medical sociology test 3
How do these third-party payers affect the physician- patient relationship?
-monitor number of patients seen by phsicians and amount of time spent with each patient -micromanage physicians' clinical decision -they decide whether to reimburse physician for services and if so much to pay
two main forms of social control in advanced society
1) bureaucratic supervision- government oversight 2) judgment by recipients of services (market response)
three types of uncertainty faced by med students
1) one cannot learn everything about medicien 2) current medical knowledge and techniques are limited 3) problems distinguishing personal ignorance from limits of available knowledge
physicians responses to patients modifications
1) point out their expertise 2) warning of threats to health if treatment is not followed 3) explaining that progress may be slow (even with correct treatment) 4) asking the patients to comply
current trends in health care delivery
1) shift from health care system shaped by doctors-> shaped by consumers and profit competition 2) shift from public's trust of doctors-> greater questioning of doctors 3) shift from specialization-> primary care and prevention 4) shift from hospital care-> outpatient care in homes and doctors offices 5) shift from costs based on doctors decisions-> fixed payments that require detail accounts of decisions
current medical school
145 accredited medical schools receive about 50,000 applications and choose about 20,000 accepted students 52% male, 48% female and 49% nonwhite 21-23 years old with bachelors degree in bio, chem, zoo, premed, or psych and at least 3.6 gpa from upper and middle class background most who enter obtain MD
flexner report
1800s= 400 us medical schools low quality instruction, poor facilities, admitted anyone who could afford tuition funded by carnegie foudnation and issues 1910 flexner was an educator- visited every med school, only 3 schools given full approval (harvard, case wester, johns hopkins)
why do we treat medical care a commodity?
19th-20th centuries= US medicine developed a model of professionalism based on independent, fee-for-service practitioners early 21st century= we now have radically different system with many doctors working as employees of hospitals and manage-care pracitces but the fee for service model still determines how health care is delivered in market based system
med school enrollement
50-50 if female excell men-- feminization of the profession decline in status and autonomy overall: decline in status
number of MDs in US
850,000 physicians are 10% high status throughout most of the world
What is causing the decline in public confidence?
Medical profession claims excellence of service and technological achievement. BUT 1) not all Americans are receiving quality care (social problem). EVEN THOUGH 2) costs are rising (economic problem).
female med students
about half now often face sexual harassment from male patients and male doctors 40% of med school faculty are women
guidance-cooperation
actute or infectious illness phy: makes decisions and provides guidance pat: aware of circumstances, cooperates, follows guidance
other medical societies
american medical women's association= addresses female specific issues speciality societies= provide continuing med education and board certification
european medical education
best training in early/mid 19th century in france and germany mid 1800s- germ theory, cellular pathology, bacteriology american students would flock to europe
results of the flexner report
better schools improved, lesser school closed (bad publicity and finances) women's medical schools closed (thought they get into male) 6 of 8 traditionally aa schools closed mainstream schools required to adhere to flexner recommendations to receive needed philanthropy from foundations become profession and powerful
mutual participation
chronic illness phy: provides insight and recommends behavior modification pat: works with doctor is full participant, modifies lifestyle (smoking, taking meds) seeks periodic checkups
what do we know about cloning
cloning may be therapeutic (cloing organs for transplant) or reproductive (cloning of people) not legal in the us
what is required for patient to comply?
