52 Lay-professional interactions and social distance

Prior to the 1960s, the predominant view in Western healthcare was that experts operated with a certain social distance from their patients, and that health professionals were largely disinterested in people’s subjective opinions and experiences. The increasing prevalence of chronic illness, people’s growing desire to have their voices heard, increasing levels of frustration with the power of health professionals, and economic reforms that gave people greater choice and personal responsibility for their healthcare, led sociologists to argue that people had far more ability to develop ‘sophisticated accounts about health and illness’ ^[1], than health professionals had given them credit for.

The emergence of qualitative research over the last half century, has shown that people’s ‘lay’ interpretations of health and illness are often at odds with the conventional wisdom of traditional ‘experts’ ^[2]. Grudgingly, clinicians, educators, researchers, and health systems at large, have recognised the importance of healthcare user’s personal perspectives ^[3]. As Arthur Frank says; ‘People are desperate for stories they can call their own’ ^[4].

The traditional functionalist account of lay-professional relationships placed medicine on one side of the ledger and patients on the other. Society gave health professionals the power to deliver care, but held them to account for doing so ^[5]. In Thomas Szasz and Marc Hollender’s work, the authors showed that in traditional healthcare the doctor’s primary motive was to focus on the biological processes underpinning the patient’s illness ^[6]. This had the effect of creating a relationship of activity/passivity in which the doctor was the active, dynamic, ‘parental’ voice in the relationship, and the passive patient was subject to the doctor’s expertise.

Many disputed this functionalist reading of the professions, though, because it assumed that healthcare professionals could be detached and objective ^[7][8]. It also ignored the powerful ideological beliefs about the body, about what was normal, and about gender, class, and race, that functionalists accepted as a necessary condition of medicine’s expertise ^[9]. Some even suggested that doctor-patient encounters were one of the principle locations where ideologies of class, race, and gender domination were established, with Habermas arguing that medicine was ‘all the more sinister’ for its much vaunted objectivity ^[10].

Sarah Nettleton developed this critique by suggesting that, ‘The extent to which consumers are dependent on an occupational group is not a function of professional expertise and lay ignorance’, but rather ‘a function of social distance between them’ ^[11]. Haroun Jamous and Bernard Pelloile described this social distance as a function of indeterminacy and technicality ^[12]. Indeterminacy referred to the aspects of the profession’s work that are hard to see and measure, and technicality to ‘the concrete knowledge and skills constituting an occupational role which can be codified, communicated, taught and learned’ ^[13]. Elite professions had succeeded by mystifying large aspects of their work and distanced themselves from their competition and their clients. They did this in order to ‘meet their obligations as objective professionals’ ^[14], and to control the healthcare process ^[15][16].

Of the pair, it is indeterminacy that holds the key to social distance because ‘even if laypeople had access to the same medical textbooks, professional journals and lectures as medical students’ ^[17], it would be the enculturated and socialised aspects of practice that distinguish lay people from experts. As physiotherapist Julius Sim wrote in 1985; ‘the medical student does not merely learn about medicine, he becomes a doctor’ ^[18]. Without the ability to absorb the ‘intangible aspects’ of practice ^[19], the student cannot become the professional. But social action theorists argued that the reliance on a degree of mystification has primarily been used to insulate elite professions from encroachment and reduced the need to explain practice with reason and logic ^[20].

In recent years, recognition of past paternalism has led to many within the Western healthcare system to move away from earlier conceptualisations of lay-professional relationships^{[21][22][23][24]}. Health professionals are much more open to seeing patients as lay ‘experts’ and providing information so that people can exercise some choice. Isabelle Stengers has described a rise of ‘connoisseurship’ amongst health service consumers, and the development of intelligent relationships between health professionals and service users ^[25][26]. By implication, many of the conversations health professionals now have with patients include a degree of uncertainty. But rather than the health professional taking on the burden of uncertainty and risk and acting on the patient’s behalf, they are now acting as if the patient has a say, by soliciting opinions before coercing the patient into doing what the health professional planned to do all along ^{[27][28][29][30]}. Nigel Malin has argued that ‘Bringing users into the matrix contributes to the extension of knowledge and confronts biomedical knowledge with new perspectives of lay knowledge’ ^[31]. ‘Titles and qualifications which formerly gave access to market power and state protection’, he suggests, ‘no longer guarantee these privileges’ (ibid).

Of course, not everything about the move towards more egalitarian lay-professional relationships is welcome. David Silverman, writing in 1987, suggested that;

‘To ask of medicine that it should cease to survey objectified bodies or give up its search for hidden truths concealed in organic processes is to demand that medicine should dissolve itself. This, of course, would be unacceptable not only to doctors, but also to all people who demand of medicine precisely that it should provide such truths’ ^[32].

A number of authors have argued that hearing more of the patient’s voice has resulted in people distrusting the advice they are given, challenging the profession’s authority, ’shopping around’ for second, third, and fourth opinions, and looking outside of orthodox healthcare services for support ^[33][34][35]. These effects are radically reshaping the landscape of lay-professional relationships, creating trepidation and ambiguity for both parties, where once patriarchal certainty was the norm. Ivan Illich put the issue most starkly, perhaps, when he stated that ‘the age of disabling professions… When people had “problems”, experts had “solutions” and scientists measured imponderables such as “abilities” and “needs”… is now at an end’ ^[36]. How then does social action relate to physiotherapy?