health and illness exam 3
Mid 20th century
"golden age of doctoring"
Light's countervailing powers and which powers have weakened the medical profession's control, and how have they done so:
- As Light (1979) pointed out, in emphasizing clinical judgements and techniques, physicians run the danger of becoming insensitive to complexities in diagnosis, treatment, and relations with patients. The results can be errors and malpractice suits - Light (1979:320) explains "their emphasis on techniques can make them oblivious to the needs of clients as clients define them: yet it is clients' trust that professionals will solve their complex problems which provides the foundation of professional power" - Medical education is having to adjust to new realities in medical practice
Reeder's significant trends in the changing relationship between physicians and their patients:
- The shift in medicine away from the treatment of acute diseases toward preventative health services - intended to offset the effects of chronic disorders - The growing sophistication of the general public with bureaucracy - the development of consumerism
Doctors are moving from being the absolute authority in medical matters toward having lessened authority
-Many patients insisting on greater equality in the doctor-patient relationship and corporate health organizations that employ doctors seeking to control costs, maximize profits, and provide efficient services that are responsive to market demand, physicians are caught in the middle
Light's countervailing power thesis (other sources of power)
-doctors are one of many powerful groups in health care ex. health care insurance, government -internally weakened (over supply in some places, uneven)
More impact by external sources
-government regulation -managed care (insurance) -the corporation (dr. are employees of company) they get benefits and regular hours
Problems with the argument:
-laypersons do judge performance of doctors -efforts at peer control are limited (rare in meetings to criticize each other)
part of the problem is in professionalism of medicine:
-restricted view of disease -rigid stratification system -separation of professional training
culture/ethnicity
-symptoms/language - a factor in both receiving and providing information -patients with different cultural background than doctors it can be hard on both sides and lead to misunderstanding on both sides
William Goode (1957) noted two basic characteristics are sociologically relevant in explaining professionalism
1. prolonged training in body of specialized and abstract knowledge 2. an orientation toward providing a service
public acceptance of claims to competence and the profession's control of its membership occurs Goode believes that additional features of the profession can be established
1. the profession determines its own standards of education and training 2. the student professional goes through a more stringent socialization experience than the learner in other occupations 3. professional practice is often legally recognized by some form of licensure 4. licensing and admission boards are staffed by members of the profession 5. most legislation concerned with the profession is shaped by that profession 6. as the occupation gains income, power, and prestige, it can demand high-caliber students 7. the practitioner is relatively free of lay evaluation and control 8. members are strongly identified by their profession
nearly ______ of the health care workforce is in the allied health care professions
60%
Advanced
Advanced practice registered nurses (APRN), nurses practitioners (NP), nurse anesthetists (NA), clinical nurse specialists (CNS)
American medicine lagged behind
Europe
Auxiliary Nursing Personnel
Nurses' aides/certified nursing assistants (CNA), orderlies, attendants
Regular
Registered Nurse (RN) and licensed practical nurse (LPN)
contractual model
a contract built up (not literal) dr. and patient come to agreement of obligations and responsibilities (integrate values, balance decision making)
Deprofessionalization means
a decline in a profession's autonomy and control over clients
Deprofessionalization:
a decline in power which results in a decline in the degree to which professions possesses, or are perceived to possess, a constellation of characteristics denoting a profession" (a decline in a profession's autonomy and control over clients)
when a patient is seriously ill the _____ style of doctor-patient interaction applies according to Szasz and Hollender (1956)
activity-passivity
Hall found that _____ represented a crucial point in the career development of the urban physician
affiliation with a prestigious hospital
medical practice is organized in a free market system
also a business, capital investment, supply and demand, bought and sold
Freidson argues that it can be ____ that physicians are dedicated to their parents
assumed
veatch (1991)
based on values of doctors and patients
john Hopkins university
became the model
most common forms of social control are missing
bureaucratic supervision
mutual participation model
chronic illness, patient works w/ dr. as full participant, work together (long term)
work ______ with physicians, nurses, dentists, and pharmacists
collaboratively
more emphasis on ______ in medical schools now
communication
changes over time in ___________ affect education
conceptualization of medicine and medical practice
Shortner's (1991) social history of doctor-patient relations
concludes they have eroded in more recent times
Emanuel and Emanuel (1992)
consider difference in information providing and relationship with patient
Inner core
controls majority of hospital positions, sig. factor
females doctors are treated _____ by male patients and colleagues
differently
problem solved:
doctors are members of self-controlled collectivity that fills a vital societal function, so professional autonomy is justified (drs. police themselves)
collegial model
dr. and patient agree among common goals, colleige --> equal status
interpretive model
dr. cabinet advisor, within values of that leader (this case of patient)
deliberative mode
dr. combination of teacher and friend gives all options but incorporates values
priestly model
dr. more of father figure; gives out all options but ultimately makes the decision
The inner fraternity
dr. part of leadership in hospitals and AMA, considered good at your practice
activity-passivity model (desperate)
dr. works hard to stabilize patient/dr. makes decisions
major barriers to _____ communication between doctors and patients
effective
American Medical Association (AMA)
established in 1847 was an important step in development of the medical field in the U.S. - expanded and protected rights and privileges of doctors - sometimes perceived as a protective trade association (organization doesn't speak for all doctors) - has lost power, but still has influence
Flexner Report (1910)
evaluation of medical school --> should have modern lab facility, quality full time faculty, students meet fine set of criteria to get in and then to graduate - at time 162 medical school and after only 31 stayed open and only three meet criteria (Harvard, Case Western, John Hopkins) report had impact -- resulted in 81 medical schools with criteria
common form of communication (by doctor)
evasion
in non emergency situations, patients are not necessarily passive
ex. that expensive with my insurance can we change prescription
Hayes-Bautista (1976)
focuses on how patients modify a physicians prescribed treatment ex. when patient is dissatisfied, dr. tries to convince (negotiation) limited to situations in which a patient is dissatisfied
in a managed care system, the ____ function of the primary care physician also has a direct effect on the patient's experience
gatekeeper
are genes commodities or property rights?
