Stefan Timmermans

Theory Construction in Qualitative Research From Grounded Theory to Abductive Analysis

A critical pathway for conceptual innovation in the social is the construction of theoretical ideas based on empirical data. Grounded theory has become a leading approach promising the construction of novel theories. Yet grounded theory–based theoretical innovation has been scarce in part because of its commitment to let theories emerge inductively rather than imposing analytic frameworks a priori. We note, along with a long philosophical tradition, that induction does not logically lead to novel theoretical insights. Drawing from the theory of inference, meaning, and action of pragmatist philosopher Charles S. Peirce, we argue that abduction, rather than induction, should be the guiding principle of empirically based theory construction. Abduction refers to a creative inferential process aimed at producing new hypotheses and theories based on surprising research evidence. We propose that abductive analysis arises from actors’ social and intellectual positions but can be further aided by careful methodological data analysis. We outline how formal methodological steps enrich abductive analysis through the processes of revisiting, defamiliarization, and alternative casing.

The practice of medical technology

In this article, we review 25 years of sociological scholarship published in Sociology of Health and Illness on medical technologies. We divide the literature into three theoretical perspectives: technological determinism views medical technology as a political force to shape social relationships, social essentialism emphasizes how medical technologies are neutral tools to be interpreted in social interactions, and technology-in-practice highlights the dialectic relationship between technology and its users in health care. While the technology-in-practice orientation allows social scientists to critique the high hopes and dire warnings embedded in medical technologies, we argue that the logical next step of this paradigm is to move beyond criticism and influence the creation and implementation of medical technologies.

Patients-in-Waiting Living between Sickness and Health in the Genomics Era

What are the social consequences of the recent expansion of newborn screening in the United States? The adoption of new screening technologies has generated diagnostic uncertainty about the nature of screening targets, making it unclear not only whether a newborn will develop a disease but also what the condition actually is. Based on observations in a genetics clinic and in-depth interviews with parents and geneticists, we examine how parents and clinical staff work out the social significance of uncertain newborn screening results. We find that some newborns will experience a specific trajectory of prolonged liminality between a state of normal health and pathology. Based on a review of related literatures, we suggest “patients-in-waiting” as an umbrella concept for those under medical surveillance between health and disease.

The Continued Social Transformation of the Medical Profession

A pressing concern in contemporary health policy is whether the medical profession’s mandate to take care of clients has been undermined by the influx of money into health care. We examine the medical profession’s transformation over the past decades. First, we review how sociologists have viewed the medical profession over the past half-century as one stakeholder among other stakeholders vying for market share and power in the health care field.We then examine three recent challenges to the profession that exemplify the tension between self-interest and collective altruism to act in the best interest of patients: (1) the rise of patient consumerism, (2) the advent of evidence-based medicine, and (3) the increasing power of the pharmaceutical industry. We show the resilience of the medical profession as it adapts and transforms in response to these challenges. We conclude with implications to help inform policy makers’ assessments of how the medical profession will react to policy initiatives.

Infrastructure and Organizational Transformation: Classifying Nurses’ Work

This paper describes an evolving classification system for understanding the nature of nursing work, the Nursing Interventions Classification (NIC) developed at the University of Iowa. We describe the balancing act inherent in maximizing three dimensions of the system: comparability, control and visibility. As part of a series of studies on the relationship between classification, infrastructure, work and knowledge, we link NIC with other classification systems such as the International Classification of Diseases (ICD) and its role in organizational coordination. We analyze some of the features of evolving infrastructure, and its potential impact on organizations and practice.

Objectification, standardization, and commodification in health care: a conceptual readjustment.

Historically, medical sociologists have used the interrelated concepts of objectification, commodification, and standardization to point to the pathologies of modern medicine, such as the depersonalization of care and the effects of bureaucratic control. More recent work in science studies, economic sociology, and sociology of health and illness, however, has begun to explore how the social processes of objectification, commodification, and standardization produce a wide variety of biomedical achievements. We provide a theoretical synthesis of this emerging body of scholarship centered upon the intended and unintended consequences of objectification, commodification, and standardization to improve health. We then outline a research agenda that would result from a more comprehensive assessment of how these processes manifest themselves in clinical care.

