Medical Sociology Exam 2

Oswald Hall: 3 Important factors in establishing prestige within the medical profession

(1) hospital affiliation - reputation of its program is prestigious (2) clientele - retaining and improving it - the lay referral system channels the patient to certain doctors but also helps the patient to make a decision about returning - goes home and discusses the doctor's decisions with their family - Best medical practice is the specialized practice because he believed that the specialist was accorded superior status by others in the medical profession; requires referrals from other doctors (3) inner fraternity - - operated to recruit new members - allocate them to positions in medical institutions - help secure patients through referrals

Guidance-cooperation model

- Arises most often when the patient has an acute, often infectious illness, such as the flu or measles - Patient knows what's going on and can cooperate with the physician by following his or her guidance, but the physician makes the decisions

Hospital Administration and RNs

- Evolution of the RN into an administrative role o Greatly reduces or eliminates the contact with patients for which nursing was organized in the first place

Communication Problems:

- Young doctors may use lots of difficult terminology when speaking to patients - Differences between physicians and their patients with respect to status, education, professional training, and authority - Failure to explain a patient's condition to the patient in terms easily understood is a serious problem - Inability to understand the potentially negative effect of threatening information

Deprofessionalization of Physicians:

- due to increased consumerism and greater government control over medical practice - patients insisting on greater equality

Steven Rank and Cardell Jacobson - Valium experiment

- experiment on having an assistant telephone 18 nurses and order them to administer a nonlethal overdose of Valium to appropriate patients o None of the nurses questioned the telephone request, and all but one suspicious nurse entered the request on a medication chart o 16 out of 18 nurses decided not to administer the Valium o high rate of noncompliance was because of an increased willingness among hospital personnel to challenge a doctor's orders in contemporary medical practice

"The Doctor-Nurse Game"

- extremely effective informal interactional style with physicians o Object - for the nurse to be bold, show initiative, and make significant recommendations to the doctors in a manner that appears passive and totally supportive of the super physician Rule - avoid open disagreement between the two o Requires the nurse to communicate a recommendation without appearing to do so, while the physician, seeking a recommendation, must appear to not be asking for it o Must both be aware of each other's nonverbal and verbal styles of communication

Inner fraternity

- how doctor's support each other - won't testify against each other typically - operated to recruit new members - allocate them to positions in medical institutions - help secure patients through referrals

Pharmacists

- women dominated field - able to rotate your schedule around - pays very well

Howard Becker "Boys in White"

- wrote a book about medical students + followed them through their rounds for a year Observed = - situational adjustment - as we go through life, we adjust to new situations - commitment = doctors/med students become cynical about things; gain appreciation for helping people = commitment

Criticism of the "Sick Role"

1. Behavioral variation - lack of uniformity among social groups 2. Types of disease - only applies to acute diseases which are temporary and easily overcome (unlike chronic diseases) 3. Patient-physician relationship - based on a traditional 1:1 interaction; different in the hospital where there is a team of physicians 4. Middle Class Orientation - emphasizes individual responsibility, strive toward good health and return to normality - fails to include what it's like to live in poverty

Criticism of Labeling Theory

1. Doesn't explain what causes deviance 2. Doesn't address other correlations to deviant acts besides social reaction 3. Doesn't address why certain people commit deviant acts and others in the same situation do not

Factors that promote self care:

1. High cost of medical care 2. Depersonalized medical care 3. Limits of medicine 4. Awareness of alternative medicine 5. Knowing about the effects of lifestyles on health 6. Desire to be in control

Parson's "Sick Role" Categories -

1. Person is exempt from "normal" social roles 2. Not responsible for his or her condition 3. Should try to get well 4. Should seek help + cooperate with a physician

Stages of illness experience

1. Symptoms 2. Parson's sick role - no normal routine 3. Seek medical attention (options/consultation) 4. Become a dependent patient 5. Rehabilitation (comply with what doctor suggests)

Mechanic factors to determine whether or an individual will seek medical care -

1. Visibility + recognition of symptoms 2. Extent to which they seem dangerous 3. Disruption of activities 4. Frequency and persistence of symptoms 5. Tolerance 6. Education 7. Needs that lead to denial 8. Competing interpretations 9. Availability of treatment resources

