Medical Sociology

Six stages of socialization

(Fred Davis 1972) •Initial innocence -desire to care for patient -But feel inadequate -May be assigned minor tasks, such as making beds •Labeled recognition of incongruity -Disconnect between training and expectations -Collectively articulate disappointment -Openly question their choice of becoming a nurse -Some drop out of school •Psyching out -Anticipate instructor's intentions and focus on these •Role simulation (end of 1st year) -Perform so as to elicit favorable responses from instructors •Provisional internalization •Stable internalization -Identify as professional nurse

Gentlemen's agreement

(Millman) •Overlook mistakes of others -Technical errors, made in good faith, less concerning -Moral errors —unreliable, uncooperative, more concerning »Subject to sanctions

Prestige Factors

(Oswald Hall) 1. Hospital affiliation -More prestigious hospitals provide better paying practices -Best residency •Program reputation and location •Internship in same community for planned practice •Friendships, professional networks 2. Clientele -Lay referral (family, friends, neighbors, coworkers) •Discuss Drs.' behavior, diagnosis, prescriptions •Reputation, popularity -Professional referral of patients -Hospital connections -Managed care restricts referrals 3. Inner Fraternities' major groups •Inner core controls central hospital positions •New recruits pegged to inherit inner core •GP's tied to the inner core through referrals •Marginal doctors with less successful practices who are not well connected

Free standing emergency centers

A facility licensed by the state to provide 24-hour emergency services to patients at the same level as a hospital-based emergency room.

AMA

AMA Founded in 1847 in Philadelphia •15% of qualified physicians were members in 2011 •79% of qualified doctors were members in 1963 Nonmembers don't need benefits •Armed forces, researchers, universities, government

Superior position and prestige of physicians

Applies to nurses, pharmacists, laboratory technicians, physical therapists: -Technical knowledge needs physician approval -Typically assist doctor in diagnosis and treatment -Subordinate to and work at request of doctor -Have less prestige than doctor

Louis Pasteur

Germ Theory, French

Golden age of doctoring

Golden age of doctoring (1950s) -High professional control -Increasing prices and overcharging -Unnecessary tests, hospitalizations, prescriptions, operations -Provider structured insurance paid for most mistakes -Major growth industry

Alternative tracks

Mid-level provider: •ANP (advanced nurse practitioner) •PA (physician assistant) Advantages: •Less time to complete education •Less cost of education •Many nurses start as RNs and progress to BSNs and NPs while still working; companies such as Kaiser Permanente have programs to pay for their education while they are employed Disadvantages: •Less autonomy (must practice under a physician)

Patient advocates

Supporter, believer, sponsor, promoter, campaigner, backer, or spokesperson.

Physician burnout

Unable to "recharge" your batteries between scheduled work shifts including symptoms of physical and emotional exhaustion, depersonalization and reduced sense

Physician Socialization

•145 accredited U.S. medical schools accepted: -20,631 out of 52,550 applicants (39%) in 2015-16 •1st year students: -48% female, for greater diversity -49% non-white in 2011, for greater diversity -Aged 21-23 typically -3.6+ undergraduate GPA -Majored in biology, chemistry, psychology, premed -Most from middle and upper classes, although changing -High probability of obtaining M.D. degree -May benefit from having close family member, friend as M.D.

Medical Education

•32-45 months of coursework •Basic medical sciences: -Anatomy, biochemistry, microbiology, pathology, physiology, pharmacology, physical diagnosis, clinical laboratory procedures, behavioral science •Clinical studies: -Work under faculty supervision •Rotations -Internal medicine -pediatrics, surgery -Ob-Gyn •Ethical principles

Work environments

•Academic medicine •Private practice: solo or partnered; concierge •Multi-specialty group practice: private versus HMO setting (Kaiser) •Veterans Affairs Hospital •Military •Outpatient versus hospital-based primary care •Loan repayment options •Other: hospital administration, pharmaceutical company, politics, media

Nursing Degrees

•Associate degree (AD) -Faster, cheaper -Vocational rather than professional programs •Designated "technical" rather than "professional" -Supervisory and management roles expanding •But roles may surpass their training -Largest source of U.S. nurses •Some hospitals require bachelor's degree -Schools offer training programs for folks with ADs •"Registered Nurse to Bachelor of Science Nurse (R.N. to B.S.N.)"

