Managing Medical Authority: How Doctors Compete for Status and Create Knowledge by Daniel A. Menchik

Abstract

Reviewed by: Managing Medical Authority: How Doctors Compete for Status and Create Knowledge by Daniel A. Menchik Gil Eyal Daniel A. Menchik. Managing Medical Authority: How Doctors Compete for Status and Create Knowledge. Princeton, N.J.: Princeton University Press, 2021. xvii + 305 pp. $29.95 (978-0-691-22354-4). The central characters in this book are cardiac electrophysiologists (EPs), a special brand of cardiologists who seek to regulate the heart and repair abnormal rhythms by implanting defibrillators and pacemakers, and by using ablation catheters to burn or cool parts of the heart. Among EPs there are some who enjoy authority as standard-setters, and others who are merely clinicians. Both participate in a common occupational project that itself needs to secure the authority of electro-physiology among other medicine specialties. Hence the book’s title. Menchik’s question is how do they—both individuals and the specialty as a whole—manage to secure this authority given the essential indeterminacy of what they do—they feed a tiny catheter two feet through a vein in order to reach the heart and there deliver a burst of heat that they hope will burn just the right amount of tissue to restore the heart to its normal rhythm. Menchik’s answer is complex and somewhat hard to piece together, but this is what I came up with: 1. Standard-setters are individuals who have developed a particular way of “organizing indeterminacy.” While burning part of the heart would seem to be “heroic medicine,” an EP observes that “most of the time you go in . . . you literally have greater than 90% chance that you are going to succeed” (p .85). 2. Standard-setters are extremely competitive with one another, but this competition, Menchik shows, plays an important role in building their authority since it leads to differentiation into niches (specific type of problems addressed by specific type of solutions). Standard-setters “lead from a niche” (p. 82), but under the constant scrutiny of peers, who are concerned that the standard-setter does not do anything too risky to hurt the overall authority of the occupational project. While the competition is normally healthy, it can sometime erupt, as Menchik shows, into “whisper campaigns,” especially at conferences (p. 212). 3. Organizing indeterminacy, however, is a collective effort. While EPs place enormous value on having “good hands,” Menchik convincingly shows that dexterity and “good hands” are the product of coordinated teamwork and the EP’s control of the social relations of the lab (p. 69). 4. These social relations, in fact, extend beyond the lab and include what Menchik calls “tethered venues.” These include, for example, the labs of trusted colleagues, with whom a standard-setter collaborates on clinical trials. These tend to be former mentees, who share with the standard-setter the particular way of organizing indeterminacy, and whom the standard-setter knows to have “good hands,” good judgment, and good control of their own lab. Hence, a crucial role in the creation of medical authority is played by the process of attracting fellows, training them, and then placing them [End Page 174] in their own labs. Successful fellows add to the prestige of the EP, but also contribute to the success of their shared methods and approaches (p. 78). 5. Another set of tethered venues are the practices of referring clinicians. The authority of standard-setters depends on carefully selecting patients that are a) challenging, so they can be wrote up as case reports; b) appropriate for the particular procedure honed by the EP, so something like a 90% success rate can be approximated. A network of relations with referring clinicians has to be carefully cultivated if a particular mode of organizing indeterminacy is to be successful. The referring clinician has to be relatively certain that their patient will benefit from the referral, and the EP has to be relatively certain that the referred patient is the right one. In a fascinating chapter about the introduction of a bed management program at the hospital he observed, Menchik shows how it disrupted this network of relations since now EPs could no longer count on always having a few open beds for these carefully selected patients...