Oswald Hall: 4 Major groups within a hospital

1. inner core - specialists who have control of the major hospital positions 2. new recruits - at various stages of their careers 3. general practitioners - lined to the inner core by the referral system "friendly outsiders" - women physicians (not members of the inner core) 4. marginal physicians - practices are less successful and would remain on the fringes of the system

AMA

American Medicine Association (1847) - founded in Philadelphia - became the single greatest influence on the organization and practice of medicine in the US - most physicians today don't belong to the AMA - conservative/expensive - Less than 1/5 of all women doctors belong to the AMA

Parson's Physician-Patient Role Relationship -

Basic mutuality of social norms - physician's role = return sick person to normal state - patient's role = recognize that being sick is unpleasant and is obligated to get well by seeking help - status and power are not equal; which is necessary for a physician to promote change

Sue Fisher - Male Doctors

Call for greater insight on the part of male doctors in dealing with female patients and their complaints

Biomedicalization

Capability of computer information and new technologies to extend medical surveillance and treatment interventions - through internet and advertising - commercialization of health products

EBM

Evidence based medicine - helps to reduce uncertainty among medical students ♣ Utilizes clinical practice guidelines, providing highly step by step instructions on medical care that the students can refer to in clinical situations ♣ Based on proven research

Type 2 Error

False negative - Initial tests show no problem; but you actually have something - May be too late when you figure it out

Type 1 Error

False positive - Doctor tells you that you have a problem when you really don't - Causes them to do additional tests

Pharmaceuticalization

Growth of drug markets internationally through large scale advertising campaigns

Roy Porter - Westernization of medicine

He finds that the healthier Western society becomes, the more medicine it craves and the greater the tendency on the part of the public to demand maximum access to it

Culture of Poverty

If they don't work, they don't get paid; more likely to show up to work when sick - feeling of fatalism - gratification is immediate, no planning for the future

Freidson's Notion of Legitimacy -

In illness states there are 3 types of legitimacy: 1. Conditional legitimacy - deviants are temporarily exempted from normal obligations and gain privileges (ex. common cold) 2. Unconditional legitimacy - deviants are exempted permanently from normal obligations and are granted privileges in their hopeless nature (ex. terminal cancer) 3. Illegitimacy - deviants are exempted from some obligations, but gain few (if any) privileges, and take on handicaps as a stigma (ex. stammer or epilepsy)

Doctor-patient Interaction

It's the patient's experience with the illness, including the relationship with the physician that allows the person to socially construct his or her understanding of an affliction and how to deal with it

Growth of medical professions

MD's 36% NPs 42% D.C. 103% PA 107% D.O. 103% RN 59% Increase in physician assistants, osteopathic doctors, and chiropractors Major increase and need for nurses

________ was the first medical school in the south.

MUSC (1824)

Medicalization

Medicine's task to control abnormal behavior by medical means on behalf of society - protect's the publics health - promotes social stability - deviance is seen as sickness

Largest single group of health workers in the US

Nurses

The Functionalist Approach to Deviance: Structural functionalism

Society is held together in a state of equilibrium by patterns of shared norms and values - expectation that all will behave in accordance with the norms and values - sickness interferes with this = deviance

1st Medical School in US -

University of Pennsylvania (1765) - you could just pay and get into med school - would have been better to go to a religious doctor during this time

Scribes

Write down all that happens within the surgery - helps to look back at all that happened

Compliance

You do what you're told to do; no point in going to the doctor if you will not comply • Compliance requires comprehension by the patient and communication is key for avoiding noncompliance

Disease

adverse physical state; physiological dysfunction

Middle and upper class SES tend to be more ___________ - oriented when it comes to doctors.

consumer

We are changing to a _____________ view when it comes to choosing a doctor.

consumer

Medicine is shifting towards doctor's working for ____________.

corporations or HMO's (Health Maintenance Organizations)

Passivity __________ in nonemergency situations.

decreases

The Sick Role views illness as ___________.

deviance

Labeling Theory

how the self-identity and behavior of individuals may be determined or influenced by the terms used to describe or classify them. It is associated with the concepts of self-fulfilling prophecy and stereotyping

Melvin + Teresa Seeman

low sense of internal control = less self initiated preventative care, less optimism, poorer self rated health, more illness, greater physician reliance

Having a medical doctor in the family makes you _____ likely to become a doctor.

more

self care

most common response to symptoms of illness - self initiated and self managed

Eliot Freidson's "lay referral system"

non professionals, family members etc., who assist individuals in interpreting their symptoms

