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In this editorial introduction, we explore how digital health is being explored at the intersection of sociology of health and science and technology studies (STS). We suggest that socio‐material approaches and practice theories provide a shared space within which productive tensions between sociology of health and STS can continue. These tensions emerge around the long‐standing challenges of avoiding technological determinism while maintaining a clear focus on the materiality and agency of technologies and recognising enduring sets of relations that emerge in new digital health practices while avoiding social determinism. The papers in this Special Issue explore diverse fields of healthcare (e.g. reproductive health, primary care, diabetes management, mental health) within which heterogenous technologies (e.g. health apps, mobile platforms, smart textiles, time‐lapse imaging) are becoming increasingly embedded. By synthesising the main arguments and contributions in each paper, we elaborate on four key dimensions within which digital technologies create ambivalence and (re)configure health practices. First, promissory digital health highlights contradictory virtues within discourses that configure digital health. Second, (re)configuring knowledge outlines ambivalences of navigating new information environments and handling quantified data. Third, (re)configuring connectivity explores the relationships that evolve through digital networks. Fourth, (re)configuring control explores how new forms of power are inscribed and handled within algorithmic decision‐making in health. We argue that these dimensions offer fruitful perspectives along which digital health can be explored across a range of technologies and health practices. We conclude by highlighting applications, methods and dimensions of digital health that require further research. [ABSTRACT FROM AUTHOR]

In the British NHS the principle of exceptionality involves assessing whether a patient is sufficiently different from the generality of patients to justify providing a treatment, such as an expensive cancer drug, not approved for routine funding. In England, individual requests for certain high‐cost treatments are considered by local panels that examine exceptionality alongside treatment efficacy and cost as the main criteria for funding. This was also the case in Wales until September 2017. Our paper draws on audio recordings of panel meetings and interviews in a Welsh Health Board to investigate how exceptionality was constructed in discussions. It focuses on the problematic combination of different decision criteria in meeting talk, particularly regarding the discourses associated with efficacy and exceptionality. Exceptionality is a fluid category that raised questions about the evidence‐based nature of panel decision making. In particular, the paper discusses the use of subgroup data from RCTs and the difficulty of deciding how small a subgroup of patients should be before it is deemed exceptional. Determining exceptionality has been an important mechanism for deciding that a minority of NHS patients can still receive high‐cost treatments not routinely provided for all. As a neglected rationing mechanism it warrants sociological examination. [ABSTRACT FROM AUTHOR]

Based on fieldwork carried out at the Early Drug Development Service of a world‐leading cancer institution, our study sheds lights on decision‐making processes at the stage where decisions are made about which clinical trial to pursue and thus which experimental drugs will feed the growing pipeline of molecularly guided therapies and therapeutic strategies available to treating physicians. The paper shows how such collective decision‐making practices by a translational research unit employ formal tools and ad hoc valuation strategies that interweave technical‐scientific matters of concern with patient‐oriented clinical ones, as part of the institutional assetization of biomedical knowledge production. In the process, decision‐making practices in part define the conditions of possibility for the provision of care in what is increasingly becoming a 'clinic of variants.' They do so by reconfiguring on an evolving basis the socio‐material ecosystem through which precision oncology is enacted as a rapidly evolving assemblage of patients, physicians, research and support staff, protocols, molecular markers, drugs and administrative components. [ABSTRACT FROM AUTHOR]

This article draws on 2 years' worth of ethnographic observation of team meetings to explore decision‐making in an NHS clinical genomics service. The focus of discussions was on ambiguous genomic results known as VUS or Variants of Uncertain Significance, which may be pathogenic but which also may turn out to be benign. In examining decision‐making around such results, we note how, in contrast to much policy and promotional material in this area, clinicians in these meetings (clinical geneticists and genetic counsellors) place great emphasis on parental phenotypes and whether the parents of a patient share the symptoms and signs of the suspected condition. This information is then combined with the result of genomic tests to decide whether the variant a patient has is responsible for their condition. This article explores the way in which clinicians attempt to flexibly enrol parents into genomic explanations through informal diagnosis of their possible phenotypes and the way in which actually meeting parents allows some clinicians to trump explanations based on documentary or photographic data. The paper sheds light on the way that earlier scholarly understandings of such decisions (around, say dysmorphology) remain relevant and explores claims that laboratory tests overrule clinical decision‐making. [ABSTRACT FROM AUTHOR]

