Test 3 Medical Sociology
New technology in medicine
"Extensive use of advanced technology for testing, diagnosis, and thescientific determination of treatment" Individualized drugs Computer-guided imagery and robotic surgery Health information through the Internet Health and medical apps, including smartphone apps
Relationship between patient and physician
- Dependent on setting - Assumes one-on-one interaction • But maybe team and hospital staff• At home, may include family
Managed Care
- Doctors "employees" in hospitals or managed care practices - A health care delivery system organized to manage cost, utilization, and quality.
Diagnostic related groups (DRGs)
- Early 1980s - Government fee schedules for Medicare patients - Ceiling on how much government will pay
Professional Standards Review Organizations (PSROs)
- Established in 1970 - Review medical care of Medicare, Medicaid patients
medical errors
- Medical errors • Unsafe procedures • Transmit infections • Amputate the wrong leg, arm, or breast • Leave instruments in the body after surgery Some can be prevented, sometimes relatively easily - Work to avoid technical and esp. moral errors - Errors relatively uncommon and rarely fatal
Medicalization/biomedicalization
- Medicalization refers to the process in which conditions and behaviors are labeled and treated as medical issues. - Biomedicalization describes the increasingly complex, multisite, multidirectional processes of medicalization, both extended and reconstituted through the new social forms of highly technoscientific biomedicine.
Government regulation
- More government regulation - Corporations in the health care market • Doctors "employees" in hospitals or managed care practices • Larger emphasis on profits - Changes in doctor-patient relationships • Patients take more critical view and are less satisfied - Smaller gap between physicians and other healthcarepersonnel • Some nurses, pharmacists, physical therapists, nutritionistshave doctorates
Guiding Principles
- Physician is an independent practitioner • Generally free of control from public • Fee-for-service medical practice
lay-referral system
- Process of seeking medical help from group of potential consultants - Begin in family and extend outward to more select individuals, including friends and neighbors—until professionals are consulted
Registered Nurses
- Typically responsible for the type and quality of all nursingcare patients receive - Follow doctor's instructions to care for patients - Supervise practical nurses
Consumerism in health care
-Attention is shifting from the producers of health care to consumers of that care -Healthcare consumerism is a movement where individuals take more control of their healthcare decisions. This growing patient empowerment makes healthcare consumers more conscientious of their health benefits and associated costs.
Stefan Timmermans, 2020
-The engaged patient -encouraging patients to make informed decisions about their own health
Consumerism in Healthcare
-a movement where individuals take more control of their healthcare decisions -will influence the future of healthcare in new ways, as their use of online resources & Telehealth continues to grow -fully 1st generation expected to share the b burden of their health benefits -they believe healthcare cost are too high & that 3rd party health payers or insurers have too much power
6 Stages of Socialization (Davis)
1 - initial innocence - nursing students wanting to do things for patients with care, kindness, consistent with the lay mother-surrogate image of nursing 2 - labeled recognition of incongruity - nursing students articulate their disappointment and openly question their choice of becoming a nurse. 3- psyching out - students attempted to anticipate what their instructors wanted them to know and to concentrate upon satisfying these requirements 4 - role simulation - students performing so as to elect favorable response from the instructors. 5 - provisional internalization - last two years of their program (gaining confidence) 6 - stable internalization - 5 and six are the two final stages, the nursing students, took on a temporary self-identity as a "professional" nurse. as defined by the faculty, and settles into this identification by the time of their graduation.
3 interaction models (Szasz and Hollender) 1956
1- Activity-passivity - When a patient is seriously ill or being treated on an emergency basis in a state of relative helplessness, because of a serious injury or lack of consciousness, usually a critical situation 2- Guidance-cooperation - when the patient has an acute often infectious disease (flu or measles) patient is conscious and aware and can follow physicians orders 3- Mutual perception model - especially applies to the management of chronic illness in which the patient works with the physician as a full participant in controlling the affliction, patients often modify their lifestyle
Four Critiques of Sick Role
1. Behavioral variation -Sick role works for serious prognosis -If not serious, continue with regular roles (no exemption) -Varies by age and gender 2. Varies by disease -May only apply to acute diseases -Temporary, physicians can cure -Less applicable to chronic diseases -Incurable -thus, it may be impossible to exempt from regular roles -Cancer, heart disease, Alzheimer's -Patient adopts a long-term sick role -Diabetes -If managed, the patient can return to normal routine 3. Relationship between patient and physician Dependant on setting Assumes one on one interaction But maybe the team and hospital staff At home may include family 4. Oriented toward middle-class Lower class may tend to deny sick role May not be exempt from work May be poor because of illness (reverse casualty) May use sick role as an excuse to avoid work (secondary gain)
Prestige within medicine (Hall) 3 factors
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 Dr.'s behavior, diagnosis, prescriptions • Reputation, popularity - Professional referral of patients - Hospital connections - Managed care restricts referral 3. Inner Fraternity-Sorority • 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,hospital CEOs - Oversee budgets, staff, other faculty • "The most powerful positions in medicine arethose associated with prestigious academicappointments in the university medical centers oflarge urban areas" (Cockerham 2022).