Midwives

nurse and lay midwives - 1600s = delivered babies with no training - started to wane with specialized medicine - lay midwives = no training; work from practice; no MD standing by - huge risk - in home delivery

Changes in medical education in the 21st century

o # of male applicants has declined almost 50% since 1975 o med school classes are no longer composed almost entirely of white males o females and racial minority students have taken their place o students from diverse backgrounds (more likely to take a humanistic approach to patients)

Greatest impacts on the autonomy of the medical profession is due to:

o 1. Government regulation - rising health care costs called for government intervention - establishment of DRGs - schedules of fees placing a ceiling on how much the government will pay for specific services - the state shifted its primary allegiance from professional interests to private interests - organized medicine has lost the power to determine health policy o 2. Managed care system - reducing the authority of physicians - systems that control the cost of health care by monitoring how doctors treat specific illnesses, limit referrals to specialists, and require authorization prior to hospitalization - doctors have to work in accordance with these regulations - can disrupt doctor patient relationships, take deep discounts out of fees, and produce large profits without developing good clinical care - means a significant reduction in authority to make referrals and choose modes of treatment o 3. Corporations in the health care business - large, for profit companies came into the health care business and created beautiful hospitals that are very expensive - physicians employed here are bound to the rules of the corporation (which are people trained in business, not medicine) - their goal is to attract patients with private health insurance that will cover the relatively higher charges of profit-making hospitals - Development of free standing emergency centers • Take business away from hospitals • Convenient locations; quick; open 24 hours - Starr states the limits of growth • The poor will not benefit • No control over retirement; more regulation + evaluations o 4. Changes in the traditional doctor-patient relationship - Leo G. Reeder - one of the first to show this change • 3 significant trends in society o 1. Shift in medicine away from the treatment of acute diseases toward preventative health o 2. Growing sophistication of the general public with bureaucracy o 3. Development of consumerism

Fred Davis: 6 Stages of Socialization for nursing students

o 1. Initial innocence - nursing students wanting to do things for patients within a secularized Christian-humanitarian ethic of care and kindness; mother surrogate image of nursing ♣ feelings of inadequacy, worry, and frustration o 2. Recognition of Incongruity - nursing students begin to collectively articulate their disappointment and openly question their choice of becoming a nurse o 3. Psyching out - nursing students attempted to anticipate what their instructors wanted them to know and to concentrate upon satisfying those requirements o 4. Role simulation - students performing so as to elicit favorable responses from the instructors ♣ exhibition of an objective and detached attitude toward patient care o 5. Provisional internalization - (last two years of program) o 6. Stable internalization - (last 2 years) ♣ in provisional and stable - took on a temporary self-identity as a professional nurse and settled into this identification by the time of their graduation

Mutual participation model

o Applies to the management of chronic illness in which the patient works with the doctor as a full participant in controlling the affliction The patient often modifies his or her lifestyle by making adjustments in diet or giving up smoking, etc

Activity-passivity model

o Applies when the patient is seriously ill or being treated on an emergency basis in a state of relative helplessness, because of severe injury or lack of consciousness o Decision making is all on the side of the doctor

The Davis Study

o Found that many students did not see nursing as their life goal o They held views that marriage and children were more important o Contingency of marriage became the decisive factor upon which all other decisions were based

Intrusion of third-party players on the traditional doctor-patient relationship:

o Government (medicare, Medicaid) o Private health insurance o Managed care programs - These entities monitor the number of patients seen by physicians and the amount of time spent with them o Relevant factors - - Shift in the state's role from protecting the medical profession to protecting corporate health care interests to reduce costs - Proliferation of commercial products for the body that the patient can use independent of the physician - Rise of chronic disease, which promotes the demand for a long term doctor patient alliance

Irving Zola's comparison of Irish and Italian American patients in the presentation of symptoms:

o Irish patients tended to understate their symptoms where Italian patients tended to overstate them Hispanic, Chinese, Korean, and other immigrants with limited English have trouble in these situations

Journal of the AMA

o Latest medical knowledge o Promoted awareness among the members of the AMA of their allegiance to the medical profession

Sam Porter

o Porter worked as a nurse o Conducted a participant observation study of the nursing staff at a large urban hospital o Found that many nurses now regard their employment as a career o With the increasing perception of nursing as a career, the notion that nurses regard their first priority as finding a spouse is out of date

