Medical Sociology Exam 3
Determinants in seeking medical care
*cost! not affordable for many individuals. - for poor: skeptical of medical care
Age, sex, race/ethnic, and class differences in illness behavior, (e.g., physician visits)
*healthcare service use greatest among elderly (65+), infants/children, females
Self-care reasons, components, and trends
*most common response to symptoms of illness reasons: - medical care expense/dissatisfaction - acute --> chronic conditions - alternative options - desire for control of health self care examples: - prevention (vitamins) - detecting problem - self treatment (medication - OTC or home remedies) - manage conditions (blood thinners, insulin, etc.) - consult with healthcare providers
Roles of physician and patient
*unequal status and power between patient and doctor physician has leverage through: - professional prestige (qualifications) - situational authority (expertise) - situational dependency (prescribing privileges) dominant role: physician subordinate role: patient - desire services, have needs, accept/reject/negotiate treatment options doctor patient relations have eroded in recent years
History of physicians and their training: Early ineffective techniques
- before American rev. doctors often ships surgeons, apothecaries - university of Edinburgh in Scotland provided best training - college of Philadelphia: 1st medical school in America - rapid increase in medical schools after 1800, quality of doctors/schools low until 1850 techniques: - bloodletting: could weaken condition - purgatives: caused vomiting - cholera treatments: ineffective - snake oil: topical applications - cocaine: toothaches, sinusitis, depression
Effective communication
- doctors and patients from same classes communicate more effectively - doctors and patients from same race/ethnicity contribute to more patient satisfaction
Golden age of doctoring (1950s)
- doctors has high professional control - increase in prices/overcharging - unnecessary tests/hospitalizations/operations/prescriptions - insurance covered mistakes - major growth industry
Government regulation - Diagnostic-related groups (DRGs)
- established early 1980s - government fee schedules for medicare patients - ceiling on how much gov. will pay
Nurses - Education and training,Trends in nursing, Characteristics of nursing students, Where they work
- largest group of healthcare workers (US) - education: four RN programs - technical/vocational, 2-year associate, 2.5-3 yr hospital based diploma, 4&5 yr university programs (bachelors - largest source of us nurses) - 70% work in hospitals/nursing homes originally a catholic activity (roman catholic nuns): - hospitals poor until late 19th century - form of charity, a calling - did not work under doctor supervision - could refuse to treat patients (unwed mothers, STD's) - low prestige occupation - status and income of nurses increased in 80s
Gender differences in medicine
- male doctors may be insensitive to female patients' needs, decisions may not be in patient's best interests Dr. Elizabeth Blackwell: 1st medical school grad Female physicians: - attend more to patient comments, medical history - more empathetic, egalitarian - better at communicating - may be seen as less of an authority figure More differences: - Women are historically underrepresented in medical school classes due to differences in socialization of boys and girls - Percentage female 1st year med students increasing - Some harassment - Gendered specialties (soft vs hard, geriatrics/obgyn/psychiatry vs surgery/sports medicine)
Health insurance coverage - Variations over time and by age and race
- medicare: 65+ - private insurance - individual, individual's employer, combination *since 2014, individuals with pre-existing conditions can now be covered - insurance coverages has changed overtime (improved 2012 and 2016) + (number and percent uninsured increased 2016-2020)
Florence Nightingale (english protestant) and her teaching philosophy
- nursing role changed in middle of 19th century - trained as nurse in germany - founded hospital for "sick gentlewomen in distressed circumstances" - brought honor, respect and code of behavior to occupation
doctor-patient interaction
- patients more active now, seek several forms of care - doctors take on multiple roles to induce adherence (educator, salesperson, cheerleader, detective) - physicians now deal with more actors (insurance, gov regulations)
Features of professionalism (Goode)
- two characteristics: prolonged/specialized training, service orientation - consolidate professional power: public accepts claims of competence, profession controls membership rather than outside authorities additional: -profession determines education/training standards - recognized by licensure - shapes legislation - high caliber students attracted to income, power, prestige
Six stages of socialization (Davis)
1) initial innocence: desire to care for patient - but feel inadequate - may be assigned minor tasks 2) labeled recognition of incongruity - disconnect between training and expectations - collectively articulate disappointment 3) psyching out - anticipate instructor's intentions and focus on these 4) role simulation (end of 1st year) - perform to elicit favorable responses from instructors 5) provisional internalization 6) stable internalization - identify as professional nurse
Five practices connecting with patients (Drs. Verghese and Zulman video)
1) prepare with intention 2) listen intently, completely 3) agree on what matters most 4) connect with patient story 5) explore emotional cues
Prestige factors (Hall)
1. hospital affiliation - more prestigious hospitals provide better paying practices - best residency (location, networks) 2. clientele - lay referral (fam, friends, neighbors) - professional referral of patients 3. four major groups in inner fraternity and sorority - inner fraternity: knowledge elite (physician-researchers), administrative elite (medical school deans, department chairs, heads of clinics)
Diagnostic and Statistical Manual of Mental Disorders (DSM)
106 disorders in 1952 --> 297 in 2000 --> 341 disorders in 2013
Percent uninsured (in slides)
9.6?