The recent development of cancer precision medicine is associated with the emergence of 'molecular tumour boards' (MTBs). Attended by a heterogenous set of practitioners, MTBs link genomic platforms to clinical practices by establishing 'actionable' connections between drugs and molecular alterations. Their activities rely on a number of evidential resources – for example databases, clinical trial results, basic knowledge about mutations and pathways – that need to be associated with the clinical trajectory of individual patients. Experts from various domains are required to master and align diverse kinds of information. However, rather than examining MTBs as an institution interfacing different kinds of expertise embedded in individual experts, we argue that expertise is the emergent outcome of MTBs, which can be conceptualised as networks or 'agencements' of humans and devices. Based on the ethnographic analysis of the activities of four clinical trial MTBs (three in France and an international one) and of two French routine‐care MTBs, the paper analyses how MTBs produce therapeutic decisions, centring on the new kind of expertise they engender. The development and activities of MTBs signal a profound transformation of the evidentiary basis and processes upon which biomedical expertise and decision‐making in oncology are predicated and, in particular, the emergence of a clinic of variants. [ABSTRACT FROM AUTHOR]

The focus on patient autonomy in American and increasingly British medicine highlights the importance of choice. However, to truly honour patient autonomy, there must be both understanding and non‐control. Fifty‐eight semi‐structured in‐depth interviews were conducted with internal medicine physicians at three hospitals in the US and one in the UK. At hospitals where autonomy was prioritised, trainees equated autonomy with giving a menu of choices and felt uncomfortable giving a recommendation based on clinical knowledge as they worried that that would infringe upon patient autonomy. Employing Habermas's Theory of Communicative Action, this paper explores how physician trainees' communication practices of using purposefully graphic descriptions of resuscitation to discourage that choice prevent greater understanding and compromise non‐control. Central to this problem are also issues of colonisation of the life‐world by the system. Physicians are fully inculcated in their respect for autonomy but unintentionally resort to strategic forms of communication that prevent patients from adequately understanding their situation because trainees feel constrained against making recommendations. However, if the ideal of autonomy is to be realised, physicians might have to move towards practices that embrace a more authentic autonomy that fosters open communication that allows for co‐creation of consensus between doctors and patients. [ABSTRACT FROM AUTHOR]

Conventional models of ‘evidence’ for clinical practice focus on the role of randomised controlled clinical trials and systematic reviews as technologies that promote a specific model of rigour and analytic accountability. The assumption that runs through the disciplinary field of health technology assessment (HTA), for example, is that the quantification of evidence about cost and clinical effectiveness is central to rational policy-making and healthcare provision. But what are the conditions in which such knowledge is mediated into decision-making contexts, and how is it understood and used when it gets there? This paper addresses these questions by examining a series of meetings and seminars attended by senior clinical researchers, social care and health service managers in the UK between 1998–2004, and sessions of the House of Commons Health Committee held in 2001 and 2005. These provide contexts in which questions about the value and utility of evidence produced within the frame of HTA were explored in relation to parallel questions about the design, evaluation and implementation of telemedicine and telecare systems. The paper points to the ways that evidence generated in the normative frame of HTA was increasingly seen as one-dimensional and medicalised knowledge that failed to respond to the contingencies of everyday practice in health and social care settings. [ABSTRACT FROM AUTHOR]