communication-> comprehension-> compliance
formal relationships
control of dominant posts within these institutions is the critical variable that distinguishes influential from noninfluential doctors
current trend of AMA
decreasing pwoer ex: opposed medicare and medicaid but it passed supported AMA but lost 9,000 members eroded reputation of credibility with lawmakers and the public
patient bias
demanding medical services, bring back to feeling
effectivness of interaction
depends on ability of participants to understand each other
feautres of professions
determien its own standards of education and training most stringent socialization experience than other occupations is legally recognized by come form of licensure has admission boards staffed by memebrs of the profess involves members in shaping legislation about profession demands high caliber students as members gain income, power, presitge is relatively free of lay evalutation and control has members who are strongly identified by profession
major barrier to communication
differences in status, education, professional training, authority
trend in relationship
doctors are empowering patients to participate in decisions about their care
how do intervening actors influence the interaction
doctors are now less paternalistic towards patients and more willing to share decision making with them
power structures
doctors careers take place in a system of formal and informal relationships cliam to position status and power become recognized and are perpetuated within the profession/mechanisms for recruitment into the inner core
physcian
dominant in sick role trained and expertise
major influences on compliance
effective communication motivation to be healthy perceived vulnerability to an illness potential for negative consequences effectiveness of treatment sense of personal control
stratification of class
effects of social distance apply to race greatest satisfaction when doctor and patient are the same race
trend in health care
eroding the long-term relationship between physicians and patients, making the interaction more like one's relationship with a cab drive or shoe salesperson
belief that "docotr is always right" iss no longer the norm
esp. among middle and upper class patients (who have equal or higher status than their doctors are well-informed about treatments, have experience with bureucracies) this trend began as part of challenges to authority in 60s (e.g. civil rights movement, Vietnam War protests)
method to reduce uncertainty
evidence based medicine (EBM) highly detailed step-by-step guidelines to use in clincial situations results= subtle rather than revolutionary (some reduction of uncertainty)
influences on entering medical school
family= having physician for parent, close relative, or fmily friend is distinct advantage in promoting desire to be doctor common reason for wanting to be a doctor to help people
heart attacks as female misconception
females get chest and or arm pain, numbness of the left side, sweating, nausea male physicians misdiagnose as stomach or anxiety problems assume estrogen protects them from heart attcks until menopause
physician bias
finding illness first and prescribing drugs, ordering tests
early medical schools in US
first established in 1765 at college of philadelphia by small group that was trained in scotland after 1800s= many medical schools establshed but training quality low and had low status until 1850s
American Medical Association
founded 1847 in Philadelphia single greatest influence on the organization and pracitce of medicine in the us aide to the power: journal of american medical association (presigous) reoganization in 1902 into local societies with authority to set its own qualification for membership-- no alternative association, important to careers
inner fraternity
four major groups 1) inner core= specialists with control of major hospital positions divided into knowledge elite (physcian-researcher) and administrative elite (physician administrator) 2) second group= new recruits at various career stages set to inherit inner core positions 3) general practioneers= linked to inner core by referral system 4) marginal physicians= less successful practice on fringes
Are genes commodities? To whom do they belong?
genes are naturally occurring organic matter, not something invented by humans, and therefore cannot be patented U.S. Supreme Court ruled in 2013= genes cannot be patented, but synthetic DNA created in a lab (complementary DNA or cDNA) can be protected under patent law
What are the possible pitfalls of genetic information?
genetic information therefore has unique implications for families and groups, potentially valuable to employers, insurance companies, researchers, and pharmaceutical firms who would use it for their own purposes
How can genetic advancements influence the physician-patient relationship?
genetic screening= physicians inform patients about what disease they might get gene therapy= physicians treat or cure disease by replacing defective genes with healthy ones designer drugs= physicians, match pharmaceuticals with patients' DNA
what is a profession
goode group engaged in prolonged training in specialized and abrstract knowledge providing a service to the public
who are the major third-party payers?
government= medicaid and medicare private health insurance companies managed care programs
arguments against treating medical care as commodity
greater discrimination against those who cannot pay greater duplication of services (which increases costs) greater dehumanizing of services designed to relieve suffering
which groups have the hardest time communicating with physicians
groups that speak little or no english especially low income hispanics as well as chinese, korean, and other immigrants
three factors to maintaing prestige within medical profession
hospital affiliation clientele inner fraternity
who's behavior is the most imporant in the interaction
how the physician acts towards the patient regardless of race or ethnicity best way to get trust
informal relationships
informal relationships also develop over time, as physicians interact with one another frequently and arrive at definition of the quality of each other's work and personal characteristics
interaction is
inherently social structured relationship and modes of discourse that is social patients experience with illness that allows the person to socially construct his or her understanding of affliction and how to deal with it does not always follow present course with mutual understanding it can have misunderstanding, uncertainity, and resistance to physicians method of treatment by patients
information can be therapeutic if
it reduces uncertainty provides a basis for action strengthens the relationship
criticism of soical control of medicine
lacks both forms of social control 1) physicians themselves establish medical standards enforced by gov regulations 2) lay persons are generally unable to judge tecnhical performance of doctors solution? physicians supposedly exhibit strong self control reinforced through formal and informal santions of collegues
Current AMA
latest released data in 2011 15% qualified doctors are members nonmembers= retired, employed by government, armed forces, research agencies, universities (don't need membership), others who disagree with AMA, do not want to pay fees, etc less than 1/5 of female physicians are members
how does social class influence this interaction
lower class: more passive in all health situations, treat doctors as authority figures, decreased sense of personal control over health matters middle/upper: more consumer oriented, discerning seekers of health care, active participants in physician-patient encounter
reasons for going to med school on class
lower= more likely to report for money and prestige socialized in med school to balance success oreintation (less success oriented students become more so, and more success-oriented students become less so) humanitarian orientation and believe in serving the sick
What is expanding the market for medical services?
