From Dyad to Triad— Mediatization and Emerging Risks for Professional Autonomy

With the emergence and spread of digital media, more business models foster and empower client participation in medical professions. With services and products ranging from rating platforms to apps targeting self-diagnosis, these businesses transform the client–practitioner relationship yet risk undermining a central pillar of professions—autonomy. Practitioners have to take legal actions against these business models, making visible the frictional interplay among the involved actors. This development calls for an analytical understanding of how this technology-induced cultural change affects professions and discourses on professionalism. We argue that a perspective on how practitioners deal with these challenges in various situations can be beneficial. Hence, we conceptualize professionals as engaged in identifying, assessing and managing risks for themselves and their clients. The emerging risk-management practices lead to an understanding of how this apparent cultural change plays an increasingly meaningful role for research on how professionalism regarding legitimation of authority is negotiated.

rating websites themselves cannot be shut down as they are protected by the universal freedom of speech, yet professionals always have to be aware of the consequences of poor ratings. Jameda and other rating platforms constitute only one example of how online platforms shape and challenge professional practices, as well as the discourse on professionalism to date. Other prominent examples are self-diagnosis platforms and apps, which were labelled the "doctor in the mouse" trend by the Australian Daily Telegraph and the Australian Medical Association in 2013. Most of these platforms and apps are mainly marketed to lay consumers without major forms of regulations in terms of their content, bearing grave consequences that are often related to false diagnoses (Robertson et al., 2014). In short, the spread of these technologies and with it, the rise of mediatized business models (Pfadenhauer & Grenz, 2012) already show significant effects on their targeted professional fields, thereby calling for a systematic understanding.
To prepare for such an understanding, first, we briefly outline two perspectives on professions and professionalism and add another on risk and uncertainty, which in our view, bridges two major aspects of how to deal with contemporary challenges posed by today's business models. First, this approach offers an understanding of contemporary socio-technical processes that undermine some of the ideal-typical components of professionalism, such as the separation from an ordinary labour market or the development and assessment of new and already established knowledge (Freidson, 2001). Second, it introduces a notion of reflexivity based on the concepts of reflexive modernization (Beck, Giddens, & Lash, 1996), which is useful in understanding the socio-technological developments that (at least in the field of medicine) reshape and reorganize both professional-laypeople relations and the discourse on professionalism. Building on these perspectives, we introduce the concept of reflexive mediatization as a standpoint on how to tackle these challenges for further research on professions and professionalism.

Professions, professionalism, and risk management
Regarding the work of Hughes (1958), who elaborated on the role of holding a mandate and a licence as the peculiar feature of professionalism, someone can argue that having a mandate means being equipped with the societal authority or duty to rule, based on the idea of central values and common needs, whereas holding a licence rests on the permission to act in specific contexts. To hold a licence and thereby be attested with professional competence, a practitioner has to obtain certain certificates that are typically bound to specific educational training (Hughes, 1958). This classic distinction appears in a new light with the rise of business models, such as Jameda. Especially due to their built-in rating systems, these business models can be perceived as commercially driven platforms of re-evaluation. With more recent approaches defining the field of professionalism as "a set of interconnected institutions providing the economic support and social organization that sustains the occupational control of work", the question to answer is where these models fit into the picture (Freidson, 2001, p. 2). To understand the impact of mediatization within this set of interconnected institutions, we have to examine in depth the five pillars on which this brief definition is built, as follows: a) the specific body of knowledge and skills, b) the occupationally directed division of labour, c) the occupationally controlled labour market, d) the occupationally controlled education and e) the profession's ideology (Freidson, 2001, p. 180). Rooted in the Weberian tradition, this approach lays a heavy weight on professionalism as an institution, leaning towards ideas resembling neo-institutionalist approaches. Regarding recent societal and political changes, some of the above-mentioned pillars have become the subject of new considerations. Some examples are how the knowledge base of professions has become fluid due to shifting institutional arrangements and expert professionalism (Brint, 1994), the influence of new political policies, such as European Union (EU) regulations, as well as the effects of globalization in terms of blurring the markets in which professions were typically looking for occupationally controlled closure (Bianic & Svensson, 2010;Evetts, 2012). Nevertheless, professionalism has always been the subject of change, especially involving either technology or its pincered position between ruling bodies (e.g., governments and consumers or rather laypeople) or both (Macdonald, 1995;Saks, 2010). Briefly stated, recent developments ask for concepts that are able to grasp the blurred boundaries that formerly constituted professionalism (Evetts, 2012).