Percentage women students in med. school
10% in 1970s 56.3% in 2020-21 Female majority for 1st time ever in 2019
Physician Assistant
A licensed professional who works under the supervision of a physician • Qualifications - Bachelor's degree, previous experience - Complete 26-month training program • Similar to master's degree - 75% were women - $119,460 average annual salary in 2021 • Licensed to practice medicine, but under physician supervision• Provides primary medical care
patient advocate
A patient advocate helps patients communicate with their healthcare providers so they get the information they need to make decisions about their healthcare.
Physician socialization
A process through which a person becomes a legitimate member of a professional society.
Functionalist Perspective
A sociological approach that emphasizes the way in which the parts of a society are structured to maintain its stability. -societies are thought to function like organisms, with various social institutions working together like organs to maintain and reproduce them.
Freestanding emergency centers
An emergency facility that is not physically connected to inpatient services.
Medical decision rule (Thomas Schef)
Clinical Decision Rules (CDRs), also known as Decision "Instruments" or "Aids," are evidence-based tools to assist the practitioner in decision-making for common complaints.
SES Barries in doctor patient interaction (cultural differences)
Compared to whites Blacks are less frequently referred to specialists VA Med. Center, Houston (Gordon et al. 2005) Black patients requested less info. than whites Doctors gave less information to black patients Hispanics receive less treatment for diabetes (Timmermans, 2020) 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, esp. undocumented, may not qualify for health insurance
Patient compliance/adherence
Doctors prescribe medications and diets and expectpatients to faithfully follow directions Compliance issues Motivated to be healthy Understand negative consequences Degree of personal control Scotland (Blaxter and Cyster 1984) Alcoholic liver patients continued to drink Did patients misunderstand? Did doctors communicate risk? Doctor recommended two or fewer glasses of sherry, so patient drankas much whisky as desired
Reasons for self care
Expensive medical care • Dissatisfied with medical care, depersonalized • Shift from acute to chronic conditions • Modern medicine has limits • Aware of alternative healing options • Recognize importance of healthy behaviors• Desire to control one's health
Biographical medicine
Focus on patient oral accounts of medical history
Germ Theory (Louis Pasteur)
He proved that food spoiled because of contamination by invisible bacteria, not because of spontaneous generation. Pasteur stipulated that bacteria caused infection and disease.
sickness as deviance
Illness is deviant because the person can no longer, perform a functional role in society
Gender as barriers in doctor patient interaction
Male physicians, female patients Doctors may be insensitive to patient's needs Doctor decisions may not be in patient's best interests E.g., hysterectomy for pelvic inflammatory condition Misdiagnose Heart attack as stomach/anxiety problems in premenopausal women Classic symptoms Chest pain, numbness on left side, nausea, sweating Estrogen protects women until menopause
Differences between Medicare and Medicaid
Medicare is a federal program that provides health coverage if you are 65+ or under 65 and have a disability, no matter your income. Medicaid is a state and federal program that provides health coverage if you have a very low income.
Gender differences in heart attack diagnoses
Misdiagnose Heart attack as stomach/anxiety problems in premenopausal women many think of chest pain as a typical symptom of a heart attack. But while both men and women can experience chest pain, women are more likely to experience atypical symptoms such as nausea or vomiting, shortness of breath, dizziness, or no symptoms at all.
Determinants in seeking medical care
Money- poor less likely to seek medical care -Less important than rent or food to most poor people -people may be skeptical of medical care
Self-care
Most common response to symptoms of illness, Self initiated and managed, preventive measure (vitamins etc.), self treatment, manage diagnosed conditions
Class differences in symptom identification (Earl Koos)
Poor ignore more symptoms Working poor may lack insurance - Employers do not provide it - Earnings disqualify use of Medicaid - Too expensive to pay for private insurance • Relative needs
Four Aspects of Sick Role
Sick people 1. Exempt for regular social roles and responsibilities -Exemption proportional to illness severity -Doctor legitimates sickness 2. Not responsible for their condition -Illness beyond their control 3. Obligated to get well, move from an undesirable state -Even if procedures are uncomfortable, painful 4. Seek competent help, and cooperate with the doctor
DSM (book)
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders. DSM contains descriptions, symptoms and other criteria for diagnosing mental disorders.