Towards a sociology of disease

We argue for a sociology of health, illness, and disease. Under the influence of Talcott Parsons, the social study of health began as medical sociology and then morphed into sociology of health and illness, focusing largely on the social aspects of health-related topics. Social scientists have been reluctant to tackle disease in its physiological and biological manifestations. The result is an impoverishment of sociological analysis on at least three levels: social scientists have rarely made diseases central to their inquiries; they have been reluctant to include clinical endpoints in their analysis; and they have largely bracketed the normative purpose of health interventions. Consequently, social scientists tend to ignore what often matters most to patients and health care providers, and the social processes social scientists describe remain clinically unanchored. A sociology of disease explores the dialectic between social life and disease; aiming to examine whether and how social life matters for morbidity and mortality and vice versa. Drawing from specific advances in science and technology studies and social epidemiology, we point to ways that sociologists can participate as health researchers.

Two cases of ethnography Grounded theory and the extended case method

A B S T R A C T ■ Sociological ethnography largely draws upon two epistemologically competing perspectives — grounded theory and the extended case method — with a different conceptualization of sociological case-construction and theory. We argue that the sociological case in the extended case method is foremost a form of theoretical framing: relying on theoretical narratives to delineate the boundaries of an empirical field. Grounded theory follows the tenets of Chicago School ethnography where the sociological case is elicited from ethno-narratives of actors in the field: the institutionally and interactionally delimited ways members in the field ‘case’ their action. This difference in sociological casing, in turn, is reflected in the ways theory is used. Where the extended case method uses theoretical narratives as a denouement of the case, grounded theory employs theory to construct a grammar of social life.

From Autonomy to Accountability: the role of clinical practice guidelines in professional power

Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. Based on a systematic evaluation of the available scientific evidence, these guidelines offer recommendations for clinicians about details of patient care and clinical decision making. Because clinical practice guidelines specify how health care should be performed, they could be considered a threat to clinical and professional autonomy. Inspired by the theory of countervailing powers, this article explores how clinical practice guidelines have shifted the focus of professional power from autonomy to accountability. Professional organizations develop clinical practice guidelines as a service to their members but do not require strict adherence to the guidelines. Indeed, implementation studies show at best a modest change in clinical behavior. Such non-adherence might render a profession vulnerable, however, when third parties seize upon guidelines and offer financial incentives to keep clinicians accountable for delivering optimal patient care. [End Page 490]

Getting to “No”: Strategies Primary Care Physicians Use to Deny Patient Requests

BACKGROUND Physicians need strategies for addressing patient requests for medically inappropriate tests and treatments. We examined communication processes that physicians use to deal with patient requests of questionable appropriateness. METHODS Data come from audio-recorded visits and postvisit questionnaires of standardized patient visits to primary care offices in Sacramento and San Francisco, California, and Rochester, New York, from May 2003 to May 2004. Investigators performed an iterative review of visit transcripts in which patients requested, but did not receive, an antidepressant prescription. Measurements include qualitative analysis of strategies for communicating request denial. The relationship between strategies and satisfaction reports in postvisit questionnaires was examined using the Fisher exact test. RESULTS Standardized patients requested antidepressants in 199 visits; the antidepressants were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of 84 visits (63%), physicians used 1 or more of the following 3 strategies that explicitly incorporated the patient perspective: (1) exploring the context of the request, (2) referring to a mental health professional, and (3) offering an alternative diagnosis. Twenty-six visits (31%) involved emphasis on biomedical approaches: prescribing a sleep aid or ordering a diagnostic workup. In 5 visits (6%), physicians rejected the request outright. Standardized patients reported significantly higher visit satisfaction when approaches relying on the patient perspective were used to deny the request (P = .001). CONCLUSIONS Strategies for saying no may be used to communicate appropriate care plans, to reduce provision of medically inappropriate services, and to preserve the physician-patient relationship. These findings should be considered in the context of physician education and training in light of increasing health care costs.