Nursing Education

•Attractive for many women (and some men) •Three types of RN programs -2-year associate degree (AD), usu community college •52% of nursing graduates in 2014-2.5 to 3 year hospital -based diploma schools •3% of nursing graduates in 2014 (may soon disappear) -4 &5 year university programs (bachelor's degree)

Trends in doctor-patient relationship

•Changes in physician-patient relation-Social status -Autonomy -Control over patients •More oversight and regulation from -Government -Managed care organizations -Insurance companies •Electronic medical recording -Conform to convention, norms, and evidence-based medicine (EBM)

Rules of etiquette

•Discourage criticism, accountability

Pharmacists

•Doctor of Pharmacy (Pharm.D.) -only degree now available (used to have B.S. Pharmacy) •6 years past high school •Roles -Fill and dispense prescriptions, other medication -Provide advice and instructions about drug use •Effects, dosage levels, how to use •Need authorization from doctor to dispense drugs •Practice in: -Hospitals, clinics, pharmacies

Early medical training

•Doctors often ships' surgeons, apothecaries, clergy •Some gained medical knowledge in Europe •University of Edinburgh in Scotland provided best training •College of Philadelphia, 1765-1st medical school in America •Rapid increase in medical schools after 1800

Changes in status of doctors

•Early 20thcentury -Physicians had solo practice, were independent, and charged fee for service •Now, dominance of med. profession declining -Doctors employees in hospitals or managed care practices -Smaller gap between physicians and other health care personnel •Some nurses, pharmacists, physical therapists, nutritionists have doctorates

Professional Standards Review Organizations (PSROs)

•Established in 1970 •Review medical care for Medicare, Medicaid patients

Diagnostic related groups (DRGs)

•Government fee schedules for Medicare patients •Ceiling on how much government will pay

Managed care

•Health Care Organizations, Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) -Control costs -Monitor doctor's treatment -Limit referrals to specialists -Require authorization for hospitalization -Doctor's authority reduced •Work within fee structure, regulations

Being Mortal

•Health decline might not be immediate •May show downward slide, with ebbs and flows

Effect of social and psychological factors on health and longevity

•Impacts on life expectancy •Impacts on incidence of disease •Effects on prevention and treatment and choices patients make in these areas •Understanding social and psychological factors are as important as understanding biological processes

Inner Fraternity

•Inner core -Knowledge elite (physician-researchers) •Research productive sign of influence -Clinical trials -Administrative elite (physician-administrators) •Medical school deans, department chairs, heads of clinics -Oversee budgets, staff, other faculty •Most prestigious positions -"Academic appointment in university medical centers of large urban areas" (Cockerham 2016)

Nurses

•Largest group of U.S. health workers •Licensed registered nurses (RNs) -Follow doctor's instructions to care for patients -Supervise practical nurses •Licensed practical nurses -Care of patients at their bedside -May supervise certified nurse's aids, orderlies, attendants •Majority (70%) work in hospitals, nursing homes -Rest work in doctor's offices, schools, public health •Originally a religious activity •Roman Catholic nuns practiced nursing -Hospitals generally for poor until late 19th century -Form of charity, a calling -Did not work under doctor supervision -Could refuse to treat patients •Unwed mothers, individuals with STDs -Low prestige occupation

Errors in medicine

•Malpractice relatively common -Few hundred in 1950s -10,000/year in 1980s -Peaked in 1988 and has since declined •Cost of malpractice insurance has declined -States set limits on size of malpractice settlement •Data bank on incompetent physicians -Disciplinary actions and malpractice awards •Medicare and Medicaid fraud

