As Dunning (1999) notes, individuals are always more-or-less dependent on other people, constantly producing and reproducing networks of relationships with other people. This is what Dunning refers to as "networks of interdependency". These interdependency ties are not restricted to face-to-face relationships. Rather they develop as part of the interweaving of interdependent people in the plural, incorporating people (individually and in groups) and wider social processes (Elias, 1978). These ties of interdependence are not static but are in a constant state of flux over time, in terms of the groups involved and the varying degrees of dependence and power relations between groups (Elias, 1987). The changing dynamics in the make-up of these figurations serve to impact upon the ways in which interdependent people within them behave. In relation to the medical profession, Waddington (1973) highlights the types of constraint on doctors and patients’ behaviour during different periods of time. Whilst doctors and their patients cannot be understood as anything other than interdependent, Waddington (1973) has highlighted some aspects of the changing dynamics of these interdependent relationships and the consequences these have on the behaviour of those individuals. In a similar way, Rojek (1985) suggests that figurations, and the interdependent groups of people that form them, have the capability to both enable and constrain the actions of those people within them. As such, figurations are always best conceived around the dynamic operation of power.
In order to understand the negotiations that take place between those in medicine on a situational level, it is necessary to explore the figurational understanding of power. If we are to understand power figurationally, we must refer to it as multi-faceted and in a process of imbalance between members of specific figurations. In the context of the
medical figuration, the relationships that occur between members of this network must be understood as a series of interconnected negotiations rather than merely exploitative or predetermined top-down relationships such as those expressed by functionalist or Marxist approaches to medical encounters. In this regard, Malcolm (2006b) suggests that "doctors should be viewed both as wielders of power in inter- personal relationships and as people influenced by the broader network of relationships in which they are enmeshed" (p. 379). For Elias, the restrictions that result from a unidirectional, static interpretation of power may prevent researchers from identifying diverse types of relational bonds within a figuration.
Friedson’s approach to understanding the medical profession, particularly his use of power and interaction, is useful for figurational sociologists and important to the ways in which we must understand inter-personal relationships in medicine and, as Malcolm (2006a, 2006b) following Walk (1997) defines, the "peculiar" practice of sports medical personnel. In a similar way to Friedson, figurational sociologists stress the importance of understanding the relative power of medical professionals in terms of a context specific continuum of power among groups of interdependent human beings. By way of some initial illustration of this continuum, I will highlight three specific medical interactions that highlight the variability of doctor-patient relations. First, when a patient is taken into hospital having been in an accident, it is reasonable to assume that the patient is dependent on doctors to diagnose their condition and to treat their condition with speed and conviction given that the patient is in no position to negotiate. In this scenario, the patient has no influence over the treatment s/he receives and thus, the doctor remains in a relatively autonomous position. By contrast, when visiting a GP, the patient’s relatively powerless position is not replicated as, in this instance, patients decide whether or not it is necessary for them to visit the doctor
as well as controlling the types and amount of information they provide to the doctor. Thus, patients have a degree of control over the management of their illness or situation. Moreover, the doctor is more dependent on the patient than in the first example given that the doctor is reliant on the patient to effectively describe their symptoms. In this scenario, there is increasing opportunity for a negotiation to take place between doctor and patient in terms of the potential treatment the patient receives.
In the third situation, where a patient may have an illness that requires ongoing self- treatment, the power relations of the doctor and patient are fundamentally different to the other two scenarios highlighted. Waddington and Walker (1991) examine this type of doctor-patient interaction and explore the challenges that illnesses such as HIV/AIDS have on the doctor’s claim to knowledge and autonomy. First, the authors suggest that HIV/AIDS represent a particularly potent challenge to doctors’ autonomy given that medical scientists have not, as yet, found a cure for the HIV virus (along with many other long-term diseases such as cancer and diabetes). This has obvious implications for the doctor’s claim to superior medical knowledge, given that medics are in a weaker position to claim they know more about the disease than those patients suffering from it. Second, given the long-term nature of the HIV/AIDS illness, Waddington and Walker (1991) suggest that such patients bring certain characteristics to the doctor-patient relationship which typically emerge from their particularly active role in the management of their own health (such as the taking of various forms of medication on a daily basis). Thus, Waddington and Walker suggest that the doctor- patient interaction is akin to a meeting between experts. Of course, the types of expertise that the doctor and patient have are different. For example, the doctor brings scientific knowledge about the actual nature of the disease whereas the patient relies
on an "experiential" knowledge resulting from living with the illness on a daily basis. In this regard, the patient may perceive that they have greater knowledge than the doctor by virtue of their lived experiences.
