Bishop Berkeley and the Adenotonsillectomy Enigma: An Exploration of Variation in the Social Construction of Medical Disposals

Observational data gathered in the out-patient clinics of eleven ENT specialists were used to explore the issue of the marked and well-documented variations in the assessment of children for possible adeno-tonsillectomy. The routinized orientation of the various specialists to the assessment process allowed the comparison of specialists in terms of their routine assessment practices. Inter-specialist variation in routines is described in terms of five parameters of difference—variation in the search procedures used in the examination of the child, variation in the decision rules making for differential stress on the examination findings relative to the history, variation on the search procedures used for the history-taking, variation in the decision rules pertaining to the history, and variation in routines according to the age of the child. Such differences in routines are the means whereby systematic variations in patient assessment are constructed. The very nature of medical knowledge provides for the possibility of these differences in routines, since the theoretical construction of a disease entity is essentially arbitrary and value-laden and since any disease entity is in effect a general name which can refer to a wide variety of different particular conditions. Extrapolating from the work of Bishop Berkeley, it can be seen that the various specialists' decision rules are specific representative ideas of appropriate surgical indications. Further, these ideas can be seen to vary both in content and in degree of specificity from specialist to specialist, to vary in degree of specificity for any one specialist from one category of patient to the next, to vary for any one specialist from setting to setting. It is the first two types of variance that may largely account for inter-specialist differences in assessment, while the third type of variance, by reducing the visibility of inter-specialist differences, may help to account for their persistence.