Visual Online Discourse Of The Medical Services Quality In Modern Russia

Abstract

The article is devoted to the consideration of public discourse regarding the quality of medical services. The overall increase in the quality of life determines the growth of requirements for how, in what conditions and with what result medical services should be provided. The inaccessibility of high quality medical services for low-income groups of the population makes social inequality in society more noticeable, causes an increase in social tension and is associated in public discourse with the commercialization of healthcare, which changes the essential purpose of this medical profession. The transformation of doctors into businessmen has a negative impact on their moral character, causes them to be indifferent or even aggressive towards patients, while for money, medical workers are ready to satisfy any requests from clients. These lind of representations can be traced within the visual online discourse of evaluating the quality of medical services. It is fundamentally important in this article to use M. Foucault's idea of how discourse is formed: the contexts and actors that are mentioned least of all actually have the biggest power that determines the situation as a whole. Thus, the authors of the article reveal the obscuring of the role of state policy in the formation of the discourse of the quality of medical services in modern Russia. The empirical base of the research became 400 virtual artifacts, collected by two intersecting semantic fields using selection by two key word combinations in Google and Yandex search engines in the "Images" sections.

Keywords: Medical services qualitysocial contracts in the field of medical servicestypes of discoursesvisual communication artifacts

Introduction

Nowadays, the quality of medical services is in the focus of attention not only for experts, but also for ordinary people. Today, in the era of the Internet, the opportunity to articulate their ideas in public spaces is implemented on various platforms by various actors and different kinds of social groups, nominating their own experts (Gallymov & Kuznetsova, 2019; Karpikova, 2015). Statements about the quality of medical services are presented not only in the form of texts, but also in the form of images or videos, both in virtual and real spaces, flowing from one to another. We can say that discourse as the practice of articulating various ideologies, concepts, scientific pictures of the world in a certain communicative space is constantly reproduced in other spaces, and all this is a dynamic field of interaction and struggle of texts, statements and other semantic artifacts. According to Foucault (1996), discourse is the practice of forming objects that are spoken of in discourses; it is a space of production and knowledge, power and practice. In addition to the physical understanding of space, it can also be presented as a semantic one: one can “talk about climate discourse, economic discourse, natural science discourse and psychiatry discourse” (Foucault, 1996, p. 163). One of the semantic areas of the formation and collision of various discourses is the sphere of medicine, understood as the sphere of collision of social, economic, and political interests of the population. In this context, the discourse of the quality of medical services ceases to be narrowly professional, but becomes more philosophical and even sociological, related to the quality of life of the population as a whole. Due to the fact that health is becoming an increasingly important value for a modern person, the discussion of the quality of the work of healthcare institutions and the quality of medical services will inevitably be one of the most popular frameworks that form public discourse (Panova, 2019). With the same inevitability, criticality will increase, the manifestations of which today in our country, which is transforming towards an increasingly authoritarian state, are not welcomed. One of the forms of the movement towards authoritarianism is "structural violence", which, according to Graeber (2016), deprives the imagination of people who would like to express dissatisfaction and make claims to the system. In the health sector, situations of structural violence are pervasive, as the system deliberately creates barriers and filters that ensure more efficient use of its resources through rigorous procedures for classifying patient needs according to system standards (Blythe & Curlin, 2018). However, such efficiency raises a large number of questions, primarily among the clients served in this system. Individual grievances and dissatisfaction are often not seen as rational and worthy of attention. At the same time, complaints about the quality of medical services, formalized by filling out questionnaires to assess the quality of medical services, quickly become toothless, meaningless and therefore safe for officials responsible for maintaining the high quality of the healthcare sector. Thus, the systemic world presented both offline and online, is determined by its content by representatives of the authorities, as a result of which critical reviews of the population are pushed either “into the kitchen” or into such zones of the online space where they are difficult to control. However, a discourse cannot be reduced to a set of official complaints, expert opinions or official statements – a discourse is very well reflected in the content of messages and images that appear on the first pages when requested in search engines. The last option, namely images as visual communicative artifacts, seems to us the most interesting object for studying the discourse of the quality of medical services due to their invisibility to political manipulation.