general rule of law -- genes are naturally occurring organic matter, not something invented by humans and therefore cannot be patented
lower income status patients
give less info
higher income status patients
give more info
informative model
give technical info but decision left entirely to patient
"golden age of doctoring"
had a lot of power and authority, self monitoring
physicians now enjoy
high status in society
Hall's factors in establishing prestige (in an urban medical career):
hospital affiliation clientele the inner fraternity inner core new recruits institutional position
separation of professional training
if all started with same foundation and then branch out --> then wouldn't have gap and challenges interacting with other health care providers
The process of deprofessionalization:
increased consumerism on the part of patients and greater government and corporate control over medical practice have resulted in the decline of the professional status of physicians
______ is the most significant element in the power structure of the American medical profession
institutional position
female doctors receive
less response but they listen more and ask more questions
process to become a doctor is
long, difficult and costly
Quality of education and prestige was
low
SES affect doctors/patents
low income patients tend to be more passive
bureaucratic supervision
missing judgement from recipient of services and someone overlooking (judgement of recipients)
professional autonomy argument:
most common forms of social control are missing
Friedson's professional dominance theory (botany and control) in 20th century
no longer an adequate theory
largest single group of health care workers in the U.S.
nurses
patient distress may not be
only physical
guidance-cooperation model
patient has acute/disease - dr. makes most decisions, but patient is involved
engineering model
patient ultimately decides, dr. provides "blue print" all info and options
evasion
patients asks question and dr. gives answer in a way patient cant understand it
rigid stratification system
physician elite health care provider, nurses and aids etc. part of health care team the dr. is still the supreme
quality of interaction can be problematic
potential to affect care
economic considerations have became a
primary motivation among doctors
history of the profession
prior to early 20th century, American medicine did not have a specialized body of knowledge
restricted view of disease
really restricted, treating disease/body not as a person
SES is a factor in both
receiving and providing info
the technique known as evidence-based medicine has resulted in improvement for medical students in
reducing uncertainty in the application of medical knowledge
professionalism
service orientation and training in a specialized body of knowledge = professional power and status
boulton and colleagues
social distance concept interaction significant affected
medical students go through a
socialization process
SES
socioeconomic status
the flexner report advanced the establishment of
standards for medical school admissions, faculty and facilities
clientele
starts with hospital affiliation, being referred
more and more female doctors, more _____
stigma
medical decision rule (Freidson)
tendency of physicians to ascribe illness to patients, rather than possibly miss something
there are at least a few significant defects in the argument that the medical profession's autonomy is justified and legitimate. Which one of those defects is exemplified by the American Medical Association's resistance to measures for cost containment?
the autonomy granted to the medical profession is granted conditionally, on the assumption that they work in favor on public interest
which of the following is NOT a trend in contemporary society affecting the physician-patient relationship, as identified by Reeder?
the expansion of free-standing emergency centers
Deprofessionalization has led to greater control and monitoring systems by
the government seeking to control costs, businesses attempting to constrain the expenses of employee health care, and insurance companies and profit-seeking health care corporations looking to maximize income
human cloning
therapeutic - the cloning of human organs for transplantation in sick people reproductive - the cloning of people themselves
recognized as potentially an important
therapeutic tool
Nurses, Physician Assistants, and other Health Care Professions
there is a wide range of health care personnel, in a fast growing field
the reason for choosing a medical career most frequently given by medical students is generally that
they want to help people
hospital affiliation
to be successful dr. have association with more important hospitals ex. universities, research hospitals
gene therapy
to treat and cure disease by giving patients healthy genes to replace defective ones
Szasz and Hollender (1956)
type of interaction depends on severity of the patients symptoms
Changing physician-patient relationships --
use internet to get information, online support, more active with doctors and more distrustful with them
institutional position
what is important in their career, professional organization related to their field/speciality
New recruits
what to do to get into inner core etc., often specialists
significant changes in medical education include more:
women, diversity, minorities
paternalistic model
work in benefit of patient, still have involvement but dr. makes decision