Students' use of prescription stimulants to enhance study performance is increasingly under the spotlight. Medical guidelines discourage general practitioners (GPs) from prescribing stimulants to students without a diagnosis; yet a considerable proportion of students acquire them from GPs. Building on Eisenberg's theoretical framework on clinical decision‐making and Conrad's sociological concept of biomedical enhancement, this study examined the social context of GPs' off‐label prescribing decisions for stimulants, using data from 21 semi‐structured interviews, including vignettes, undertaken with Flemish GPs. Results identified two groups of GPs: (1) hard‐liners who strictly follow medical guidelines and who would only prescribe in case of an appropriate diagnosis and (2) context‐dependent GPs who would prescribe stimulants depending on the patients' symptoms and extent of need. GPs' decisions depend on one‐on‐one doctor‐patient interactions (i.e. the extent of empathy from the doctor and the extent of assertiveness from the patient); the extent to which GPs define concentration problems as medical problems; GPs' interactions with fellow health care workers; as well as GPs' interaction with the wider community. By disentangling these influences, this paper advances both theoretical and practical understanding of the sociological context in which GPs' off‐label prescribing behaviour occurs. [ABSTRACT FROM AUTHOR]

Across the UK, wide‐ranging efforts have been made to enhance citizen access to psychological therapy. Clinical psychologists are key providers of and gatekeepers for therapy. This article is concerned with how clinical psychologists foster access (or not) to psychological care. More specifically, it interrogates how psychologists manage, and make decisions around, patient referrals. Following a referral, psychologists must resolve an uncertain situation: should they accept a referral and continue with an assessment? Thereafter, they must decide whether a patient is suitable for their service – and for therapy more generally. Certainty is synthesised against a backdrop of sometimes powerful pressures to meet service targets. Taking cues from medical sociology and science and technology studies (STS), this article interrogates some of the uncertainties around access to psychological therapy, and how decisions made by clinical psychologists involve negotiations of patient, service and professional ontologies. To do so, it draws on interviews with 40 psychologists across England and Scotland. The paper spotlights a professional group that is often absent from or only dimly lit within sociological observation and analysis: clinical psychology. Through attending to the discourses of psychologists, I extend conversations about uncertainty through a distinctive case study. [ABSTRACT FROM AUTHOR]

Shared decision-making ( SDM) has been widely advocated across many branches of healthcare, yet there is considerable debate over both its practical application and how it should be examined or assessed. More recent discussions of SDM have highlighted the important of context, both internal and external to the consultation, with a recognition that decisions cannot be understood in isolation. This paper uses conversation analysis ( CA) to examine how decision-making is enacted in the context of antenatal screening consultations in Hong Kong. Building on previous CA work (Collins et al. , Toerien et al. 2013), we show that, whilst previously identified formats are used here to present the need for a decision, the overriding basis professionals suggest for actually making a decision in this context is the level of worry or concern a pregnant woman holds about potential foetal abnormality. Professionals take an unknowing 'epistemic stance' (Heritage ) towards this worry, and hence step back from involvement in decision-making. We argue that this is linked to the non-directive ethos that prevails in antenatal screening services, and suggest that more research is needed to understand how the enactment of SDM is affected by wider professional contexts and parameters. [ABSTRACT FROM AUTHOR]

The MERIDIAN study examined whether in‐utero MRI (iuMRI) improves the accuracy of diagnosis of foetal brain abnormalities, when used as an adjunct to ultrasound anomaly scanning. A diagnostic iuMRI differs from routine ultrasound screening because of its infrequent use and scanning procedure. Nested within this trial, this sociological study explored the acceptability of iuMRI as a technology and its contribution to parental decision‐making. Our sociological interpretation of the role of iuMR images in prenatal diagnosis draws on narrative interviews with women (and some partners) who underwent MRI imaging at three different centres. Overall, participants found iuMRI helpful in decision‐making because it either confirmed or disconfirmed previous results, or provided additional information. Expectant couples experienced the iuMR imaging process as informative, but also as having emotive and practical value. Our paper extends the existing sociological literature on antenatal testing and visualising the foetus, by using iuMR diagnostic imaging to further explore the concept of the unborn entity. Our data suggest that alongside the iuMR images, the 'parental gaze' and accompanying commentary are used by parents to construct and transform foetal and parental identities despite ongoing uncertainties about, and shifting social contexts to their pregnancy. [ABSTRACT FROM AUTHOR]