Problem Statement

Trust in the healthcare system is eroding today. Official assessments of the quality of medical services are often designed in such a way that people do not have the opportunity to speak out about what they really do not like. The image of the quality of medical services, which is discussed informally, remains behind the scenes. It becomes clear that the assessment of the quality of medical services is highly dependent on its context. For example, discussing a person's health in the context of a medical examination for a driving certificate may be very different from talking to a doctor about an individual's health prospects in the context of occupational risks. The intonation, themes, even the vocabulary of the same person in these two cases will be very different, although this will not be a lie, but the result of dependence on the difference in discourses. So, depending on the context of the conversation, a person can not only draw some conclusions, but also make different decisions, take different obligations, adopt different norms.

When it comes to evaluating health services, it is important to understand the contexts in which different societal discourses arise. The study of this issue can be based on the concept of social contract between doctors and society, proposed by Holden (2017), in which the social contract is considered as an unwritten agreement about some mutual norms and obligations, which by its nature is fluid, changing and redefined. The research problem here will be to determine the ability of representations of the social contract to become the organizing idea of public discourse. Also, the problem of the study is the identification of public trust in the quality of medical services within the framework of the discourse. The very definition of how public trust in medical services is visualized in the Internet discourse is problematic, since trust is what is between the individual, medical institutions, the state and other public institutions (Gille et al., 2017). One of the ways to identify public trust could be its visual representation in the form of the expression by the stakeholders of the process of providing medical services of a complex of various social emotions.

The motivation for the search for new methods of measurement of public trust is the serious danger of a social crisis in case of its complete destruction. Public trust in the quality of medical services is especially important during a pandemic, when socio-economic disadvantages are superimposed on problems of social inequality, which causes a critical attitude towards receiving any medical services from official medical institutions. In many low- and middle-income countries, the situation has reached crisis proportions requiring serious action (Kane & Calnan, 2017).

The crisis of trust in the healthcare system and the quality of medical services is developing today all over the world, including Russia. This is due not only to the fact that new technologies and medicines have appeared, but also to the fact that the standards of the quality of life in general have increased, which is reflected in the increased requirements of the population for the quality of medical services and the conditions for their provision (Nikolaev, 2015). On the other hand, the massive commercialization of the healthcare sector in general has exacerbated social relationships in different societies. Thus, the 2012 English Health and Welfare Act marked a fundamental reform in the health sector in England, which placed the interests of government over the interests of patients or professions and undermined the traditional partnerships between representatives of the medical profession and patients (Speed & Gabe, 2020). The victory of the ideology of cutting government spending against the backdrop of providing profits to medical corporations has led to the fact that it is patients and doctors who are parties to which too much has been attributed. As for Russia, here the transformations of the 1990s, which led to the conclusion of a more or less stable social contract in the socio-political sphere, did not end with the formalization and stabilization of the ideological discourse in the health sector. Over the past three decades, the Soviet model of universal free health care has shifted towards a combination of public, private and semi-private services under the influence of neoliberal ideology. These changes are becoming more tangible in the emergence of new consumer relationships between consumers and healthcare providers (Temkina & Rivkin-Fish, 2019). The reflection of these processes in political discourses is often invisible to ordinary citizens; such narrow issues are usually dealt with by specialists who have their own specific discourse as a set of terms, images and contexts (Fadeeva, 2020).

Understanding that citizens, who are more and more concerned about their state of health against the background of an unfavorable economic situation, also have their own discourse, the authorities are trying to influence it, pushing to the periphery discussion of the low quality of medical services, although the presence of this problem in the public consciousness is a fact. recorded by quantitative sociological research. Attempts to involve in the process of assessing the quality of medical services not only professionals, but also representatives of patient communities and public organizations in general (Savinskaya et al., 2017) certainly create a certain information veil, but do they penetrate these innovations in public discourse are a big question. The state media are trying to impose on the public life the idea that medical services in Russia are becoming more and more qualitative, and control over their implementation is becoming more stringent. Such interventions occupy entire segments of the Internet space. At the same time, the discourse of dissatisfaction with the quality of medical services does not disappear anywhere, taking the place between stones like sand and water. This discourse is much easier to spot in areas such as humor and satire, popular sayings (memes) and anecdotes. Despite attempts to control critical speech discourse by the state, visual forms of communication still remain a space of free interpretations and therefore it can be the very productive field for sociological research that attracted our attention in this study. Here we relied on the idea that, ultimately, the study of images in terms of sociology implies the discovery of visual rationales that shape social practices and are constituted by them (Burri, 2012).

