The commonly occurring metaphors and models of the doctor-patient relationship can be divided into three clusters, depending on what distribution of power they represent: in the paternalist cluster, power resides with the physician; in the consumer model, power resides with the patient; in the partnership model, power is distributed equally between doctor and patient. Often, this tripartite division is accepted as an exhaustive typology of doctor-patient relationships. The main objective of this paper is to challenge this idea by introducing a fourth possibility and distribution of power, namely, the distribution in which power resides with neither doctor nor patient. This equality in powerlessness-the hallmark of "the age of bureaucratic parsimony"-is the point of departure for a qualitatively new doctor-patient relationship, which is best described in terms of solidarity between comrades. This paper specifies the characteristics of this specific type of solidarity and illustrates it with a case study of how Swedish doctors and patients interrelate in the sickness certification practice.

Being a “good” doctor nowadays involves more than having virtues and capacities conducive to the content of encounters between physicians and patients. Physicians can and must be able to act on the surrounding conditions of the doctor-patient encounter, in order to keep external interests at bay. Hence, the patient-related virtues, such as compassion, prudence, temperance and the like might not constitute sufficient cause for “good” doctoring. Resistance against the invasion of external interests requires another set of capacities. In this compilation thesis, one such capacity is explored: cunning. While certainly not part of the repertoire of skills in relation to the patient, cunning intelligence is an indispensable “virtue” of good doctoring insofar as doctors must cleverly navigate institutions that block off paths toward the ultimate ends of healthcare. The role of cunning is examined through a particular case, namely, the struggle over social insurance, especially sickness benefits (“sjukpenning”), and the complex relationship between physician, patient and the Swedish Social Insurance Agency (“Försäkringskassan”). In these times of increased austerity, physicians have honed skills, retaining thereby good medical practice, and by extension also maintaining the integrity of the patient-related virtues of medicine. In the empirical material, techniques were identified, particularly with respect to the way in which the sickness certificate is written to ensure approval by the SSIA. Based on these findings, the ambiguities, contradictions and possibilities inherent in the cunning resistance of physicians are analyzed and problematized. Despite its many issues, what doctors do when issuing sickness certificates in this particular way, is certainly motivated and carried out by more than mere ignorance. Cunning intelligence is not merely a defective form of prudence (phronesis), nor is it simply an instance of instrumental reason (techne), but rather an ability that occupies a distinct place among the intellectual abilities generally ascribed to professionals. Finally, I explore if the use of these capacities indicates a change in the doctor-patient relationship. I argue that both doctor and patient are conditioned by an equality in powerlessness—the hallmark of “the age of bureaucratic parsimony”, which can be appropriately described in terms of solidarity between comrades.

The relations of power between healthcare-related institutions and the professionals that interact with them are changing. Generally, the institutions are gaining the upper hand. Consequently, the intellectual abilities necessary for professionals to pursue the internal goods of healthcare are changing as well. A concrete case is the struggle over sickness benefits in Sweden, in which the Swedish Social Insurance Agency (SSIA) and physicians are important stakeholders. The SSIA has recently consolidated its power over the sickness certificates that doctors issue for their patients. The result has been a stricter gatekeeping of sickness benefits. In order to combat the inroads made by state institutions into sickness certification, and into the sphere of medical practice, some doctors have developed cunning "techniques" to maximize the chance to have their sickness certificates accepted by the SSIA. This article attempts to demonstrate that cunning intelligence-the ability of the weak to "outsmart" a stronger adversary-plays an important role in the practice of medicine. Cunning intelligence is not merely a defective form of prudence (phronesis), nor is it simply an instance of instrumental reason (techne), but rather an ability that occupies a distinct place among the intellectual abilities generally ascribed to professionals.

This article deals with the ways Swedish General practitioners (GPs) informally deal with the stricter standards of sickness certification and the implications of understanding these ways in terms of ‘resistance.’ In recent decades, procedural and bureaucratic changes within the Swedish sickness benefit system have curtailed physicians’ clinical discretion with regards to the sickness benefit approval for patients. By both formal and informal means, the Swedish Social Insurance Agency (SSIA) has consolidated its power over the decision-making process. Despite widespread dissatisfaction among physicians with the current system, acts of open defiance do not seem to occur. However, as shown in a recent qualitative study, Swedish General practitioners have developed informal ‘techniques’ (ranging from simple exaggerations in the certificates to complex constructions of apparent objectivity) for intentionally circumventing the stricter sickness certification standards. Taking that study as a point of departure, this article will consider the use of techniques as a form of everyday resistance. Three dimensions of ambiguity arise which require further attention, namely: (1) the multiple motives and shifting target of resistance; (2) the complex blend of power and powerlessness which defines the situation of GPs and their resistance, and (3) the fundamental ambiguity of the resistant act of issuing sickness certificates tactically, as a particular mix of compliance and resistance.

OBJECTIVES: To explore informal and unsanctioned techniques general practitioners (GPs) employ as a means to increase the likelihood of sickness certificate approval, following the Swedish Social Insurance Agency's (SSIA's) consolidation of the gatekeeping role in sickness benefit evaluation.

DESIGN: Qualitative semi-structured interviews with 20 GPs working in Swedish primary care. A thematic analysis of the transcribed material was carried out to map different techniques employed by the practitioners.

RESULTS: Eight techniques were identified, particularly with respect to the way in which the sickness certificate is written to ensure approval by the SSIA. The identified techniques were most commonly adopted when the patient's case was perceived to be at high risk for rejection by the SSIA (such as psychiatric illnesses, chronic pain etc.).

CONCLUSIONS: The findings imply that the informal and unsanctioned techniques are complex and ambiguous. They are used intentionally and covertly. The study also suggests that, while the consolidation of SSIA's gatekeeping role may have resolved some sickness absence issues, a consequence may be that GPs develop unsanctioned techniques to ensure compliance.