medicalization: public is expressing less confidence in medical field while simultaneously demanding more medical services problem is structural-> over doctoring to fit demands
history of relationships
medicine= used to be low-status occupation until beginning of 20th century (with advancements in medical training) upward mobility of physicians= peaking in 60s (with image of caring physician and trusting patient) but as status increased, physicians became increasingly distant patients then became more active, informed participants in health care
why is the status of doctors declining
most exciting career opportunities like investment banking, hedge funds, private equity firms, etc high risk high reward jobs --college dropouts becoming billionaires, slipping into being a safe option
patient compliance
most patients comply with treatment however, some pay little attention to physician guidance true especially when 1) symptoms are not obvious 2) when patients begin to feel better
medical practitioners
mostly ships surgeons, apothecaries, and clergy (get while studying in europe) few had been trained in university or medical school
What are other ways that technology is influencing medicine?
new forms of drug delivery (pills, injections, patches, nasal sprays, inhalers) hospitals or clinical treatments now available at home (some chemotherapy) use of robotics and computer guided imagery (robotic surgery)
treatment for women
not always in best interest of the women not listening to the patients ex: hysterectomy, doctors change behavior upon knowing marriage and relationships to doctors
female physicians
often have less authority than male conflict with career and motherhood specialize in "soft" as compared to "tough" ones women who move into top specialities tend to adopt masculine traits like assertive, highly professional, not expressing warmth
osteopaths
originally focus on spinal manipulation to cure health problems began in 1860s in kirksville MO Andrew Taylor Still 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
as physician authority decreases
patient consumerism increases when it comes to health care, an identifiable pattern among many Americans is one of consumerism, in which the consumer wants to make informed choice and the services available and not be treated as inferior
in nonemergency situation
patients are not passive, ask questions seek explanation, make judgments, resist treatment, check info on the internet
How is technology changing the physician-patient relationship?
patients can consult physicians using home computers, email, skype, teleconferencing, etc. physicians can use computers to diagnose illness, determine treatment, and learn new protocols drugs can be ordered and delivered online shift away from biographical medicine to focus on the patient's oral account of his or her medical history
model (hayes-bautista)
patients often attempt to modify prescribed treatment by phsyicians by 1) trying to convince physician that treatment is not working 2) countering treatment with actions of their own
what do we know about miscommunication?
patients seek future care elsewhere lower class and women have the most miscommunication
public confidence in medical profession
peak in 20th century early= low-> mid=high-> late= declining still have high regard the movement of public opinon has been toward less confidence in physcian authority
How do social factors influence these online behaviors?
people worried about stigma of illness (anxiety, herpes, urinary problems) often seek info online people lacking social connection form electronic support groups (esgs)
early medical education
physcians had service oreintation but no formal trianing
clientele
physicians must promote their practice to attract and retain clients (as in commercial enterprise) lay-referral system= important for both finding physicians and evaluating services (behavior diagnoses, prescriptions) status hierarchy of specialities= from high (neurosurgery, thoracic surgery, cardiology) to low (geriatrics, dermatology, psychiatry) require refferals from other primary care docs- referrals are becoming restricted to list approved by manage health orgs
Strucutre of AMA
power=consolidated in hands of relatiely limited number of physicians vast majority of members= content to let AMA represent them to congress and other gov agencies no forum for dissent within AMA (due to system of electing national officers through its House of Delegates rather than directly by membership)
female dominated specialities
primary care, geriatrics, pediatrics
professionalization requirements
public accpetance of claims to competence control of membership consolidate power after established, formalize social relationships with clients, colleagues, and official agencies outside the profession
How does prenatal genetic testing influence abortion decisions?