Research Questions

Proceeding from the fact that the analysis of the virtual discourse of the quality of medical services is to reconstruct the processes of social objectification, communication and legitimization of the semantic structures of this thematic field based on the description of communicative visual artifacts existing in the Internet space, we posed the following research questions.

1. Is it possible to detect the influence of the use of different search engines (Google and Yandex) on the composition and semantic content of visual communicative artifacts when selecting research files?

2. What exactly is the difference between the interpretation of the image of medical services in the neutral and critical-satirical domains, if we study the following criteria: semantic content, situations, actors, social emotions, partnership or dependence; profession or vocation; recognition and pride or rejection, fear and dislike.

3. What social emotions are manifested in different discourses of the quality of medical services and how do they relate to the idea of the existence or destruction of social contracts in the health sector?

4. Is it possible to determine the contexts of the formation of individual discourses when studying various arrays of visual artifacts (paintings or photographs) selected according to arbitrary criteria by research in the online space?

5. Is it possible to single out independent discourses within arbitrarily selected thematic zones?

6. Is it possible to identify different types of social contracts behind the discourses of the quality of medical services in different communication spaces.

7. What topics are excluded in different discourses of medical services and what role does this play in determining the issue of "quality of medical services".

8. Do discourses on the quality of medical services differ in terms of their intentions to optimize the existing social order?

Purpose of the Study

The general goal of the study is to expand the discourse of discussing the quality of medical services in modern Russian society by identifying new areas of reflection. In this article, we do not plan to give an objective assessment of the quality of medical services in modern Russia given by various social actors. The aim of the work is only to discuss the specifics of the interpretation of such a concept of "quality of medical services" in various domains of the virtual space, to determine the logic of the formation of different discourses of "quality of medical services" in these domains. The initial task of our research was to identify the existence of specific discourses of “quality of medical service” by selecting an array of visual artifacts of a specific orientation (neutral and critical-satirical domains) to form research arrays. The next task was to identify the actors generating discourse in accordance with its structure presented earlier. Further, the task was to identify the relationship between the discussed problems of the quality of medical services with the ideological content of the very concept of "medical service", as well as to identify the contextual significance of interpreting the quality of life of the Russian population as a whole for the formation of various discourses. In this study, ideologies mean types of social contracts imposed by various discourses as grounds for obtaining a particular quality of medical services. In this regard, another research goal was to consider how different discourses distribute power, responsibility, norms and obligations among the actors that arise in the discourse.

Research Methods

The methodology of this study will be a multimodal analysis of the virtual discourse for assessing the quality of medical services. At the same time, the assessment of the quality of medical services will not be considered by us as an official audit procedure or sociological survey. By analyzing the discourse of evaluating medical services, we can interpret communication artifacts presented in various virtual spaces. By artifacts, we mean stopped, frozen texts or images, which are momentary fixation of certain stages of the communicative process, but what is reflected in them will be interpreted as a process. In turn, the combination of these artifacts will also be interpreted as a reflection of the processes taking place in society, which themselves must be interpreted. At the same time, the selection of specific domains will be carried out as a result of the author's interpretation of the "systemic" and "life worlds". The most likely domain that reflects the artifacts of the "life world" is the sphere of visualization of social criticism, realized in the form of cartoons on the theme of the quality of medical services. In our opinion, the systemic world with its latent structural violence can be represented by a neutral “documentary” fixation, which in our case will be defined by the keyword “photo”. Considering the totality of images that interpret the quality of medical services as a discourse of the systemic and life worlds, it is possible to determine the angles of view of this concept and highlight the accents. The necessary technique to clarify the perspective in which the concept of "assessment of medical services" is considered will be the determination of the social status of the actors of interactions described in a particular discourse.

In accordance with the Fucoldian tradition, special attention will be paid to the search for actors that could be present, but are absent, as well as the definition of situations that could exist, but are not recorded. Analyzing different domains, as spaces with different discourses of the quality of medical services, in each of these spaces we will identify a number of key points. First of all, hidden and explicit actors will be allocated in each of the domains. Actors in the foreground are characters who represent the medical service as such. An important research question will be to determine which actors are involved in the delivery of a health service and what are their functions? What kind of communication takes place between these actors - in explicit and latent forms? What is the goal-setting of the authors and how is the power resource distributed? How do the vital and systemic worlds coexist in the analyzed images? What images do different discourses operate with and what do they take outside of their own articulation?