We argue that the discussion on professionalism has reached the point where it has to account for new challenges posed by mediatization. Mediatization can be conceptualized as a dynamic interplay that becomes visible through technology and its induced socio-cultural change. We identify business models that build on emerging technologies, such as online platforms and apps, as the main driving forces for this change, especially since these foster new forms of participation that bear unforeseeable consequences for the involved actors (Pfadenhauer & Grenz, 2014). We contend that only recently, some of these consequences have reached the field of professions by undermining formerly occupationally controlled areas of these professions and ultimately targeting a core pillar of professionalism, their autonomy. Following Evetts' (2011) argument, we assert that some principles of professionalism have been outstandingly successful, only to turn against its core. The aftermath of this development ranges from evaluation programmes to supervision constraints and the undermining of business models such as Jameda, which lead to professional practice and the discourse on professionalism being increasingly confronted with external control and competition. These challenges are each addressed differently by the more prominent approaches in the research on professions and professionalism, namely, the institutionalist neo-Weberianism (Saks, 2010) and the more discourseoriented approach to the difference between occupational and organizational professionalism (Evetts, 2006(Evetts, , 2012. Focusing on the field of medicine, we elaborate on how these approaches could benefit by adding the perspective of risk and uncertainty, considering professional practice and the discourse on professionalism in order to tackle questions arising from societal and technological developments, such as mediatization. One of the major aspects of the neo-Weberian approach to professionalism is based on the occupationally controlled market closure. This concept is able to define the boundaries of professions at three major levels, whilst accounting for differentiations within a profession by the same means (Saks, 2010). The first level focuses on self-governance, which refers to closure in the sense of restricting access to the profession. The second relies on the ability to define the needs of laypeople who seek or depend on the profession's knowledge. The third leans towards closure in the profession itself, setting standards and thereby organizing work (Freidson, 1994). With this in mind, this model could easily scale from a perspective on practices (i.e., in the professional-laypeople relation) to rather macro-oriented developments, such as the emergence of specific markets. Although it seems that this approach can be perceived as intrinsically dynamic, it remains unclear how this model accounts for more recent disruptions posed by the likes of Jameda or apps used for self-diagnosis. With the neo-Weberian approach being based on processes of control and closure, the blurring effects seem to pose a challenge, especially since authority, autonomy, public trust and a credential ideology can be regarded as key concepts in this approach (Saks, 2010(Saks, , 2012Svensson, 2010).
Examining public trust and autonomy in the medical field, we can identify a shift from an overall high level of trust in professional self-regulation (Allsop, 2006) to the emergence of new forms of legitimacy as observed on rating platforms and the like. The possibility to rate doctors, not by means of their medical skills, education or occupationally controlled body of knowledge but by their clinic hours, staff or social skills, presents a new economically driven challenge, which should be consid-ered. In this regard, it seems that doctors currently face a greater degree of surveillance, not only by governmental actors but also by their clients. The same situation can be observed in the ongoing trend of digital self-diagnosis. Health and medical apps can be regarded as having a major impact on how the human body is understood, visualized, as well as treated by both medical practitioners and laypeople (Krieger, 2013;Lupton, 2014Lupton, , 2015Lupton & Jutel, 2015). In this sense, mediatization can be viewed as a driving process in which the doctor-patient relationship, as well as the practice of medicine, enters the liberalization phase (Lupton, 2015). Although the consequences of this development have yet to be fully outlined, this situation already shows that mediatization and the corresponding emergence of business models, such as Jameda, and the trend of self-diagnosis via apps limit public trust and with it, the autonomy of doctors in practice. On the other hand, these new economically driven actors act as competitors and thereby limit the profession's ability to provide market closure as is typically the case with mediatized business models (Grenz, 2017). From this point of view, the neo-Weberian approach has to address these challenges in order to stay eligible.