Transitions in healthcare delivery
The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.
Midwives
Women who were often older and widowed that helped deliver babies and helped take care of women with health problems • Assist mothers in childbirth - One of earliest forms of care for women • 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 • Two types - Nurse midwives • Supervised by physician - Lay midwives • Deliver babies without the supervision of a physician • Deliver babies in the home• Licensed in 16 states
Nurse Practitioner
a nurse with graduate training who often works as a primary care provider
Functions of physician
diagnose and treat injuries or illnesses and address health maintenance
Techno-medicine
extensive use of advanced technology for testing, diagnosis, and the scientific determination of treatment
Social contagion
imitative behavior involving the spread of behavior, emotions, and ideas
Superiority of physicians
most of us have agreed to trust science and evidence-based conclusions. We trust doctors when they time and again heal us.
Flexner Report
outlined, in 1910, the shortcomings of U.S. medical schools that did not use the German model that promoted medical education on the principles of scientific discovery
Factors in weakening medical profession
peer evaluation
Pharmacists
specially trained and licensed professionals who specialize in the preparation and dispensation of drugs • Doctor of Pharmacy (PharmD) - Only degree now available (used to have B.S. Pharmacy) • 6 years past high school • Roles- Fill and dispense prescriptions, other medication • Serve in person and by mail and telephone - Provide advice and instructions about drug use • Effects, dosage levels, how to use • Need authorization from doctor to dispense drugs • Supplement rather than challenge healthcare practitioners - Practice the "art of discretion" with physicians• Practice in hospitals, clinics, pharmacies
Social standards and control
the ways in which medicine functions (wittingly or unwittingly) to secure adherence to social norms; specifically by using medical means or authority to minimize, eliminate or normalize deviant behavior.
American Medical Association (AMA)
• AMA was Founded in 1847 in Philadelphia - 15% of qualified physicians were members in 2011 • 79% of qualified doctors were members in 1963 - Nonmembers do not need benefits • Armed forces, researchers, universities, government, private industry - Central interest as a protective trade association or in public welfare? • Specialty societies are growing - American College of Surgeons - American College of Physicians - American Medical Women's Association • Publishes Journal of the American medical association (JAMA), 1883 to present • Opposed many healthcare reforms - E.g., Medicare • Supported some aspects of the Affordable Care Act - Opposed aspects that would reduce physician pay autonomy
Nursing Education
• Attractive for many women and some men • Four types of RN programs - Technical and vocational schools, varying lengths • In person and on-line; 14% of nursing graduates in 2019 - 2-year associate degree (AD), usu community college • 37% of nursing graduates in 2019 - 2.5 to 3 year hospital-based diploma schools • <2% of nursing graduates in 2019 (may soon disappear) - 4 & 5 year university programs (bachelor's degree) • 47% of nursing graduates in 2019 - The largest source of U.S. nurses
Changes for medical professionals
• Beginning of the 21st century saw decline indominance of medical profession - Rising costs, resistance to cost controls - More government regulation - Corporations in the health care market • Doctors "employees" in hospitals or managed care practices • Larger emphasis on profits - Changes in doctor-patient relationships • Patients take more critical view and are less satisfied - Smaller gap between physicians and other healthcarepersonnel • Some nurses, pharmacists, physical therapists, nutritionistshave doctorates
Rules of etiquette
• Discourage criticism, evaluation, accountability - Fear of reprisal for speaking up officially - Blame the patient
Health insurance coverage and types (Gender)
• Females more likely to - Visit physicians • May receive earlier diagnosis and treatment - Have higher morbidity - Take better care of themselves - Be admitted to hospital • Pregnancy results in doctor visits ages 15-45- But less than 20% of all doctor visit
Health insurance coverage and types (Age)
• Health service use greatest among elderly (65+) - Have public health insurance (Medicare) - Some disabled, ill • Visit physicians • Hospitalized more • Infants and children also visit doctor - Ensure healthy life, treat ailments, vaccinations • Ages 18-64 have fewer doctor visits
Nurses
• Largest group of U.S. health workers in the U.S. • Licensed registered nurses (RNs) - Typically responsible for the type and quality of all nursingcare patients receive - Follow doctor's instructions to care for patients - Supervise practical nurses • Licensed practical nurses (LPNs) - Care of patients at their bedside - May supervise certified nurse's aids, orderlies, attendants • Most (70%) work in hospitals, nursing homes - Rest work in doctor's offices, schools, public health agencies • Originally a religious activity • Roman Catholic nuns practiced nursing - Hospitals generally for poor until late 19th century - Form of charity, a calling • Those providing the services could attain spiritualsalvation by helping those less fortunate - Did not work under doctor supervision - Could refuse to treat patients • Unwed mothers, individuals with STDs - Low prestige occupatio