Particularly important in the context of our topic is the issue of differences in interpretations of the circumstances and conditions for the implementation of medical services in different domains. A more specific form of analysis would be to determine who created the communication artifacts we selected and why? Who is the author and who is behind the author of the image? Who is the key actor who puts the meaning and content in the concept of the quality of medical services, and how does the interpretation of this phenomenon depend on this? What is the essence of the communicative message embedded within the images? To whom is it addressed and from whom does it come? Is the production of this image the result of a creative act, an arbitrary movement of human thought, an individual reflection of the attitude to what is happening, or is it the result of systemic violence, as a result of which images are produced mechanically? The last question brings us to thinking about the possibilities and limitations of the influence of the life world on the systemic world, even in the spheres of creativity, which before the advent of (post) industrial society were a zone of freedom of expression.

Another level of analysis of discourse as a social phenomenon and a multilayer communicative process is the comprehension of the process of forming the very array of images, selection and screening of observation units. Here, the communicative environment comes to the fore, in which the discourses we study are formed, namely, Internet resources, which were taken by us as what is perceived today as a pre-established constant of existence. In order to reveal the formative role of the information space itself, we deliberately took two different search engines that differ in their algorithms for selecting information, which probably have different ideological grounds. Determining these differences is also one of the key research questions of this work.

As a research method, we used a qualitative and quantitative analysis of thematic images, considered as elements of specific discourses for assessing the quality of medical services in modern Russian society. Based on the structure of discourse, considered in this article as its immanent characteristic, visual images were analyzed from the point of view of reconstruction and identification of participants in the discourse, their statuses, goals of communication; situational characteristics, as well as the way they communicate.

The theme, as a structure-forming element of discourse, will be redefined and refined by us in the course of collecting empirical material and its meaningful analysis. Initially, we understand the subject matter as “the quality of medical services”, which includes such simpler units as “medical services”, “recipient and provider of medical services”, “quality of medical services as a measure of satisfaction with them”. However, the analysis is likely to highlight discourses on more specific and narrow topics.

As the object of research in this part of our article, we used video images taken on the Internet in the most popular search engines in the Russian Federation Google and Yandex in the "Pictures" and "Images" sections. The basic query was the phrase "quality of medical services", but the sample was formed on the basis of adding the words "photo" and "caricature" to this phrase. As a result, a set of 200 images was formed, with 50 original images taken from each category, while excluding repetitions, remakes, and also irrelevant images. Further, the analysis was carried out in the following stages: written reflection and subsequent triangulation of the semantic content of artifactors, then - axial coding of images based on the structural units highlighted above, entering codes into the matrix, quantitative comparison of codes in different categories.

Findings

First of all, let us characterize the features and differences of image arrays taken from two different search engines - Google and Yandex. When comparing the first hundred images that appeared for the query "quality of medical services photos" in the Google system with a similar array formed by the Yandex search engine, the differences are very noticeable at first glance. So, in the Yandex search engine, 100% of the photographs are staged, all are made in bright white and blue tones interspersed with red or burgundy elements (doctors' ties, symbolically marked hearts, syringes with blood). All photographs show doctors or medical workers in blue and white coats with stethoscopes, in most cases, medical workers smiling into the camera, posing openly. 22% of photographs include an impersonal silhouette of a doctor. All the doctors in the photographs are young, only 2 of the photos show men of mature age, the gender balance in the photographs is observed, both men and women are equally represented. In most cases, doctors posing for the camera demonstrate a closed pose, either with their arms crossed over their chest or covered with a folder. About a fifth of the plots in the photographs depict doctors making notes or studying the record on paper or tablets, half of such cases involve communication between several medical professionals, and not as an equal discussion of colleagues, but rather in the form of consulting younger colleagues with a higher-status specialist. Note that the latter type of images was encountered only three times.

The emotional portrait of those portrayed is overly positive. Doctors show wide smiles in all photographs when they look directly into the camera. Only in a small number of cases, the smile is directed to the side, but not always at patients. The overall image of patients is very poorly represented. While present in only a quarter (24%) of the photographs, the patient is either deliberately removed and out of focus, or turned sideways or backward, or partially present (showing an arm or part of the back), but several photographs include patients near the reception. The whole array contained 4 photographs of shaking hands, 2 of them reflected a congratulatory or final gesture, and 2 photographs symbolized support and sympathy. In fact, such physical contact can be viewed as questionable in the framework of modern medical ethics. There was no partner conversation between the patient and the doctor. 3 photos show a semblance of a consultation, 3 of them contain elements of augmented reality. And only one photograph, without getting out of the general color and style range, demonstrates a critical plot when the doctor's gloved hands apply a stethoscope to an open wallet with cards. This photograph is so invisible against the general background that its critical orientation is not immediately apparent. Thus, the photographs reflecting the idea of the quality of medical services in the representation of the Yandex search engine demonstrate the well-being of doctors, the presence of a large number of young doctors, not just satisfied, but inspired by their work, well-groomed and energetic, working in excellent conditions and a wonderful atmosphere. At the same time, they appear to be a kind of closed caste, "keeping their secrets", remote from patients, who in turn do not appear to be people aggravated by serious problems.