Regarding organizational budget cuts, with new forms of jurisdiction by the EU and clients, in general, becoming more demanding, another approach to researching professions tries to account for these developments. Building on some of the claims already established by Freidson (2001), such as the unique forms of occupational control, this discourse-oriented perspective points out the "dual character of professions" (Evetts, 2006, p. 137), which on one hand lies in the occupationally regulated provision of service and its governance. On the other hand, it is characterized by the use of occupationally regulated knowledge, which is applied to accumulate economic power. With the adoption of new public management and other forms of exterior control, the argument outlines how professionalism can be perceived as a discourse of control, directed increasingly by means of economic gains within organizations. At this point, professionalism as a means to organize, regulate and standardize specific practices or fields is bound to managerialist control and can, therefore, be summarized as organizational professionalism (Evetts, 2012). In contrast, this form of discourse has to be separated from what Evetts calls "occupational professionalism" (Evetts 2012, p. 6), which is closely bound to typical key concepts of professions, such as autonomy, a specific body of knowledge and years of higher education, which result in occupational identities and work cultures. It seems clear that these concepts aim towards understanding that diverging interests and an increasing number of external factors shape both the interior and the exterior organization of professions. Therefore, the argument aims to uncover professionalism's "third logic" (Freidson, 2001) as to some extent already assimilated by other groups, leading to the dissemination of former, strictly occupationally regulated forms of governance.
Concerning our introductory example, we point to newer forms of control that seem to influence the discourse on professionalism. With platforms and apps, we identify new developments in the discourse on organizational professionalism since these products are solely grounded on providing as many economic gains as possible. For example, with Jameda, doctors are left out of the equation as their service becomes a "product" that is negotiated through the platform providers and the laypeople using it. The only way for doctors to be heard and therefore shape the discourse is by either going to court or adapting to the standards and the regulations built into the platform. Jameda therefore provides an example of how mediatization or more precisely, mediatized business models, affect the discourse on professionalism at both organizational and occupational levels. Regarding organizational professionalism, the built-in managerial logic of these business models is shown by their way of visualizing and accounting for doctors through ratings and standardized forms of presentation. As for occupational professionalism, it transforms the trust relationship between practitioners and clients since it provides a tool for constant observation, which in some cases, even undermines the autonomy of practitioners. Following Znaniecki's early work on social roles and exclusive knowledge, researchers may classify present-day professionals as licensed "arbiters" (1975, p. 36) who are consulted in doubtful situations, with the belief that they provide technical advice. Their knowledge and skills are thereby inseparably combined in practice, with their tasks at hand typically divided into making a diagnosis, designing a plan and executing it accordingly. In this sense, professionals can be defined as "risk workers" (Horlick-Jones, 2004, 2005 dealing with the uncertainties and the potential risks of their clients. From this perspective, professions can be regarded as occupational and institutional arrangements that are equipped with specific roles for the challenges of dealing with the uncertainties of modern lives in at-risk societies. Professionals are extensively engaged in "doing risks" through their institutional entanglement and use of expert knowledge (Evetts, 2012;Montelius & Nygren, 2014;Nygren, Öhman, & Olofsson, 2015).
Generally, risk can be understood as a phenomenon of modern societies that is closely connected to the differentiation and democratization of knowledge. The ubiquitous status of risk can be described as an unintended consequence of professionalization since it replaced former societal forms of legitimizing knowledge, in which a specific system of beliefs was able to explain and answer almost any given circumstance in life (Alaszewski & Brown, 2007;Berger & Luckmann, 1966). "The less we rely on traditional securities, the more risks we have to negotiate. The more risks, the more decisions and choices we have to make" (Beck, 1998, p. 10). Concerning the field of medicine, this development led to a major change in the doctor-patient relationship (Hitzler & Pfadenhauer, 1999). As opposed to the doctors' status in the 19 th century, when they were able to decide and therefore issue prescriptions from the standpoint of personal authority (Alaszewski & Brown, 2007), today's practitioners are bound to informed consent, supported and regulated by law or in more recent cases, even shaped by predictive technologies and algorithmic decision making (Chorev, 2016). Regarding these developments, doctors are currently closer to becoming informed advisors in terms of how patients can or should deal with their risks. This development has been accompanied by standardization, making vulnerable the body of knowledge circulating within the professions. Ultimately, this corresponds to an erosion of trust in sources of expertise, not only in medical professions, with grave consequences for practitioners and clients alike as this ultimately leads to a structural undermining of expert authority (Horlick-Jones, 2004;Pfadenhauer, 2006). Therefore, we plead for further involving the perspective of risk and uncertainty in the discussion on professions and professionalism.
