The Dynamics of Medical Authority

Despite our interest in determining our health decisions, physicians have great control over our bodies, minds, and lives. Their pronouncements are more widely-accepted than those of stakeholders that range from nurses to pharmaceutical companies, and they are able to set high prices for their care, sometimes leading patients to shoulder massive debt to pay off medical expenses.

How do doctors manage this privileged authority? This paper uses over six years’ worth of ethnographic data to answer this question, incorporating factors internal and external to medicine. I argue that doctors manage their authority in the context of competing for status among doctors who share with them an interest in developing new knowledge. Specifically, the terms for status among doctors will be closely tied to the expectations of these peers regarding how knowledge is produced, and public expectations for the practice of medicine. Physicians compete with peers for status by making a case for the quality of the knowledge they have developed and would like to have orient practices profession-wide. Those seeking to have their knowledge widely adopted are observed by peers in a range of venues, and judged in terms of qualities that they would like to have represent the profession’s authority with outside stakeholders. Those doctors who put medicine’s authority at risk though engaging in behavior deemed culturally inappropriate are denied the opportunity for visibility that comes from being given access to medicine’s key venues. Consequently, these doctors’ knowledge is unlikely to become dominant, ensuring that these physicians potentially able to place the group at risk are denied positions that would enable them to represent the collective in a negative light.

This dynamic and contingent model, I argue, better explains how authority is gained and lost in medicine than the static, institution-centered, and hierarchical model that presently dominates.