When comparing this array with a similar array selected as a result of a similar search query in the Google system, noticeable differences are immediately revealed. First of all, let's make a reservation that the array obtained as a result of a request in the Yandex system did not require cleaning, since there were no duplicate photos, no remakes, or photos that were irrelevant to the request.

The array in the Google system turned out to be less monolithic, and although in a third of cases it demonstrated a similar emotional and even color gamut with the array of images in Yandex, still the photos were practically not repeated (in the array collected in the Google system, there was only one photo, on Yandex, as well as one collage using an element of this photo). At the same time, in the Google array, despite the word “photo” stated in the request, much more photos with augmented reality, as well as images made in computer graphics editors (about 18%), were encountered. However, the main difference between these arrays was that Google quite often contains photographs of documents (price lists, price lists and receipts), the meaning of which in the Internet space is to demonstrate real conditions and prices. Now we are not talking about the fact that this is indignation or, on the contrary, evidence in favor of the high quality of medicine. We only testify about the differences in the arrays of the collected visual content. At the same time, it should be pointed out that Google search suggest also around 12% of documentary photographs among staged images, most part of which correspond to the topic of "social and medical" services and demonstrate the provision of services to children with mental problems and physiological disorders, also there were documentary photographs of some real medical procedures. Another difference in the results of the query through the Google search was the appearance of several staged photos with babies, as well as one image of a wheelchair user. In general, in the Google array, advertising posters of hospitals and institutions providing medical services, photographs with lists of such services, individual types of services, promotion of various forms of payment (by installments, gift coupons, by shares, costing forms, etc.) are sufficiently represented, various supplementary health insurance forms. Many photographs are related to the topic of tax deduction for using paid medical services. Attention is also paid to the opportunities to receive free services for compulsory medical insurance: there are not only forms and procedures for receiving, but also photographs of leaflets explaining the rights to medical care for the homeless. In general, almost half of all photographs are represented by photographs of texts, among which there are orders, legal and regulatory documents, samples of contracts, title pages of scientific articles and dissertations. There are also photographs of slides from presentations made on the topic of medical services, diagrams assessing the place of paid medical services in the total volume of health care costs.

In terms of critical content, there was also a single staged photograph showing the counting of dollars against the backdrop of a medical website unfolded on a computer screen. Thus, the difference between the visual range presented in the two search engines Google and Yandex clearly demonstrates the differences in the discursive space formed by various actors with quite different intentions. Thus, it seems that the Yandex search engine is actually completely occupied by the discourse of commercial medicine. The actors in this case are not doctors, whose images are so deliberately shown in the foreground. They are too clearly supported by skilful medical businessmen who create simulations of the medical process, which positions it as a sphere of high competence of medical workers, their self-confidence, the kingdom of closed knowledge, solving patient health issues without any problems and even without his participation. However, the "wrapping" quality of beautiful symbols, suspicious of their impeccability, too clearly ignores the existence of real life with its problems of patients and doctors, the quality of life of patients and the general population. As for the array given to the Google search engine, its space represents a noticeably different discourse both in terms of the composition of actors and in the topics and circumstances associated with the provision and receipt of services. Further, we analyzed the arrays of visual images formed by the query "quality of medical services" with the addition of the word "caricatures", also formed in the above search arrays. At this step, the sharp difference between the semantic content and the previous set of images immediately catches the eye. It is noticeable that in the area of critical and satirical representation of the topic of the quality of medical services in the search engines Google and Yandex, differences in the nature of the array of images are again noted. As in the first case, in Yandex, the nature of images is more monolithic from the point of view of the image type: when forming an array of 100 images, only 5% of the images that appeared, which were remakes of existing cartoons, including additional comments, were eliminated as irrelevant. Thus, we obtained an array of images that correspond to the definition of a caricature as a drawn image, focusing attention on the comic elements of reality.