A major advantage of including this perspective could lie in overcoming the ideal-typical implications of rationality for professional practice, consisting of identifying, assessing and managing risks. In doing so, it becomes possible to broaden the perspective towards specific risk-management solutions and challenges that have impacts on both relations and practices involving clients, as well as other professional practitioners. This seems especially fruitful since the already addressed variable power and authority of professionals over their clients and the control of their work are heavily bound to these specific risk-management solutions (Freidson, 1986). As Evetts points out, risk-management practices and their implications entail unintended consequences on the prioritization and ordering of work activities, as well as focus on target achievements, to the detriment or neglect of other less measurable tasks and responsibilities, which ultimately challenge the occupational value on which professionalism is grounded (Evetts, 2012; see also Pavlin, Svetlik, & Evetts, 2010). Therefore, we agree with the argument that it no longer seems useful to draw a clearly defined line between professions and other expert occupations (Svensson & Evetts, 2003). Instead, we propose to further include the perspective on risk management and the driving forces for risks in the discussion on professions and professionalism.

Mediatization of professions and professionalism
From this perspective, the apparent risks and risk-management practices can be identified as involving an increasingly frictional interplay among technology, clients and practitioners (Andreassen & Trondsen, 2010;Krieger, 2013;Lupton, 2014). To understand this interplay, researchers need concepts that help contextualize to what extent these risks are related to socio-technological developments. Hence, technologies responsible for this development have to be understood as socio-cultural artefacts. This already implies that apps, platforms and the like are first and foremost socially embedded products of people, with specific histories (Lupton, 2014;Thomas & Lupton, 2016). In this sense, technology-induced cultural change becomes observable as a microprocess affecting human actors and their social relations (Krotz, 2003). To approach the effects of this technology-induced cultural change in the field of professions, the concept of mediatization seems fruitful (Couldry & Hepp, 2013). Although it may initially seem contradictory, this concept's advantage lies in its ability to bridge the often-diverging perspectives on how the complex relation between technology and cultural change should be approached (Knoblauch, 2013). Mediatization is therefore not bound to a clear either/or distinction (Beck, 2003), allowing us to capture the processes that currently blur the boundaries between professions and professionalism. As Livingstone and Lunt (2014) propose, mediatization is most useful as a second-order investigation, which assumes the function of gathering and focusing different perspectives on the relationship between technology and specific socio-cultural contexts, such as politics, education, sports and of course, professionalism. Accordingly, research on the mediatization of professionalism may include perspectives on how technology shapes government policies, practitioner practice, as well as the relationship with clients.
Regarding our example, we introduce some aspects of how we think the mediatization concept helps us understand the pitfalls and challenges accompanied by and responsible for the emergence of mobile health phenomena or the iHealth movement (DeJong, 2013) and its implications for practitioners. Besides Jameda as the example targeting the German market, the apparent presence and availability of online platforms and other technologies, such as apps that distribute medical knowledge, are on the rise. Moreover, the catalogue of digital health technologies influencing practitioners today does not stop there. Ranging from web counselling on platforms (e.g., patientslikeme.com) to 3D-printed prosthetics and apps specifically targeting medical students, these technologies, now more than ever, shape professional practices involving both education and occupational work (Lupton, 2016).