Abstract: Our paper explores the value‐laden and epistemic resources that scientists working in epigenetics and developmental programming of health and disease (DOHaD) mobilise to produce scientific representations of pregnancy and parenthood, which in turn imagine norms, values, and responsibilities for the protection of future generations. In order to do so, we first describe the place of questions regarding the relative weight of paternal and maternal influences on the health of the offspring in the discursive formalisation of this research in scientific publications. This enables us to identify the mutual constitution of ‘prototypes’ (i.e. experimental designs, settings, techniques) and ‘stereotypes’ (i.e. social meanings, beliefs, norms and values) of parental roles in DOHaD and epigenetic biomedical sciences, by means of a specific gendered figuration of paternal influences: the ‘father‐as‐sperm’. Second, and drawing from a set of interviews (N = 15), we describe a tension between this dominant, objectifying molecular discourse and the perspective of individual scientists. The situated perspective of individual researchers provides in fact evidence for a conflictual (moral and epistemic) economy of gendered engagements with parental figurations in DOHaD and epigenetic research, and consequently suggests a more fine‐grained, as well as conflictual web of socio‐political positioning of this ‘knowledge’ in its societal circulation. [ABSTRACT FROM AUTHOR]

Classical dilemmas of how to distribute limited resources have been rekindled by the rise of advanced, high‐cost therapies. Building on a case study of a novel gene therapy in neuropaediatric care, this article explores the dilemmas that explicit priority setting can create for frontline professionals and develops a typology of professionals' responses to these dilemmas. Despite political attempts to centralise priority setting and spare health professionals from having to consider treatment costs at the 'bedside', this study shows that concern for economic efficiency and budget control nonetheless need to be handled and balanced against other accountabilities in the daily work of frontline professionals. Contributing to the sociological debate on priority setting and rationing, this study develops an analytical perspective attuned to the relational aspects of frontline work and the challenges related to the balancing of diverging ideas of good conduct. Further, focussing on an empirical field at the forefront of genomic medicine, this study brings the sociological debate on priority setting and rationing up to date with current developments in precision medicine. [ABSTRACT FROM AUTHOR]

This study is set against the backdrop of the evolving order of a health care system in a province implementing a set of concurrent reforms. The study investigates how ‘knowledge work’ of multi-disciplinary health care teams is actually done and how it is co-ordinated across sites. Knowledge work involves three processes: the creation of new knowledge during the transfer of knowledge, in the context of the application of knowledge to their collective clinical decision-making. Institutional ethnography is used to explore the social and institutional forces that shape the knowledge work of health care providers in and across multi-disciplinary teams by way of examining how the texts trans-locally organise the formation and functioning of multi-disciplinary teams. The study confirms that in the course of their collective clinical decision-making, teams’ dialogical exchange facilitates the articulation of tacit knowledge and opens up the communicative space for the creation of new knowledge. In addition to this confirmatory finding, the study contributes to the existing health-related knowledge management by illustrating the importance of the social, communicative aspects of the knowledge processes, and in particular, the relationship between knowledge and the social organisation of power. [ABSTRACT FROM AUTHOR]