It should be noted that in most cases hand-drawn drawings are accompanied by hand-written inscriptions. However, 32% of the images include lettering in computer type. 9% of cartoons are not accompanied by text at all, sometimes being quite simple and eloquent, and sometimes leaving room for ambiguous free interpretation. As for the formation of an array of cartoons, formed on the basis of the Google search engine, there, as in the case of photographic images, irrelevant images were encountered more often than in Yandex. Thus, when selecting 100 images, 8 commercial images demonstrating the artistic style in which it is proposed to draw a caricature to order were screened out, 5 images included not the caricature itself, but its display on an educational presentation, 7 images turned out to be thematically irrelevant, not directly related to the field of medicine. Also, the array included many cartoons, indexed as American caricatures of various periods of the 20th century American with translation, which were also excluded, as well as thematic hand-drawn images and photos that did not carry any plot meaning. Note that during the formation of the array of cartoons, a large proportion of intersections was noted - 28 cartoons were common for both arrays collected in Yandex and Google.

Speaking about the content side, let us point out the list of topics into which the visual series of images from the corpus in the Russian search engine breaks down. Most of the cartoons here criticize doctors who show themselves in the most unworthy way in relation to patients. Most often, a doctor is credited with an orientation towards receiving money for the provision of medical services. This financial orientation is usually combined with blackmail, when the patient is faced with a choice - money or life, as well as money or torment. In situations where the patient needs pain relief, as a rule, it is portrayed as an opportunity to receive a blow to the head with something heavy (a hypertrophied hammer) instead of medication. The hypertrophied primitive tools of dentists (huge drills, hammers, pliers) are stereotypically depicted. In all these situations, patients appear helpless, frightened and submissive. Another avenue is the depiction of fraud - figurative or specific. In some cases, the doctor deliberately points out the absence of grounds for free treatment, too cheap insurance, and the absence of mentioning specific patients in the constitution. Doctors deliberately create queues, immediately freeing up space for paysites, and doctors also provoke the wrong behavior of patients in order to have clients in the future. The maximum generalization can be found in cartoons, where patients are depicted as vegetables that need to be processed "spud", with a hint that after such "processing" these people will become an easily accessible source of money. Talking about paid medicine, cartoonists show that in some cases the services offered become so absurd that it causes embarrassment and shame even among the doctors themselves, although sometimes they are not realized by the patients. In addition to fraud, the cartoons demonstrate the indifferent attitude of doctors towards patients, which is demonstrated by several common plots: medical workers, in principle, demonstrate isolation from patients at all levels - from the reception desk to the office of the head physician, doctors work with patients automatically and disinterestedly, objectifying people. A stereotypical plot is when doctors can refuse to treat patients if they do not have money, surgeons can stop an operation or other procedure in order to understand what exactly is paid for. Specifically, "black" humor is the patient's references to God and religion in case of danger to their lives, based on the play on words that are present in everyday Russian. The play on words also appears in cartoons, focusing on the topic of patient health complaints. The ambiguous classic phrase "what are you complaining about", which is an integral part of the verbal discourse of doctors, is deliberately misunderstood in visual discourse that goes beyond institutional medicine. For example, one part of this expression is emphasized - "what" - referring to the amount of money that the patient intends to pay to the doctor in order for him to consider his complaints. Another perversion of the expression "what are you complaining about" may be the understanding of this question as "who are you complaining about." The questioning of medical professionals about the patient's very right to a "complaint" is sarcastically considered.