Most prominently, these technologies' impacts on practitioners' risk management can be observed as new participatory possibilities for clients. This especially holds true for chronically ill patients using the Internet and specific platforms for decision-making and care practices, as well as for pregnant women consulting apps for self-diagnosis (Kraschnewski et al., 2014;Thomas & Lupton, 2016). Additionally, the use of online reminders, appointment apps or care-planning solutions shapes today's medicalization, with the promise to improve care and patient compliance (Lupton, 2013). Nevertheless, the discussion on this democratization of healthcare via technology is in danger of being heavily biased with all too optimistic expectations for technological progress (DeJong, 2013). What seems to be left out from this discussion concerns the disruptive forces that are inherent in the spread of these technologies. Not only do practitioners and patients need access to specific resources to be able to get in touch with such technologies, but they also require a certain set of skills to use these correctly. Additionally, the sheer number of apps and platforms available today leaves both practitioners and clients with the challenge to choose one, depending on what they are seeking. Furthermore, the Jameda example points to the major lack of regulation until now. This includes both a jurisdictional framework of how these technologies ought to operate and what their contents should comprise.
Especially, the last point has major implications for the client-professional relationship as it leaves practitioners with the need to adapt to the specifications of a business model. Thus, the impact of digitalization does not stop with the implementation of apps in the everyday practice of medical practitioners or the already established "googling for a diagnosis" (Tang & Ng, 2006). As Lupton points out, the devices and the content produced that go hand-in-hand with digitisation have significant implications for how the human body as an object is negotiated and treated by professionals and laypeople alike (Lupton, 2014(Lupton, , 2015; see also Lupton & Jutel 2015). Furthermore, digitisation challenges a particularly important aspect of professionalism as it undermines professional autonomy.
Autonomy is perceived as one of the core characteristics of professions, yet professions are not rooted in autonomy itself, but it is the socio-historically grounded justification of their expertise and with it, their ability to determine what is wrong with their clients or more generally, with society (Mastekaasa, 2011). Besides the connection between this concept of autonomy and Hughes' (1958) early suggestions on the difference between a licence and a mandate, the socio-historical foundation behind this sort of autonomy is the one affected by the socio-technological change. As soon as practitioners start to suggest that women should use specific apps to influence maternity and future planning for care (O'Higgins et al., 2014;Robinson & Jones, 2014;Rodger et al., 2013;Tripp et al., 2014), and clients start to rate their doctors in terms of waiting time and appointment availability (as they can on Jameda and other platforms), these factors influence the justification of professional autonomy (Thomas & Lupton, 2016).

Conclusion
Focusing on the mediatization of professionalism provides researchers with a perspective from which the socio-technological contexts responsible for the rise and success of digital technologies can be understood as entailing a frictional interplay. Regarding medical practitioners, this frictional interplay involves the commercially driven entanglement and blurring of boundaries between service providers and consumers, which ultimately challenge the professionals' relationship with and authority over their clients. This entanglement is increasingly characterized by "feedback loops" (Lash, 2003, p. 54) between the involved service providers (e.g., app developers and platform operators) and clients, leaving practitioners to react according to the actions of both groups. Such reactions range from providing profiles on rating platforms to dealing with self-diagnosed patients. From this perspective, the resulting risk-management practices play an increasingly meaningful role for research on how professionalism in terms of the legitimation of authority is negotiated in practice. This especially holds true since these services perform a significant function with regard to available information on risks for laypeople (Lupton, 2014;Rich & Miah, 2014). Nevertheless, focusing on either these new services or the way that clients are using them would narrow the perspective on the emerging forms of engagement. Instead, this relationship has to be viewed as built on and constituted by constant processes of negotiation, which to some extent are made visible by the provided technology in doctor ratings, forum posts and personalized or privatized health data. Consequently, the ongoing commercially driven entanglement between business models (e.g., app development and user data-based platforms) and their clients bypasses the traditional dyadic healthcare service encounter in a twofold manner. Either the professionals are consulted only after their clients' self-diagnosis or group diagnosis, or doctors have to abide by the specifications of a business model that targets their clients, leaving them out of the equation. Either way, both these phenomena provide possibilities to negotiate the role and the autonomy of practitioners, with them only playing a minor role (Keeling, Khan, & Newholm, 2013;Robertson et al., 2014). In response, practitioners have to develop specific risk-management strategies according to these challenges. To reveal the effects and the unintended consequences of the mediatization of professions and professionalism, we argue that a perspective on risk drivers and risk management may reveal vital insights to uncover the apparent and emerging socio-technological interplay among rising business models, professional practitioners and their clients.