Ineffective early techniques

•Many techniques ineffective, painful, dangerous, or fatal •Bloodletting=could weaken condition •Purgatives=caused vomiting •Cholera treatments=ineffective

Factors in weakening medical profession

•Medical profession weakened since beginning of 21st century -Oversupply of doctors -Government regulation -Employers who pay for health insurance -Third party payers -Changes in doctor-patient relationship

Iatrogenic effect

•Medically induced illnesses or deaths •Maybe due to -Unsafe procedures -Transmit infections -Over/or misprescribed drugs -Amputate wrong leg, breast -Leave instruments in body after surgery •Alabama, 2007-08 -Doctor liberally prescribed painkillers and sleep medication -Killed several people

Government regulation

•Medicare and Medicaid legislation in 1960's -Provide for elderly, poor •Opposed by AMA •Professional Standards Review Organizations (PSROs) •Diagnostic related groups (DRGs)

Doctor-nurse game

•Nurses do not directly challenge doctor's orders -Informal interaction -Supports doctor's authority, nurses subordination •Nurses indirectly make recommendations -Patient experienced death in family, unable to sleep •Doctor indirectly asks for recommendation -What has been helpful previously? -Both save face »Nurse seen as great at her job »Doctor seen as competent with patients and staff

Florence Nightingale

•Nursing role changed in middle of 19th century •Nightingale English Protestant •Trained as nurse in Germany •Founded hospital for "Sick Gentlewomen in Distressed Circumstances" in 1853 in England •Brought honor, respect, code of behavior to occupation

Nursing Trends

•Nursing was less attractive because of -Low pay, long hours, low status, stress •Status and income increased in late 1980s •Increasingly drawn from middle, upper class -Seen as solid middle class occupation •Increasingly viewed as longterm career •Affordable Care Act may increase nursing

Midwives

•One of earliest forms of care for women •Assist mother in childbirth •Two types: •Nurse midwives -Supervised by physician •Lay midwives -Assist on their own -Deliver babies in the home -Licensed in 16 states •Midwives attended -Virtually all births in colonial America -Half of births in 1900 -Exceptionally few births in 1950 •Medical profession argued for hospital deliveries -Surgical skills, access to drugs, sanitary conditions •Resurgence of midwives for -Natural childbirth, home deliveries, drug-free deliveries -Includes middle-class women

Flexner Report

•Only three medical schools fully approved: -Harvard, Johns Hopkins, Western Reserve •Recommended schools should have: -Full time faculty -Lab and hospital facilities available to students •Med students should receive education in: -Natural sciences •Resulted in closure of: -Women's medical schools -6 of 8 African American medical schools

AMA guiding principles

•Physician is independent practitioner •Generally free of control from public •Fee-for-service medical practice

Evidence based medicine

•Proven diagnostic and therapeutic procedures: •Can result in: -step-by-step instructions for medical care -Reduces uncertainty -Requires applying evidence to individual patients from large clinical trails & population-based studies •Can increase uncertainty

Physician assistants (PAs)

•Qualifications -Bachelor's degree, previous experience -Complete 26-month training program •Similar to master's degree -75% were women -$98,000 average annual salary in 2015 •Licensed to practice medicine, but under physician supervision •Provides primary medical care

Gatekeepers

•Screens patients before referring to expensive procedures and specialists •Treatment may be delayed or denied

Transitions in healthcare delivery

•To system shaped by consumers and profits from one run by doctors •Decline in public trust of physicians •To emphasis on primary care and prevention rather than specialization and subspecialization •To more outpatient care in doctors' offices and homes, rather than hospitals •To payments based on detailed accounts rather than fixed prepayments •Managed care system -Doctors are employees

Professional Power of Physicians

•Two basic characteristics: -Prolonged and specialized training -Service orientation •Consolidate professional power with: -Public accepts claims of competence -Profession controls membership rather than outside authorities

Double agent

•Work for patients and managed care organization •Become patient advocates for specialized care