Those with chronic diseases like HIV/AIDS, diabetes and long-term cancers, are less likely to accept an uncritical and passive cooperation to the doctor’s terms and this highlights major challenges to the more traditional conceptions of the doctor-patient relationship where doctors could claim - relatively consistently - autonomy and expert knowledge relative to their patients. In this regard, if doctors are to retain the confidence of their patients, they must modify traditional images of what constitutes an appropriate doctor-patient relationship as it is in these instances that doctors are increasingly reliant on lay assessments to continue treatment.
This kind of relationship is also applicable to the current study’s analysis of sports medicine, where the patient is likely to have relatively in-depth knowledge of their illness or most likely, their injury (particularly if the injury is a recurring one) given that the body, and the maintenance of it, is the athlete’s primary concern. In this situation, athletes feel relatively empowered to claim expert knowledge relative to their doctor or other health-care provider. The ways in which this alters the balance of power between sports medicine clinicians and their patients will form one of the central issues to be dealt with in the current study (see Chapter 8).
The above discussion has highlighted some of the central tenets that led to the development of medicine as a market for medical care. It has also drawn attention to the shifting power dynamics between doctor and patient throughout the eighteenth and nineteenth centuries. Both Jewson (1974) and Waddington (1973) highlight the
broader constraints on doctor-patient relations and the implications for the relative power and claims to autonomy between these individuals in the medical context.
The claim to knowledge in the management and assessment of illness is a significant power resource for those enmeshed in the medical figuration. In the previous chapter, it was concluded that a number of the traditional sociological approaches to the professions proposed that the doctor (or medical expert) by virtue of his acquired scientific knowledge was able to successfully mobilize his/her knowledge to wield power over their clients but this is a relatively simplistic understanding of doctor- patient encounters. For example, at one end of the continuum, post-structuralist theorists would argue that the patient knows more about their body than anyone, given that they are the only person who has experience of being in that body, with its feelings, sensations etc. At the other end, a functionalist approach would consider the doctor as having the ability to access an extensive body of scientifically generated medical knowledge and thus is able to understand the medical problem more fully.Of course, for figurational sociologists the notion that one actor has ultimate power over another is another example of dichotomous thinking and thus, something Elias advocated avoiding. If the claim to expert knowledge is representative of the relative power that one individual has in an interactive relationship (for example, the consultative relationship between doctor and patient), then the ability to claim superiority of knowledge over another is dependent on the situational context of the interaction and the broader structural constraints placed upon those individuals who are attempting to claim superior knowledge.
One thing that emerges from this discussion, and which leads into a figurational approach to the sports medicine profession, is that medical professionals become
increasingly powerful as a consequence of their ability to persuade others that what they do is different, specialised and unique to them. In essence, medicine is the profession that claims to have monopoly knowledge over the human body. The reason why sport is interesting is because in some respects it offers a challenge to this medical dominance. Athletes (implicitly) claim monopoly knowledge over how to get the human body - their body - to perform to its maximum. Clinicians’ perceptions of athletes’ ability to claim knowledge and autonomy over the direction of consultations, as well as their capacity to make decisions on treatment programmes, is an important feature of the analysis of sports medicine clinicians’ relations with their athlete- patients.
4.5. Limitations of current figurational literature
Although Waddington (1973) provides a perceptive account of professionalisation processes and an understanding of doctor-patient relations, his use of figurational tools is implicit in the work examined in this review. Whilst Waddington (1973) considers claims to autonomy in the doctor-patient relationship, a more adequate understanding of the autonomy of medicine per se is not merely the bargaining processes that take place between patients and doctors, but an appreciation of the statuses and relationships that exist between other groups involved in the broader network, for example, other health professionals such as physiotherapists as well as coaches and managers. In this regard, Jewson’s (1974) analysis is more figurationally explicit as he examines the interdependent relationships and power dynamics between a number of other health professionals, such as physicians, surgeons and apothecaries during processes of medical professionalisation, all of which claimed to have expert knowledge over the other. Jewson (1974) suggests that to speak of the medical
profession as a homogeneous group would be inadequate and thus it is more realistic to investigate occupational groups as divided into several fractions, each attempting to claim ascendancy over the others in an attempt to establish a monopoly over knowledge. Thus, those employing a figurational framework must be aware that those individuals involved in medicine are not static and separate but groups of interdependent human beings. Ignoring this would be to engage in what Elias would consider "naively egocentric" thinking (Elias, 1978: 14).