Repeatedly the authors of cartoons focus attention on the fact that doctors are using outdated or inadequate tools, symbolizing a cynical attitude towards the sick and dying, or the fact that the patient's death was chosen as a fairly simple alternative in the existing conditions - regardless of whether patients want to die or not. Another focus of attention is the cartoons depicting the differences between paid and free medicine. It demonstrates the presence of excellent equipment in one space, the courtesy and hospitality of medical workers when it comes to paid medicine - and complete collapse, aggression from the medical staff, lack of treatment options and cruelty of procedures when it comes to state "free" service. In particular, a popular topic is the use of enemas as an outdated and meaningless tool, as a replacement for more advanced treatments or high-tech tools. Only in isolated cases is there a reverse discourse - doctors are seen as victims of a situation when they are forced to work in poverty-stricken medicine. In critical cases, doctors find themselves with outdated or non-working equipment. They are ready to dance in front of the patient for lack of other treatment options. Also featured are images of tired, exhausted and poor doctors who regret the death of a patient while he is already in the cemetery. The specific medical culture is not the central theme in the cartoons, however, the tendency of doctors to drunkenness in the operating room is emphasized several times, sometimes the low level of doctor's qualifications, reaching the point of absurdity, is emphasized. At the same time, about a fifth of the cartoons in the array are devoted to the fact that doctors are seen as victims of the optimization of the medical industry. Thus, the intensification of work with a patient is mocked when a whole team examines one patient at the same time, or one doctor uses a stethoscope with branched ends, simultaneously applied to all parts of the body. The reason for irony is also a bias in medical practices, when a whole team receives all the information from one stethoscope, which is used by only one doctor. At the same time, it is the state that begins to threaten doctors, demonstratively preparing to punish those who provide "unnecessary services" in a situation where doctors are at the forefront in the fight against coronavirus. Of course, the irony in this depiction is that this threat is a form of manipulation of both patients and doctors by the state. The situation with the sending by President Putin of medical equipment to help patients with coronavirus in the United States did not escape ridicule when it was demanded by Russian patients.

Doctors are also depicted in the drawings, carrying their cross to Calvary in the form of a symbol of medicine - a red cross. Direct comparisons were found between modern, extortionately expensive medicine and the free Soviet health care system, the rise in tariffs and prices for medical services in a metaphorical form of those fleeing from the elderly and disabled people with their modest incomes. In isolated cases, politicization of what is happening is also found - for example, once an image was noted in which a deputy happily announces the preservation of free medicine, but a poor audience asks him about his fate, realizing that free medicine is not for her.

Against this background, there is a rather modest attention to the personal characteristics of the patients themselves, which can affect the quality of medical services. So, only twice is there a reference to the fact that patients are treated with alcohol (and not with vodka, but only with beer, which reflects the change in the nature of alcohol consumption in Russia in recent decades). In isolated cases, patients who do not notice the "knife in the back", complaining of a runny nose, are mocked. There are patients who have adapted to their diseases in a very weird way on their own, in the absence of medical assistance, - for example, they are taking a shape of four legged animal which causes laughter and a certain respect for their ingenuity. But most often the patient in the caricatures is only a supporting character, an object, and not a subject, who in most cases is forced to endure pain and inconvenience, is shocked by the prices of medical services, have to pays money and allows himself to be fooled and even humiliated by cruel and meaningless medical procedures. Only in a few cases can one find indications of the elements of partnership between patients and medical professionals, when the patient is forced to help doctors, even when he is sick, because otherwise doctors simply cannot cope.

Conclusion

Interpreting the results obtained, we point out that during the analysis of the collected arrays of visual communication artifacts, several internal discourses were identified: commercial, human rights, medical ethics criticism discourse, medical services commercialization criticism discourse, and patient discourse. The commercial discourse is notable for the promotion of the concept of a medical service as a service not associated with serious problems. A beautiful cover of a magical product that solves any client's problems at a price that is not negotiable, but is supposed to be worthy of its attractive image. The absence of a mention of the price for such services, the very implicit symbolic representation of patients, the complete absence of other stakeholders all draw us to the Fukoldian understanding of the situation: determining how the power resource is distributed under these conditions of insufficient information. Obviously, the visual series conveys to us the idea of the omnipotence of doctors, as a closed, prosperous and closed caste, either over the diseases of patients, or over the patients themselves. However, the complete absence of the social context of the population's dissatisfaction with the state of their health and the quality of medical care, as well as the exceptional theatricality of the characters, tells us that there is a completely different force behind this image. This power is commercial companies, not only determining the content, but also completely displacing the state, which is actually removed from the context, as well as from the number of actors, thereby providing business with complete carte blanche in the field of interaction with customers, whoever they are, on based on their rules. This is how the social contract of this discourse can be interpreted. In addition to the commercial discourse of the quality of medical services, we also found a human rights discourse that unites the fixation of the inappropriate cost of services, but also problematizes price policies, government obligations and practices of their violation, as well as the struggle to improve the economic situation of patients. Despite the relative weakness of this discourse, in our opinion, it is this discourse that has the best prospects for development and influence both on the public consciousness of civil society and on the quality of medical services. As for the analysis of the phenomenon of Fucoldian absence, only public organizations are completely excluded from the human rights discourse, but other actors, such as the state, business, as well as individual individuals defending their rights, are represented in it in a quite tangible, albeit indirect way. To summarize, let us point out that the human rights discourse is quite chaotic, however, there is an intention in it to search for some “lost social contract”, but no new certainty about the distribution of rights and responsibilities of participants in the process of providing medical services has been established. In the arrays of visual communicative artifacts, we also identified a discourse of social criticism of the quality of paid medical services and a discourse of criticism of free medicine, within which there are thematic dominants of ethical violations and commercial frauds carried out directly by medical personnel. In these discourses, the idea of the destruction of the social contract of the Soviet paternalistic type is clearly traced, but no hints of new mutual agreements are noted. Critical patient discourse focusing on the role of the client in the process of ensuring adequate quality of medical services is very weak. There are also traces of communications on the conflict between paid and free medicine as providers of medical services of different quality. The last, but perhaps very important observation made as a result of the analysis of the social-critical discourse of the quality of medical services is again based on the Fucoldian approach: the political background of what is happening in the social-critical discourse is generally absent. The smallest exceptions that mention the political actions of the state only confirm us in the idea that it is beneficial for someone that in public discourses the quality of medical services remains a bone of contention between business, patients and doctors, and the state remains above the fray. Thus, there is a feeling that in the discourses of the quality of medical services, the identification of medical workers as actors who achieve their economic and social superiority, as well as administrative and even physical power over patients, dominates. And this masks the decisive role of political actors in ensuring that the discourse of the social contract in the provision of quality medical services to the population is not defined, and the role of the state in regulating and controlling the quality of these medical services does not become a subject of discussion.