Early ineffective techniques of physicians
• Many techniques ineffective, painful,dangerous, or fatal - Bloodletting - could weaken condition - Purgatives - caused vomiting - Cholera treatments - ineffective• Some more recent treatments questionable
Iatrogenic illnesses and deaths
• May be due to - Medical erros - Adverse effects • Over- or mis-prescribe drugs (and drug interactions)- E.g., Liberally prescribe painkillers and sleep medications- Only 0.16% of deaths in 2018 due to complicationsof medical and surgical care (NCHS, 2021
Golden Age of Doctoring
• Notable factors - High professional control - Increasing prices and overcharging - Unnecessary tests, hospitalizations, prescriptions,operations - Provider-structured insurance paid for most costs, inc.mistakes - Major growth industry
doctor-nurse game
• Nurses do not directly challenge doctor's orders - Informal interaction - Supports doctor's authority, nurse's subordination • Nurses indirectly make recommendations - Patient experienced death in the family, unable to sleep • Doctor indirectly asks for a recommendation - What has been helpful previously? - Both save face» Nurse seen as great at her job » Doctor is seen as competent with patients and staff - Doctor-nurse game is changing • More assertive nurses • More male nurses • More female doctors
Florence Nightingale
• Nursing role changed in middle of 19th century • Established nursing as a distinct and honorableoccupation • 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 tooccupation
Gentlemen's Agreement (Millman)
• Overlook mistakes of others - Technical errors, made in good faith, less concerning » Doctors should work hard to learn from mistake - Moral errors—unreliable, uncooperative, more concerning » Subject to sanction, social isolation, poor recommendation
Roles of physician and patient
• Patients now - More actively participate - Seek several forms of care • Chronic, acute, preventive, curative, palliative • Drs take on multiple roles to induce adherence - Educator, salesperson, cheerleader, detective • Physicians now deal with more actors - Insurance companies, managed care system, government requirements - Share decision-making with patients
History of physicians and their training
• Physicians in the U.S. used to lack lengthy training in specialized knowledge • Before American Revolution - Doctors often ships' surgeons, apothecaries, clergy • Some trained in Europe • College of Philadelphia, 1765 - 1st medical school in America • Rapid increase in medical schools after 1800 - Quality of schools and of doctors low until 185
Evidence based Medicine (EBM)
• Proven diagnostic and therapeutic procedures - Can result in step-by-step instructions for medical care - Reduces uncertainty, doubt, increases consistency - Requires applying evidence to individual patients fromlarge clinical trails & population-based studies • Improves application of medical knowledge - E.g., treating cancer, heart disease; COVID-19 vaccine
Gatekeeper
• Screens patients before referring for expensive proceduresand specialists - Treatment may be delayed or denied
Importance of Social Networks
• Suggest, advise, influence, and coerce individuals • Lay referral system - Process of seeking medical help from a group of potential consultants - Begin in family and extend outward to more select individuals—including friends and neighbors—until professionals are consulted • Nicholas Christakis and James Fowler (2008) - Social Contagion Theory - How social networks predict epidemics • Flu, COVID-19• Obesity, smoking, drinking - Quitting smoking easier if people in network also quit - Smoking often a shared behavior • Also applies to happiness• Central take-home point?
Sick roll (Talcott Parsons)
• The Social System (1951) - Function of medicine, role of sick individual in society - Physician's role is to return sick person to normal state of functioning - First sociologist to demonstrate the function of medicineas form of social control - Health is positive, worth maintaining - Being sick is • Not deliberate • Undesirable • Form of deviant behavior • Dysfunctional to individuals and society - Sick person motivated get well and quickly
Features of professionalism (Goode)
• Two basic characteristics - Prolonged and specialized training - Service orientation • Consolidate professional power - Public accepts claims of competence - Profession controls membership rather thanoutside authorities • Profession determines education/training standards • Student exposed to stringent socialization • Profession recognized by licensure • Licensing boards staffed by profession members • Profession primarily shapes legislation • High-caliber students attracted to income, power,prestige • Lay evaluation and control have minor impact onpractitioner • Strong identification of members by profession
Double Agent
• Work for patients and managed care organization - Become patient advocates for specialized care