3 interaction models (Szasz and Hollender)
Activity-passivity - seriously ill patient in critical condition, helpless - doctor actively stabilizes patient Guidance-cooperation - patient with acute condition (flu, fracture) - doctor makes decisions that the patient follows Mutual participation (often the norm) - manage chronic conditions - cooperate with checkups, lifestyle changes, medications
Rules of etiquette
Discourage criticism, accountability
Managed care - Double agents and gatekeepers, Patient advocates
Double agents: - work for patients and managed care organization -- become patient advocates for specialized care Gatekeepers: - screens patients before referring for expensive procedures and specialists -- treatment may be delayed or denied
Sick role (Talcott Parsons) - Four aspects
Functional sociologist; writer of The Social System; demonstrated medicine as social control sick role: being sick is undesirable, dysfunctional to individuals and society *works best for acute conditions *needs to be refined, reframed, redeveloped four aspects: 1. exempt from social roles 2. not responsible for illness 3. obliged to get well 4. seek help
Percentage women students in med. school
In 2020/21 about 56% all students entering medical schools were women
Differences between Medicare and Medicaid
Medicare: federal program that provides health coverage if you are 65+ or under 65 and have a disability, no matter your income. Medicaid: state and federal program that provides health coverage if you have a very low income. - longer time in waiting rooms - no personal physician - more bureaucracy - return to home after treatment (living situation may not promote health + healing)
Sickness as deviance
Parsons: Illness is deviant because the actor can no longer, perform a functional role in society
Functionalist perspective
The functionalist perspective: - emphasizes societal-level processes - social systems are interconnected - changes in one part of system changes the others Homeostatic approach to deviance: - maintain function, social order, social control - crime, mental illness are dysfunctional (disrupt social order) - physicians control and maintain social order Sanctions: - moving deviant people to jails, prisons, mental hospitals, juvenile detention, nursing home
Immigrant health coverage
among non elderly US population in 2019: - most lawful permanent residents must wait five years before they can enroll in medicaid - some lawfully present immigrants may quality for emergency services paid by medicaid - some states provide prenatal care to immigrant women
Subordinate position of a nurse to a doctor
applies to nurses, physician assistants, pharmacists, lab technicians, physical therapists. - technical knowledge needs physician approval - typically assist doctor in diagnosis and treatment - less prestige than doctor
Midwives: history, roles
assist mothers in childbirth - one of the earliest forms of care for women - resurgence of midwives for natural birth, home deliveries, drug-free deliveries
Consumerism in health care
attention is shifting to consumer orientation in healthcare
SES and gender as barriers
barriers to doctor-patient interaction: - age, gender, culture, SES interactions SES: - middle/upper class have more personal control: consumer oriented, receive more info, assertive, personalized service - doctors + patients from same classes/race communicate more effectively
Factors in weakening medical profession
beginning of the 21st century saw decline in dominance of medical professions - rising costs - government regulation - corporations in the health market - changes in doctor-patient relationships - smaller gap between physicians and other healthcare personnel
Class differences in symptom IDs (Earl Koos)
class 1: most successful most likely to identify symptoms requiring doctor visit class 2: middle class class 3: lower class less likely to identify symptoms requiring medical attention all classes agreed to seek medical treatment for blood in stool or urine, excessive vaginal bleeding inhibiting factors for lower class: cost, fear, relative need
Social standards and control - Errors in medicine, Iatrogenic illnesses and deaths, Professional Standards Review Orgs (PSROs)
errors: - malpractice complaints are relatively common (peaked in '88 and has since declined) latrogenic (induced medically): - may be due to unsafe procedures, transmit infections, wrong amputation - adverse effects (over or mis prescribe drugs) - .16% of deaths in 2018 are due to complications of medical care PSRO's: - established 1970 - review medical care of medicare, medicaid patients
Registered Nurses (RNs)
licensed registered nurses (RN's): supervise practical nurses, follow doctors instructions to care for patients licensed practical nurses (LPN's): care of patients at bedside
Cultural differences
low income, less educated hispanics (and some asian immigrants): - speak little english - uncomfortable in impersonal settings - no regular source of care - difficult to navigate through healthcare system immigrants may not quality for health insurance compared to whites: - blacks less frequently referred to specialists - hispanics receive less treatment for diabetes different cultural perspectives may create difficulties with interactions
Consumerism in healthcare
lower class: - fate at mercy of environment - fatalist attitudes middle/upper: - make informed choices about available services - can alter environment
