Abstract
The article explores how understandings of patients with symptom diagnoses, notably fibromyalgia, are shaped by the introduction of a new medical decision-making support tool used to assess patients’ ’work capacity’, together with a revision of the Swedish social insurance. Findings from two recently concluded empirical studies are used to demonstrate how notions of ’the social’ are mobilised to undercut patients’ claims to medical legitimacy and right to sick benefits. Interviews with medical professionals, civil servants and social insurance case officers indicate that fibromyalgia patients’ clinical narratives should demonstrate ordered social circumstances if their symptoms are to be categorised as belonging to a ’medical’ sphere and thus fall within the remit of the social insurance. The main determinant in this categorisation was if patients were thought to be capable of functioning in a workplace. The workplace as constituted through the interviews was a site that removed patients from the perilous domain of ’social circumstances’ and placed them in an arena in which their symptoms, while still unsignified, could be understood as affecting ’work capacity’.
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Notes
I use the term symptom diagnosis to mean conditions that are ‘not defined in terms of organic pathology, but on the basis of their symptoms’ (Nettleton et al, 2004).
Fibromyalgia is a long-term condition characterised by widespread musculoskeletal pain. Symptoms are often permanent but can vary in severity and sometimes location. There are currently no laboratory tests available that can establish that a patient suffers from fibromyalgia, thus making patient history and self- assessment procedures important tools in the diagnostic process.
Vahlne Westerhäll (2008) uses the example of a single mother of five with shoulder pains.
As the thrust of the paper is to discuss ways in which a condition is categorised as ‘non-medical’, the term ‘sickness’ is deliberately used throughout this text. ‘Sickness’ is the term closest to ‘sjukdom’ in Swedish and there are no common synonyms such as ‘illness’ or ‘disease’ that are used to make a distinction between the experience of ill-health and professional recognition of pathology. The terms ‘illness’ and ‘disease’ do appear in the text in sections discussing epistemic hierarchy, and when citing literature that make use of the terms.
Specialists from different fields of medicine were recruited by the National Board of Health and Welfare to write the recommendations for their area of expertise, a process that also served as means to legitimate an initiative that in some parts of the medical profession was viewed as a potential infringement on their professional jurisdiction (Eriksson et al, 2014a). In a recent study of how the support tool was devised, interviewed experts stressed that the tool should only be used in a consultative capacity, but were positive towards the general goal of firming up doctors’ sick-leave assessment practices (Eriksson et al, 2014b), a sentiment that resonates with findings from a follow-up survey assessing how the support tool has been received in the professional community (Alexandersson et al, 2009).
Large financial incentives were introduced for county councils [landsting] that could show a high percentage of approved sick leave certificates, which in turn prompted a multitude of quality assessment projects and training initiatives aiming to teach doctors to fill out sick leave assessments that would satisfy the standards of the Social Insurance Agency.
As stated earlier, I attempt to use the terms ‘disease’ and ‘illness’ in this text sparsely because the topic of analysis is in part the process by which conditions of ill-health become understood and labelled as one or the other. When they are used I take ‘disease’ to mean a medically recognised and accepted bounded entity referring to pathology, while ‘illness’ refers to (as-of-yet) epistemically and therefore ontologically unstable experiences of suffering.
The decision support tool and standardised assessment form at the heart of the new system can also be seen as instruments in the making and mobilisation of certain kinds of fit or unfit bodies, and read in terms of governmentality or bio-power (Foucault, 1978; Rose and Miller, 2008); the research findings could certainly be developed in this direction.
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Eriksson, L. Diagnosis at work – On sick leave in Sweden. Soc Theory Health 13, 162–179 (2015). https://doi.org/10.1057/sth.2015.1
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DOI: https://doi.org/10.1057/sth.2015.1