneumonia and influenza, Respiratory symptoms)
17.0% Actions (Preventive procedures, Operations, Therapeutic procedures, Administration)
14.4% Cardiovascular/circulatory (Blood pressure -hypertensive disease; Arteriosclerotic heart disease; Cardiovascular symptoms)
13.0% Nervous system/sense organs (Ear diseases; Disorders of eye; Central nervous system symptoms; Central nervous system disorders)
11.7% Injury/poisoning (Sprains and strains of joints and adjacent muscles; Abrasions; Contusion; Arm fracture; Scalds; Laceration- leg)
10.5% Skin/subcutaneous tissue (Dermatitis/dermatoses; Skin & subcutaneous tissue infections; Symptoms affecting skin/integumentary tissue)
9.7% Musculoskeletal/connective tissue (e.g. Arthropathies ; Rheumatism;osteopathy; chondropathy; acquired musculoskeletal deformity)
8.4% Investigations (History; Examination; Diagnostic procedures/lab tests/radiology)
8.1% Mental (Neurotic, personality and other non- psychotic disorders, Non-organic psychoses)
7.5% Digestive (Gastrointestinal tract symptoms; Oral cavity, salivary glands, jaw diseases; Duodenal diseases;Intestinal and peritoneum diseases)
7.1% Genito-urinary (e.g. Urinary system diseases; Genito-urinary symptoms; Female pelvic inflammatory diseases; Male genital organ diseases)
6.7% Infectious/parasitic (e.g.Viral and chlamydial diseases; Mycoses; Bacterial food poisoning; Viral diseases with exanthema)
etc

If you cast your eye down that list, for most of them there will be signs. And frankly, if doctors in general can't identify signs for most of the things they treat then that would be an appalling indictment of medicine. But it surely is not true. Medicine has got to the point of having all sorts of investigations rather more subtle than 'are bones sticking through the skin?'.

So, how do medical professionals manage to write 'conditions that lack objective 'signs of disease' constitute the largest group of complaints in primary care'? I think the only way that could be true is if all the 'conditions that lack objective 'signs of disease' are lumped together in one group and all the other conditions are split into very small groupss, like, instead of 'Injury/poisoning', there is 'ankle sprains' and 'cuts on leg'...

Hutan · Sep 16, 2020

In amongst the sociology-speak is some interesting analysis.

A similar interpretation of patient advocacy within the context of insurance medicine can be given: arguably, the function of GPs’ rhetorical work is to ensure fair treatment for patients whose conditions are poorly understood by a system governed by biomedical ideology.
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This work is set in Norway - there are some observations about how patients get access to welfare benefits there. What is very clear is that it matters what office is assessing a claim and it matters what GP you have.

It also seems that diagnosis is very dependent on what doctor you see. It is easy to imagine such situations skewing the composition of people with a particular diagnosis.

Peter: (…) if a diagnosis is needed (mhm), in relation to NAV for instance (mhm), one need only send a referral to [name of a doctor] at [a place in the city where Peter works], and you're guaranteed to have that diagnosis [ME] after one visit (mhm, yes!). Guaranteed!

Beth: Yeah, that's right.

Sue: That's rather interesting, right (yes, yes), that's …

Peter: So you can order the diagnosis (yes) in that way (mhm).

Beth: It was like that in [another city where Beth used to work] too. There was this rheumatologist who was very into that, and if you sent them [the patients] there, they'd get the diagnosis [fibromyalgia] (yes, yes). That was quite all right (interviewer: mhm) (mhm).
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Midnattsol · Sep 16, 2020

Hutan said: ↑

In amongst the sociology-speak is some interesting analysis.

This work is set in Norway - there are some observations about how patients get access to welfare benefits there. What is very clear is that it matters what office is assessing a claim and it matters what GP you have.

It also seems that diagnosis is very dependent on what doctor you see. It is easy to imagine such situations skewing the composition of people with a particular diagnosis.
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Unfortunately, yes.

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Rhetorical work and medical authority: Constructing convincing cases in insurance medicine, 2020, Rasmussen

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