Den gode læge
En antropologisk undersøgelse af russiske familielægers skabelse af en faglig identitet i et felt under forandring

Den gode læge: En antropologisk undersøgelse af russiske familielægers skabelse af en faglig identitet i et felt under forandring Pedersen, Vibe Hjelholt DK 314 K

This thesis focuses on the creation of professional identity among Russian family physicians. The analysis is based on fieldwork carried out amongst privately and publicly employed family physicians in St. Petersburg from May till November 2001.

The education of family physicians in St. Petersburg started in 1996 when family medicine was introduced as part of a larger reform of the Russian health care system. The reform was meant to replace a large proportion of specialists in primary health care centres (so-called 'policlinics') with family physicians. The intention was to increase efficiency, and shift focus to prophylactic aspects of healthcare.

In my interviews, the family physicians express great pride in their education and work. They believe family medicine to be better than "Russian medicine", because of its economic and medical efficiency, and because it observes patients' rights, and international standards for treatment. Furthermore, they stress their own strict observation of these principles, and see this as something that separates them from other Russian doctors.

However, my observations of family physicians' medical work indicate that they often break these principles themselves. They do not always use medicines with proven effect, or allow their patients to participate in decision-making concerning the treatment. Despite this, the family physicians clearly feel that they are doing the right thing regarding the treatment, and in most cases the patients seem satisfied with the treatment. These inconsistencies in the family physicians' construct of themselves suggest that this perception is neither solid nor unchanging, but rather a constant "becoming", which is created in relation to other actors in the field - patients, their relatives, peers, other healthcare workers, and the anthropologist.

In order to examine the family physicians' creation of professional identities, I take narrative theory, noticeably by Hastrup (1995, 2002), Mattingly (1998, 2000), and Fabian (1991) as my point of departure, as well as theories on social practice (Bourdieu 2000), power relations in medicine and elsewhere (Foucault 1976, Bruner 1986) and various regional theories on social relations and practices in Eastern Europe (Rivkin-Fish 2000, 2002, Bruno 1998, Giodani & Kostova 2002). Following Hastrup, I argue that the family physicians' actions in different social settings can be seen as a creation of different 'plots', which shape different narratives of "good" medical treatment, and define different spaces of action for the physician and the patient.

In their interactions with me and with medical colleagues, the family physicians act according to a "plot of efficiency", seeing themselves as "pioneers", who are creating a better kind of medical treatment for the future; one which is more economically and medically effective. In their interaction with the patients, a "plot of trust" is defined in which the physician has the role of "guardian angel", providing care and relief from immediate suffering to the patient. "Good" treatment, in this setting, implies an establishment of personal trust between the physician and the patient. This morally legitimises the physician's authority over the patient, as opposed to the illegitimate authority given to the physician by the Russian state, which has proven incapable of providing security and social justice to its citizens. This personalized bond also gives the patient hope of receiving a more engaged, and less hurried, treatment than that which is the norm in Russian policlinics.

When physicians follow their role as "pioneers" in the clinical setting, they focus on improving the patient's health on a long-term basis, demanding that the patient adopt a healthier life style. When they act as "guardian angels", they focus on relieving the patients' immediate pain and suffering, which also implies taking responsibility for the treatment and not informing the patient.

The "treatment narratives" also refer to a "master narrative" of social change, which draws on the shared understandings of the Russian (formerly Soviet) society as "wrong" and unfair. Relating to this narrative, the family physicians create a common identity as "pioneers" striving to create not only better treatment, but also ultimately a better society, in which state imposed regulations will provide security and social equality to all. But the family physicians also relate to this narrative when acting as "guardian angels", striving to create personal bonds of trust, which will bring, not only better treatment, but also immediate security and social opportunities for themselves, their immediate family and friends, and for their patients. Through this narrative of social change the family physicians thus place themselves in the present, moving towards an immediate or a more distant future, and at the same time separating themselves in time and space from other Russian physicians, who they see as belonging to a past associated with an unjust and immoral Soviet state.

My analysis shows that the two 'plots' are constantly negotiated in clinical interaction. When the physician acts as a "pioneer", he attempts to make the patient change his lifestyle according to his definition of a "good" (i.e. healthy) life by giving him responsibility over his own life. The patient tries to resist this and instead strive to define a "plot of trust" in order to receive more immediate care. However, this refusal is incompatible with the patient's role in the "plot of trust" as a passive receiver of care, as well as with his role in the "plot of efficiency" as a responsible individual striving towards a healthier life. The physician rebukes this refusal and tries to force the patient to be responsible and follow the long-term prophylactic perspective for treatment, thereby confirming the physician's role as "pioneer" and validating his refusal to provide more immediate relief. This direct exertion of power fits the physician's role as "guardian angel" and the patient concedes. However, by refusing to provide immediate relief, the physician fails to gain the patient's trust, and his authority therefore remains morally illegitimate. My analysis thus shows that the creating of narratives in social interaction is not only an individual creation of identity and meaning, but also an active creation of social worlds and thereby also an exertion of power on other actors inhabiting these worlds.