William Goode: 2 basic characteristics of professionalism

o Prolonged training in a body of specialized and abstract knowledge o Orientation toward providing a service

Information can be a tool in medical situations if it meets 3 tests:

o Reduces uncertainty o Provides a basis for action o Strengthens the physician-patient relationship

Renee Fox

o Two traits of a medical student ♣ Ability to be emotionally detached from the patient ♣ To tolerate uncertainty

Abraham Flexner

o Visited every medical school in the country and issued his famous "The Flexner Report" in 1910. o He noticed the lack of quality medical education in the US o He recommended that - medical schools should consist of full time faculty, standards and qualifications for acceptance into medical school should be raised, should be conducted on a graduate level. o Flexner wanted medical schools to be apart of universities where medical students could receive a strong education in the natural sciences

Doc in the Box

open 24/7 always a doctor on call very convenient wait in line

Lower class persons tend to be more ________ in dealing with doctors as authority figures.

passive

Social networks

people who belong to exclusive groups are: A. more likely to seek medical care (if within beliefs) B. less likely to seek medical care if their beliefs support skepticism

____________ educated are the most likely to have their questions ignored and to be treated impersonally.

poorly

Sickness

social state; impaired social role for the ill

Illness behavior is a __________ and culturally learned process.

socially

Illness

subjective state; individual's psychological awareness of having a disease

Earl Koos's "The Health of Regionville"

supported the idea that low income people visit the doctor less however, by 1970, the poor had the greatest utilization! - people with lower SES are more likely to frequent ERs - more likely to turn their illness over to the doctor - more passive - fatalistic attitudes

Lower class and _________ have had the most communication problems with physicians.

women

Internet Medicine

• Apps for medical problems • Spread of health information via social media • Electronic support groups - social support Robotics and computer guided imagery may increase efficiency and precision in surgery and reduce the need for extensive hospitalization

New Genetics

• Can determine a person's genetic probability for cancer, etc. • Human Genome Project - provided researchers with a map of the human genetic code o Genetic information is potentially valuable to employers, insurance companies, etc. o Opens up the possibility for discrimination • Prenatal genetic screening o Option of abortions for fetuses identified with gene defects • Human cloning - o Either therapeutic (cloning of organs for transplantation) or reproductive (cloning of people themselves)

Florence Nightingale

• English protestant who wanted to be a nun but then decided to be a nurse because she was not Catholic • She established a hospital for "sick gentlewomen in distressed circumstances" • She offered her and her nurses services to the British military • Then instigated a fund raising effort in order to create a nursing school at St. Thomas Hospital in London - became the model for nursing education

Nursing Education

• Florence Nightingale developed these schools • The new nursing schools were affiliated with hospitals that provided financial support • Increasing number of women entered the labor market as a result of immigration from abroad or migration from rural to urban areas • Respectable position in their community • In the beginning of the 19th century nurse's students were seen as inexpensive and exploitable sources of hospital labor • Trend - all RNs have a bachelor's degree • Nursing as a career has been enhanced because of the Affordable Care act which increased the amount of patients into the nation's health care system on a regular basis

Rose Weitz - ICU doctors

• ICU doctors were unwilling to share decision-making authority in the case of her brother in law o The doctors preferred talking to the father but did not receive much more information or decision making o Although sometimes this is the case, mutual participation is the norm in most doctor-patient interaction

Control of Medical Education

• In the beginning - anyone with money could pay to go to medical school • The AMA established the Council on Medical Education to improve education • Abraham Flexner o Visited every medical school in the country and issued his famous "The Flexner Report" in 1910. o He noticed the lack of quality medical education in the US o He recommended that - medical schools should consist of full time faculty, standards and qualifications for acceptance into medical school should be raised, should be conducted on a graduate level. o Flexner wanted medical schools to be apart of universities where medical students could receive a strong education in the natural sciences

Women Physicians

• Increasing number of women physicians • Female physicians tend to be more empathic and egalitarian in their relationships with patients • Patients feel more of a partnership with their physician when it's a woman

Paul Atkinson

• Key feature in the consultation is the physician's dominant role in the encounter and the assertion of control • Lower class patients have difficulty in holding the doctor's interest

Male Physicians and Women Patients -

• Lack of male sensitivity • Sexist attitudes Tendency to misdiagnose heart attacks for stomach or anxiety problems