The professional autonomy of physicians often requires they take responsibility for life and death decisions, but they must also find ways to avoid bearing the full weight of such decisions. We conducted in‐person, semi‐structured interviews with neonatologists (n = 20) in four waves between 1978 and 2017 in a single Midwestern U.S. city. Using open coding analysis, we found over time that neonatologists described changes in their sense of professional autonomy and responsibility for decisions with life and death consequences. Through the early 1990s, as neonatology consolidated as a profession, physicians simultaneously enjoyed high levels of professional discretion and responsibility and were often constrained by bioethics and the law. By 2010s, high involvement of parents and collaboration with multiple subspecialties diffused the burden felt by individual practitioners, but neonatology's professional autonomy was correlatively diminished. Decision‐making in the NICU over four decades reveal a complex relationship between the professional autonomy of neonatologist and the burden they bear, with some instances of ceding autonomy as a protective measure and other situations of unwelcomed erosion of professional autonomy that neonatologists see as complicating provision of care. [ABSTRACT FROM AUTHOR]

During daily hospital ward rounds, medical teams, led by doctors, assess the progress of an individual patient's health. It is widely reported in the research literature that nurses play a relatively passive role during these rounds, because although they may have valuable information about the patient's condition and progress, and indeed their role includes advocacy on behalf of their patients, nurses nevertheless can experience difficulties in participating during case constructions. Here we report an instance from a (gastro‐surgical) ward round in a Finnish hospital, in which nurses played a key role in reversing a consultant's initial decision to discharge a patient. They did so not by directly challenging the consultant's opinion, but by employing indirect means to introduce their discrepant perspective: they provide descriptions and ask questions that draw attention to information that results in the doctor coming to a different assessment than theirs of the patient's condition, and a different decision about what should be done (the patient was not discharged from hospital). The encounter reported here is taken from a corpus of ward round discussions in a Finnish hospital. The method of our study is Conversation Analysis. [ABSTRACT FROM AUTHOR]

Despite substantial efforts in the past 15 years to professionalise the field of clinical ethics consultation, sociologists have not re‐examined past hypotheses about the role of such services in medical decision‐making and their effect on physician authority. In relation to those hypotheses, we explore two questions: (i) What kinds of issues does ethics consultation resolve? and (ii) what is the nature of the resolution afforded by these consults? We examined ethics consultation records created between 2011 and mid‐2015 at a large tertiary care US hospital and found that in most cases, the problems addressed are not novel ethical dilemmas as classically conceived, but are instead disagreements between clinicians and patients or their surrogates about treatment. The resolution offered by a typical ethics consultation involves strategies to improve communication rather than the parsing of ethical obligations. In cases where disagreements persist, the proposed solution is most often based on technical clinical judgements, reinforcing the role of physician authority in patient care and the ethical decisions made about that care. [ABSTRACT FROM AUTHOR]

New biotechnologies such as assisted conception are socially embedded artefacts that raise context‐specific ethical, moral and social anxieties. In contexts where the regulations of these profitable developments are limited or ambiguous, and competition between private facilities is high, individual doctors become morally and socially responsible for determining the parameters of administering such therapies. Ethnographic research at two private fertility centres in Colombia reveals that doctors do not determine boundaries based on monetary gain but rather personal morals, social norms and professional obligations. Medical professionals hold diverse perceptions of assisted conception, and often struggle to make decisions regarding who should access such therapies, who are ideal gamete donors and the fate of extra embryos. The complexity of these perceptions applied in a context of limited regulation and the competition of private medicine impacts the praxis of assisted conception. As doctors determine the boundaries of their practice they not only create variation between clinical practices, but also make moral decisions regarding who should be parents, how families should be formed and the significance of embryos. Thus, in navigating their everyday practices, doctors also shape the social world. [ABSTRACT FROM AUTHOR]