public attitudes toward abortion- in the case of genetic defects- has become increasingly negative
womens health movement
reaction to lack of male sensitivity to female patients ex: natural childbirth, midwifery, home childbirth, self help, abortion rights, breast cancer research funding
poor communication
refusing to explain because they think they wouldn't understand being vague, evasive, or frightening
socialization in med school
renee fox 1) emotional detachment from patient: depersonalizing patients so they could concentrat on learning what was mecially important 2) ability to tolerate uncertainty
20th century us medical
research starts to surpass europes massive economic investments by rich philanthropists (carnegie, rockefeller) to maintain "the moral, social, and economic orde of corporate capitalism)
Activity-Passivity
serious illness--injury or lack of consciousness phys: total decision making power pat: contributes little or nothing to interaction ICU doctors
model of interaction (thomas szasz and marc hollender)
seriousness of patients symptoms= determining factor in doctor patient interaction
comparing female and male doctors
similar diagnostic therapeutic skill levels but different communicaiton female: more empathetic, egalitarian, respectful, and responsive to patients, more attentive to patient's comments and medical histories, better communication, providing preventative care, following clinical guidelines create greater sense of partnership between patients and female doctors male drs: talk about skill and treatment female: help and care
how to understand the relationship regarding class
social distance sharing social class are more likely to share communication style and communicate effectively with them differing communication comes from difference in class and lose the ability to negotiate within the medical encounter
19th century medical advancements
stethoscope, anesthesia, hormone theory, surgical procedures, staphyloccus discovered, x-ray
what explains specialty segregation?
strucutrual= women kept from advancing to top positions by barriers (like lack of mentors) voluntaristic= women make occupational choices according to stereotypical gender expectations they are socialized to follow
patient
subordinate accept, reject, or negotiate
hosptial affliatoin
successful urban medical career= require affiliation with prestigious hospital best residencies= not best quality of teaching but program's reputation and location
male dominated specialities
surgery, sports med, internal medicine
flexners recommendations
taught by faculty that is qualified and full time implementation of admissions standards training by universites on a graduate level lab and hospital facilites made available to students intergeration of teaching and research at same institutions
what do we know about internet usage?
there are about 10,000 websites on health problems of all americans: 85% use the internet, 72% have looked online for health info typically investigate whether they/someone else has a disease or health problem, search for treatment options, seek information and about health care providers, and look for tips on staying healthy new trend= increase use of mobile and smart phones health-related issues
Why doesn't English proficiency solve the rest of the communication problems?
today's medicine is delivered in context of middle class norms and values (scientific beliefs, sophisticated tech, cooperation with physicians) helps explain the struggle of lower class groups ex: give less info to black patients, cycle created by then they requesting less than white middle class groups
decline in confidence is related to
treating medical care as a commodity medical practice= organized around financial profit in free-market system arguments for treating medical care as a commodity - greated efficiency in providing services -greater incentive for research and development -greater responsiveness to patients (as consumers)
hidden curriculum
undercurrent of norms, values, and viewpoints that are embedded in training and adopted 1) informal training received during immersion in medical school instills professional authority and autonomy in future physcians 2) hidden curriculum promotes unequal system of stratification in health care delivery
common medical methods in beginnign
unpleasant and often fatal bleeding and purgatives
status of osteopaths
used to be seen as "quackery" + now= part of mainstream medicine with added skill of spinal procedures by mid 20th century=receiving scientific medical training (surgery, pharmacology) 1953= recognized by AMA 19 osteopathic colleges in US award DO degree american osteopathic association= promotes professionalism among osteopaths current trend= absorption into medicine about 82,000 practicing
medical treatment
usually begins with face-to-face dialogue
social class differences
very important factor to communication poorly educated=most likely to have questions ignored or treated impersonally upper/middle= receive more personalized service, more active in presenting ideas, seek further explanation about conditions upper middle class physicians= communicate more info to patients than physicians with lower middle or working class backgrounds (How they were socialized)