Doctor patient relations and new technology

• Medical databases allow people to obtain medical information online rather than from their doctor • Electronic monitoring devices • Physicians can be consulted by computers - skype, teleconferencing • Prescription drugs can be ordered online • Medical practice has been more dependent on technology

Early development of nursing as an occupation

• Nursing was originally a volunteer service • Nurses were told they could attain spiritual salvation by helping those less fortunate • Distinctly middle-class occupation

William Goode: Professionalization

• Once public acceptance occurs - o The profession determines its own standards of education and training o The student professional goes through a more stringent socialization experience than the learner in other occupations o Professional practice is often legally recognized by some form of licensure o Licensing and admission boards are staffed by members of the profession o Most legislation concerned with the profession is shaped by that profession o As the occupation gains income, power, and prestige, it can demand high-caliber students o The practitioner is relatively free of lay evaluation and control o Members are strongly identified by their professions

Mary Boulton - Social distance

• Social distance • Patients who are similar to physicians in social class are more likely to share their communication style and communicate effectively

Medicine in the Mid 20th century:

• Time of escalating prices and over charging; unnecessary tests; surgical operations, etc. • Physicians incomes were 7 times the national average • Light + Hafferty - countervailing power = to show how the medical profession was but one of many powerful groups in society - the state, employers paying for health insurance, patients, and medical complex - all competing to fulfill its interests in health care o These other entities ended the monopoly that was the medical field o Weakened through an over supply of doctors + the lack of success at resisting government controls

Osteopaths

• Work with physicians with the added skill of training in spinal procedures • Founder: Andrew Taylor Still o Believed that illness was caused by a dislocation of one or more bones in the spinal column and that a pathological condition in one of the body's organs affects other organs

Marie Haug + Bebe Lavin found that -

• better educated and younger adults tended to be more skeptical of physician motives in providing treatment More likely to question the doctor about tests

Deprofessionalization

• decline in power which results in a decline in the degree to which professions possess, or are perceived to possess, a constellation of characteristics denoting a profession. o Decline in a profession's autonomy and control over clients

Peter Conrad

• medicalization is a form of collective action in that patients seek medicalization of their problems • Have evolved to advocate more medical intervention (ex. Aids, PTSD)

RNs

• responsible for the nature and quality of all nursing care patients receive, as well as for following the instructions of physicians regarding patients o Supervise practical nurses and other health personnel

Candace West - Women Physicians

• some patients may perceive women physicians as less of an authority figure than male

Howard Waitzkin

• studied information given in medical care and found that social class differences were the most important factors in physician-patient communication SES became a factor in both providing and receiving medical information

Freidson: Social control of Medical Practice

• the choices of clients act as a form of social control over professionals and can mitigate against the survival of a group as a profession or the career success of particular professionals • Freidson found that rules and standards existed to define the limits of acceptable performance by physicians associated with the group - norms governing colleague relations restricted the evaluation of work and discouraged criticism o Etiquette was more important than accountability o Confrontation with a colleague was considered distasteful

Oswald Hall

• the decision to study medicine is largely social in character; it originates in a social group that is able to generate and nurture the medical ambition

Freidson

• those of lower SES are not likely to be difficult patients o Higher status have the potential to be a serious challenge o Americans have become more knowledgeable about medicine and are more likely to question

Edward Shorter

• traced the social history of the doctor-patient relationship o Medical profession evolved from being a relatively low-status occupation to a highly respected scientific field o Have seriously eroded in recent years

Stein, Watts, and Howell

♣ - reexamined the doctor-nurse game later and determined that a different situation exists o Nurses are no longer willing to be treated as mere subordinates by physicians o Due to ♣ Declining public esteem for doctors because of questioning of the profit motive in medical practice ♣ Increased # of women doctors ♣ nursing shortage has emphasized to doctors the value of highly trained nurses ♣ most nurses today are educated in academic settings ♣ women's movement may be encouraging nurses to define their own roles with greater autonomy o Men comprise about 6% of all RNs ♣ Not as likely to play the doctor-nurse game

Transition in health care delivery due to:

♣ A system run by doctors to one shaped by the purchasers of care and competition of profits ♣ Decline in the public's trust ♣ Change in emphasis on specialization to primary care and prevention ♣ Less hospital care to more outpatient care in homes ♣ Less payment of costs incurred

Nurse Practitioner/Clinician

♣ RN trained in diagnosis and management of common ailments needing medical attention ♣ Provide some of the same care as physicians