The Doctor as Parent, Partner, Provider or Comrade? Distribution of Power in Past and Present Models of the Doctor-Patient Relationship.

The commonly occurring metaphors and models of the doctor-patient relationship can be divided into three clusters, depending on what distribution of power they represent: in the paternalist cluster, power resides with the physician; in the consumer model, power resides with the patient; in the partnership model, power is distributed equally between doctor and patient. Often, this tripartite division is accepted as an exhaustive typology of doctor-patient relationships. The main objective of this paper is to challenge this idea by introducing a fourth possibility and distribution of power, namely, the distribution in which power resides with neither doctor nor patient. This equality in powerlessness-the hallmark of "the age of bureaucratic parsimony"-is the point of departure for a qualitatively new doctor-patient relationship, which is best described in terms of solidarity between comrades. This paper specifies the characteristics of this specific type of solidarity and illustrates it with a case study of how Swedish doctors and patients interrelate in the sickness certification practice.

Doctors that "doctor" sickness certificates: cunning intelligence as an ability and possibly a virtue among Swedish GPs.

The relations of power between healthcare-related institutions and the professionals that interact with them are changing. Generally, the institutions are gaining the upper hand. Consequently, the intellectual abilities necessary for professionals to pursue the internal goods of healthcare are changing as well. A concrete case is the struggle over sickness benefits in Sweden, in which the Swedish Social Insurance Agency (SSIA) and physicians are important stakeholders. The SSIA has recently consolidated its power over the sickness certificates that doctors issue for their patients. The result has been a stricter gatekeeping of sickness benefits. In order to combat the inroads made by state institutions into sickness certification, and into the sphere of medical practice, some doctors have developed cunning "techniques" to maximize the chance to have their sickness certificates accepted by the SSIA. This article attempts to demonstrate that cunning intelligence-the ability of the weak to "outsmart" a stronger adversary-plays an important role in the practice of medicine. Cunning intelligence is not merely a defective form of prudence (phronesis), nor is it simply an instance of instrumental reason (techne), but rather an ability that occupies a distinct place among the intellectual abilities generally ascribed to professionals.

Unsanctioned techniques for having sickness certificates accepted: a qualitative exploration and description of the strategies used by Swedish general practitioners.

OBJECTIVES: To explore informal and unsanctioned techniques general practitioners (GPs) employ as a means to increase the likelihood of sickness certificate approval, following the Swedish Social Insurance Agency's (SSIA's) consolidation of the gatekeeping role in sickness benefit evaluation. DESIGN: Qualitative semi-structured interviews with 20 GPs working in Swedish primary care. A thematic analysis of the transcribed material was carried out to map different techniques employed by the practitioners. RESULTS: Eight techniques were identified, particularly with respect to the way in which the sickness certificate is written to ensure approval by the SSIA. The identified techniques were most commonly adopted when the patient's case was perceived to be at high risk for rejection by the SSIA (such as psychiatric illnesses, chronic pain etc.). CONCLUSIONS: The findings imply that the informal and unsanctioned techniques are complex and ambiguous. They are used intentionally and covertly. The study also suggests that, while the consolidation of SSIA's gatekeeping role may have resolved some sickness absence issues, a consequence may be that GPs develop unsanctioned techniques to ensure compliance.