Gender differences in heart attack diagnoses
male doctors may misdiagnose heart attacks in women (different symptoms than men)
Medicalization and Pharmaceuticalization
medical institution can control deviance - medical professional expands boundaries of conditions that may not be medical (cosmetic) - managed care can limit specific services and also support medicalization by covering specific services - ... *increase range and cost of medical care, challenging, but also comes with benefits
Patient compliance/adherence
multiple takes: educator, salesperson, cheerleader, detective
Bio-medicalization
new computer technologies can expand surveillance and treatment through: - genetics - bioengineering - individualized drugs - patient databanks - digitized patient records - chemo prevention *increase range and cost of medical care, challenging, but also comes with benefits
"Doctor-nurse game"
nurses do not directly challenge doctor's orders - informal interaction - support doctor's authority, nurse's subordination - nurse makes indirect recommendations - doctors indirectly asks for recommendation though the doctor nurse game is changing: - more mutual respect + collaboration in recent years - more assertive nurses - more male nurses - more female doctors
Social contagion (Christakis & Fowler)
one's social networks predicts epidemics in their life (drinking, smoking, obesity, happiness)
Importance of Social networks
our social networks can suggest, influence, advice, coerce us into making good/bad health decisions
Gentlemen's agreement (Millman)
overlook mistakes of others - technical errors: made in good faith, less concerning - moral errors: unreliable, uncooperative, more concerning
Timmermans: "The Engaged Patient"
patients have become more engaged in advocating for their own health: engaged patients relates to the rise of the internet as a tool, patient-doctor interaction in epidemics, health inequities
American Medical Association (AMA) - Guiding principles, Flexner Report
physician is independent practitioner: - free of control from public - fee-for-service medical practice flexner report: - three med schools approved (harvard, john hopkins, western reserve) - the report recommended that schools have full time faculty, lab and hospital facilities available to students, students receive education in natural sciences
Lay-referral system (Eliot Freidson)
process of seeking medical help from a group of consultants (family --> friends/neighbors --> professionals)
Germ Theory (Louis Pasteur)
proved that food spoiled because of contamination by invisible bacteria, not because of spontaneous generation
Evidence based medicine
proven diagnostic and therapeutic procedures - reduce uncertainty and doubt - requires applying evidence from clinical trials and population-based studies
Medical decision rule (Thomas Schef)
rather than deny illness, doctors biased in finding illness - may order lab tests and x-rays, prescribe drugs, refer to specialist
Freestanding emergency centers
retail medical clinics: - shopping centers/big box stores - 24/7 hours typically - short waiting time - treat minor ailments - reasonable prices
Sick role (secondary gains; critiques)
secondary gains: - exempt from responsibilities - gain some privileges (access to drugs) - financial gains (claiming sick for welfare/gov assistance) - social security (eligibility if disabled) critiques: 1. behavioral variation - sick role does not apply to minor conditions - varies by age/gender 2. varies by disease - may only apply to acute/chronic disease/incurable/long term conditions - does not apply to conditions such as diabetes (managed condition) 3. patient/physician relationship - dependent on setting - assumes one on one interaction 4. stigmatized individuals - mental illness - cancer (social rejection, impaired image of body) - STD's *fewer research $ on lung cancer deaths than colon or breast cancer 4. oriented toward middle class - lower class tend to deny sick role (cannot take work leave, may be poor due to illness, may use sick role to avoid work, may not be exempt for work)
New technology in medicine
shift from biographical medicine --> techno medicine: - focus on patient oral accounts of medical history --> technology use for testing/diagnosis/determination of treatment health apps: - claim expertise, algorithmic authority - monitoring devices, telehealth, prescription ordering, health info - online healthcare can be helpful for stigmatized and emabrassed individuals + support groups online
Nurse Practitioners
similar to physician assistant - often supervised by off site physician who's on call - may be increasingly common with: affordable care act and primary care centers in retail stores (target, walmart, cvs) - treat minor injuries, vaccines, chronic, prescriptions)
Physician socialization - Medical education
socialization: - increasing diversity among 1st year students - biology, chem and pre med are common undergrad degrees - businesslike demeanor, emotional investment in patients - tolerate uncertainty
Pharmacists
specialize in the preparation and dispensation of drugs - need authorization from a doctor - supplement rather than challenge healthcare practitioners
Physician assistants (PAs)
working under the supervision of physicians - provides primary medical care - mostly women