References

1. Blythe, J. A., & Curlin, F. A. (2018). "Just do your job": Technology, bureaucracy, and the eclipse of conscience in contemporary medicine. Theoretical Medicine and Bioethics, 39(6), 431-452. https://doi.org/10.1007 / s11017-018-9474-8
2. Burri, R. V. (2012). Visual rationalities: Towards sociology of images. Current Sociology, 60(1), 45-60.
3. Fadeeva, Е.V. (2020). Access to free medical assistance in Russia: State and problems. Sotsiologicheskie Issledovaniya, 4, 94-104.
4. Foucault, M. (1996). The archaeology of knowledge. Nika-Center.
5. Gallymov, R. R., & Kuznetsova, Y. A. (2019). Quality of health care in the Russian Region: A comparative analysis of «subjective» indicators. Sotsiologicheskie Issledovaniya, 9, 146-153.
6. Gille, F., Smith, S., & Mays, N. (2017). Towards a broader conceptualization of the 'public trust' in the health care system. Social Theory and Health, 15(1), 25-43. https://doi.org/10.1057/s41285-016-0017-у
7. Graeber, D. (2016). The utopia of rules: On technology, stupidity and the secret joys of bureaucracy. Ad Marginem Press.
8. Holden, A. C. L. (2017). Dentistry’s social contract and the loss of professionalism. Australian Dental Journal, 62(1), 79-83. DOI:
9. Kane, S., & Calnan, M. (2017). Erosion of trust in the medical profession in India: Time for doctors to act. International Journal of Health Policy Management, 6(1), 5-8.
10. Karpikova, I. S. (2015). Quality and availability of medical services: Population and health care experts’ opinions. Sotsiologicheskie Issledovaniya, 6, 53-57.
11. Nikolaev, V. G. (2015). Reform of the Russian public health system and the value conflicts of professionalism. Journal of Social Policy Studies, 13(4), 611-626.
12. Panova, L. (2019). Access to healthcare: Russia in the European context. Zhurnal Issledovanii Sotsial'noi Politiki, 17(2), 177-190. DOI:
13. Savinskaya, O. B., Dudchenko, O. N., & Mytil, A. V. (2017). Methodological audit of independent quality evaluation in social sphere: Possibilities and limitations. Journal of Social Policy Studies, 15(1), 97-112.
14. Speed, E., & Gabe, J. (2020). The reform of the English national health service: Professional dominance, countervailing powers and the buyers' revolt. Social Theory and Health, 18(1), 33-49. DOI:
15. Temkina, A., & Rivkin-Fish, M. (2019). Creating health care consumers: The negotiation of un/official payments, power and trust in Russian maternity care. Social Theory and Health, 18(4), 340-357. https://doi.org/10.1057/s41285-019-00110-3