2013 ASA DISSERTATION AWARD RECIPIENT:
Daniel A. Menchik, Assistant Professor at Michigan State University, received the 2013 award for his dissertation, “The Practices of Medicine: Knowledge Application and Authority Acquisition in Professional Work.” Menchik completed this work at the University of Chicago, under the supervision of Andrew Abbott, Edward Laumann, and David Meltzer. In the dissertation, Menchik notes that we give physicians unprecedented control over our minds, bodies, and lives, and asks two questions: What are the conditions under which we provide and revoke their privileged authority? And how do physicians come to practice in the way they do? To answer these questions, Menchik examines both how physicians’ uses of medical knowledge are organized by local logics and needs, and also how distant venues influence the actual content of this knowledge. His theoretically advanced and methodologically innovative work shows that studies of physicians’ practices – including evidence-based medicine – will benefit from attention to these local and distant influences.
The dissertation’s novel and ambitious research design is an ethnography of multiple nested venues. It focuses on physicians’ tasks rather than their institutional setting, recognizing that there isn’t only one “shop floor” for ethnographic observation.
Menchik gathered data over 6 years in 6 different venues, both inside and outside the hospital setting. Inside an elite tertiary care teaching hospital, he followed cardiac electrophysiologists as they responded to the requirements of different tasks on the wards, in an electrophysiology lab, and in administrative meetings. Outside the hospital, he followed doctors to other venues that shape how physicians learn and practice medicine, including industry-sponsored meetings and international conferences. These venues are often excluded from consideration in medical sociology, but they are important venues in which physicians present their most unusual cases; where industry representatives try to influence their practices; and where discoveries with the potential to change the field are presented and discussed among colleagues.
Arguing against a more institutionally-focused view that sees doctors’ actual practices as incoherent and disorganized, Menchik shows that doctors’ practices and use of medical knowledge are considerably more organized and structured than they may seem, and that they are organized by the opportunities and constraints created within and across the multiple venues where doctors teach, work, and socialize. Menchik observes that doctors are simultaneously embedded in multiple economic, political, and scientific relationships, and regularly find themselves pursuing a variety of interests—such as running a profitable practice, impressing a senior physician, and seeking to enhance their status with colleagues. The dictates of doctors’ central work tasks determine which interests dominate in a specific time and place, by activating logics that structure uses of knowledge. Three types of logics of practice – the situational, personal, and positional logics – are particularly influential in organizing the practice of medical knowledge.
When practices are compared across multiple venues that relate to a given task, is it possible to see how the venues are linked in a political economy that explains how doctors choose one practice rather than another, and why they might make choices that would exact high prices from individuals and the state. Physicians are conscious of feedback loops that operate across nested venues, and they will pursue those practices that will simultaneously maximize their status inside the field, and serve to sustain the profession’s authority with outside stakeholders. Through six chapters focusing on different tasks or problems, the dissertation shows how the practices that occur in a particular venue link to constraints and opportunities elsewhere. It also describes how members of the profession sanction those who hurt the reputation of the field by acting unethically or deviating from standards established by elites. Menchik thus shows how the processes individual physicians use to maintain authority within the field also serve to sustain the profession’s authority with outside stakeholders. The dissertation finishes by proposing that its dynamic and contingent model can better explain how authority is gained and lost in medicine than the static and hierarchical model that presently dominates.
Theory and methodology are tightly interwoven in this work, each contributing to advances in the other and to empirical advances in the sociology of knowledge, medical sociology, and the study of authority. The dissertation also enhances our understanding of how and when knowledge differs from practice. It shows that doctors’ practices are not wholly shaped by their training, but also by the variety of interests and multiple roles they fill inside and outside the hospital. “The Practices of Medicine” is an outstanding piece of research that is important sociologically and for what it tells us about the medical profession.