Abstract
Colter J. Uscola on Medical Authority.
Medical Authority: How Doctors Compete for Status and Create Knowledge by Daniel A. Menchik Princeton University Press, 2021
Medical authority is always up for debate. The COVID-19 pandemic is a testament to this fact, as people across the political spectrum battled for and against medical knowledge. In Managing Medical Authority: How Doctors Compete for Status and Create Knowledge, Daniel A. Menchik explores how Electrophysiologists (EPs) manage authority over patients and other stakeholders in the field. Through what Menchik calls a tethered venues approach, he investigates hard to observe individual-collective relations, attending closely to the objects and methods doctors use to maintain status across situations. By progressively gaining entry into the upper echelons of cardiology, Menchik guides readers through an occupational project in which standard-setting EPs work to maintain their footings as leaders in an ever-changing field.
Managing Medical Authority is an accomplishment of methodological ingenuity. The work is based on over 12 years of ethnographic work spanning 6 contexts, or “venues” (i.e., inpatient hospital wards; laboratories; boardrooms; industry-sponsored training programs; industry-sponsored technology meetings; and international networking conferences). Beyond focusing solely on the contexts at hand, Menchik homes in on the interconnections between these spaces—the “tethers” (e.g., novel procedures, flagging educational institutions during presentations, gossip, and anatomical vocabulary)—to uncover how spaces and the people who occupy them collaboratively function to sustain prestige. Menchik also conducted 121 interviews with global stakeholders in cardiology to sharpen the focus of the project. From shadowing doctors in a residency program to presenting at an annual meeting for cardiology, Menchik went from medical outsider to insider, gleaning detailed accounts of the interconnected world of cardiology.
Rather than focusing solely on physicians or a single hospital, the book examines an occupational project that ties industry, physicians, and patients together to sustain medicine. In so doing, it encapsulates the working relationships between a broad range of people who contribute to the establishment, reinforcement, and implementation of EP procedures. Procedural tasks expand outward from a single venue into many, and the presence of individuals who are often seen as outside medicine (e.g., company representatives) become primary to maintaining medical authority. Menchik further provides insight into how hospital administrators and outside agencies (e.g., universities and tech companies) collaborate to sustain the strength of medicine by imagining which practices will be relevant in the future. As if shadowing Menchik himself throughout the span of his research, the text brilliantly builds in each of these layers through rich descriptions developed throughout each chapter.
The occupational project of cardiology is forward-thinking, oriented around defining and crafting new understandings of medical observations and producing novel solutions. Menchik attends to these concerns by detailing how EPs manage authority through the organization of indeterminacy in cardiology. In a discipline that is constantly changing, stakeholders and standard-setting physicians define problems and advocate for specific solutions that call for particular tech or other resources. Some EPs in the study, for example, secured their grip on the field by leveraging cutting-edge technology while maintaining relations with tech-based stakeholders to create silos of authority around practice. In another context, such as at an international conference that live-streams, the same EP would present their method to the world alongside industry stakeholders while refining their method based upon outside contributions from individuals invested in the occupational project. Problems are created among both doctors and stakeholders, such as tech industry or patient advocacy groups. While obstacles are labeled and subsequent solutions are developed and sharpened collectively through debate across venues, practitioners gain control of procedure alongside the advance of practice.
Managing Medical Authority further underscores that competition for status and other resources, rather than reducing the efficacy of medicine, contributes to its sustenance. This counterintuitive finding occurs because EPs are trained to effectively leverage their tethers. That is, they present the success of their methods across contexts, hold conversations about clinical trials, integrate novel techniques, and form guidelines in ways that produce a culture of ingenuity. In short, EPs’ habit of challenging each other elevates the standard of quality in their field of practice.
Alongside EPs, who belong to a legacy of standard-setting and who routinely promote the work of and train colleagues, company representatives strive for success and promote their work (and products) to successful EPs. In so doing, a multiheaded leadership structure develops in medicine. This culture of collaboration, unlike a top-down leadership model, leads to a diversity of viewpoints, allowing, for example, guideline documents to incorporate expertise from a wider range of practitioners. While shielding medicine from the rise of singular leaders, multiple voices and methods are given attention. This process of competition bolsters medicine. As individual doctors witness other doctors across venues promoting their work and gaining support, EPs become committed to the occupational project.
Collegial rivalry also contributes to a bridging of multiple venues, spotlighting for doctors myriad ways current practices may need to adapt to remain relevant. Working in various contexts allowed stakeholders in Menchik’s study to divide up tasks, drawing on colleagues’ excellence across a variety of practices. These allowed EPs to demonstrate proficiency in a multitude of tasks, improve the quality of their technique, and maximize the support they built for their methods. As EPs developed and demonstrated individualized mastery, they collectively supported the occupational project by adapting to the everchanging discipline of medicine.
No matter the institution—whether medicine, education, or religion—managing authority is a collaborative effort. The present work explores how authority is maintained through the interconnections of spaces and people who, ostensibly, need not function together. Yet, Menchik underscores that competition, often seen as a destructive force, is a motivational power that forms the flux necessary to fuse medicine into the powerhouse it is today.
Managing Medical Authority is an essential contribution to public sociology and beyond. Not only does this work highlight how authority is managed, it reveals how this process can lead to trust. Through collaborative work contributing to the project of medical prestige alongside high-status individuals, like EPs, other actors gain success. Though this process is obscured from public view, it becomes publicly relevant as it is translated into medical practice, impacting the health of people around the world.