Medical decision-making in the subjunctive mood. An ethnographic study of the enactment of shoulder care

Medical intervention commonly derives from standardized guidelines based on the biomedical logic that the status of clinical evidence should guide the ‘rational’ use of healthcare resources. However, such logics leave out the relational and situational aspects of medical decision-making as it unfolds in the clinic, where the key question “is it worth it?” comes to epistemically challenge the idea of evidence based guidelines and decision-making models.<br/>Based on 10 months of ethnographic fieldwork in two shoulder clinics in the orthopedic services of the public healthcare system in Denmark, we explore how the clinical encounter is a dynamic space of comparing, weighing, and evaluating surgical and non-surgical treatments that challenge the idea of decision models guided by evidence and patient preferences. In shoulder care, clinical evidence for the existing treatments is sparse, which leaves room for situated comparing and weighing of uncertainties in the potential context of a surgical intervention that is irreversible and carries the risk of harm.<br/>We argue that although clinical consultations are framed as diagnostic and decision-making events, patients and clinicians seek ways to manage the frustration of living with chronic pain and the uncertain effects of treatments. While surgical options are enacted as ‘conditional certainties’ in the subjunctive mood (Whyte, 2005) – indicating the ongoing and simultaneous existence of doubt, hope, and uncertainty – we argue that good care for shoulder patients emphasizes the uncertain potential of treatments and the continuation of care across professional and institutional boundaries when treatments fail to meet expectations.