Telecare can offer a unique experience of trust in patient‐nurse relationships, embracing new standards for professional discretion among nurses, but also reflects an increasingly complicated relationship between nurses and doctors. The study uses ethnographic methodology in relation to a large 5 million euro project at four hospitals caring for 120 patients with COPD. Twenty screen‐mediated conferences were observed and two workshops, centring on nurses' photo elucidation of the practice of telecare, were conducted with a focus on shifting tasks, professional discretion, responsibility and boundaries between nurses and doctors. Analytically, the study draws on Star's notion of 'infrastructure' and Mol, Moser and Pols's ideas of care as 'tinkering'. Infrastructure is understood as human and non‐human conduct that is embedded into wider organisational conventions, sites and structures. The analysis demonstrates and proposes that, in telecare, greater accountability, discretion and responsibility are imposed on the nurse, but that they also have less access to the means of clinical decision‐making, namely, doctors. The article explores how relational infrastructures ascribe the professions they constitute (nurses and doctors) functions of power and accountability and highlights the ethical problem of the nurse being given greater responsibility while simultaneously becoming more dependent on the doctor. [ABSTRACT FROM AUTHOR]

Abstract: People diagnosed with brain tumours enter new and unfamiliar worlds in which they must make complex and previously unimaginable decisions about care, treatment and how to live their lives. While decisions are increasingly based around care pathways, these are embedded in values that often fail to accord with those of patients. In this article, we examine the cases of people with a brain tumour and how they, their families and healthcare professionals navigate and intervene in the course of life‐threatening disease. We use ethnographic data (2014–16) and modified social theory to highlight: (1) patients’ interpretations of disease and care and how they might differ from dominant biomedical logics; (2) complexity and contingency in care decisions; (3) rapid and unanticipated change owing to disease and bodily change; and (4) how people find ways through a world that is continually in motion and which comes into being through the combined action of human and non‐human agencies. Our modified ‘healthscapes’ approach provides an analytic that emphasises the constant precariousness of life with a brain tumour. It helps to explain the times when patients’ feel bumped off the pathway and moments when they themselves step away to make new spaces for choice. [ABSTRACT FROM AUTHOR]

This article draws on ethnographic data from a Norwegian emergency primary care clinic ( EPCC) to explore nurses' discretionary application of guidelines. Specifically, it analyses nurses' discretionary use of the Manchester Triage System ( MTS) when performing face-to-face triage, that is, assessing the urgency of patients' complaints. The analysis shows how nurses assessed patients at odds with MTS prescriptions by collecting supplementary data, engaging in differential diagnostic and holistic reasoning, relying on emotion and intuition, and allowing colleagues and patients to influence their reasoning. The findings also show how nurses' reasoning led them to override guidelines both overtly and covertly. Based on this evidence, it is argued that nurses' assessments relied more on internalised 'triage mindlines' than on codified triage guidelines, although the MTS did function as a support system, checklist and system for supervisory control. The study complements existing research on standardisation in nursing by providing an in-depth analysis of nurses' methods for navigating guidelines and by detailing how deviations from those guidelines spring from their clinical reasoning. The challenges of imposing a managerial logic on professional labour are also highlighted, which is of particular relevance in light of the drive towards standardisation in modern healthcare. [ABSTRACT FROM AUTHOR]

Institutional ethnography ( IE) is used to examine transformations in a professional nurse's work associated with her engagement with a hospital's electronic health record ( EHR) which is being updated to integrate professional caregiving and produce more efficient and effective health care. We review in the technical and scholarly literature the practices and promises of information technology and, especially of its applications in health care, finding useful the more critical and analytic perspectives. Among the latter, scholarship on the activities of economising is important to our inquiry into the actual activities that transform 'things' (in our case, nursing knowledge and action) into calculable information for objective and financially relevant decision-making. Beginning with an excerpt of observational data, we explicate observed nurse-patient interactions, discovering in them traces of institutional ruling relations that the nurse's activation of the EHR carries into the nursing setting. The EHR, we argue, materialises and generalises the ruling relations across institutionally located caregivers; its authorised information stabilises their knowing and acting, shaping health care towards a calculated effective and efficient form. Participating in the EHR's ruling practices, nurses adopt its ruling standpoint; a transformation that we conclude needs more careful analysis and debate. [ABSTRACT FROM AUTHOR]