Professional Dominance

The Social Structure of Medical Care

Robert A. Manners

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351496414
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

In the United States today we are confronted by a number of serious social problems, not the least of which concern the character of our basic human services. In each of the broad public domains of welfare, education, law, and health there are crises of public confidence. Each in its own way is failing to accomplish its essential mission of alleviating material deprivation, instructing the young, controlling and righting criminal and civil wrongs, and healing the sick. The poor, the student, the offender and the victim, the sick-all have in some way protested the failure of the institutions responsible for them. And these protests occur at a time when the human services are absorbing an increasingly massive amount of money and manpower. Awareness of that crisis intensified in the second half of the twentieth century. Increasing energy has been invested in research designed to determine what can be done. Each of the human services has long had its own research tradition, but during the sixties each has also made a concerted effort to mobilize and use the skills of such comparatively new disciplines as sociology. Owing to these new demands, sociology itself has grown. The hitherto obscure specialties of the sociology of law and medicine and the established specialties of criminology and educational sociology have taken on new vigor. In applying themselves the task of studying the human services, however, these segments of sociology have had to choose between two different strategies. Rather than dealing with the details of the human services for their own sake-and this lack of detail in a characteristic limitation of the second approach-this book shall instead attempt to stand outside the system in order to delineate one of its critical assumptions and a strategic feature of its basic structure. This book deals with the concept of profession, for the concept rests on assumptions about how services to laymen should be controlled and is realized by a special kind of

Part 1
A SOCIOLOGICAL APPROACH TO MEDICAL CARE

1

The Present State of Medical Sociology

Some years ago Robert Straus made the useful distinction between an approach to the study of medicine which he called sociology in medicine and another which he called the sociology of medicine.¹ The distinction is important both conceptually and practically, for it includes within it the means of distinguishing what has been called social medicine in the past and what has grown to become over the past few decades a rather new approach to the area. The new approach is a potentially liberating one in that it can remove both medical knowledge and the practical arrangements for applying that knowledge to human affairs from the rather unhealthy intellectual and political isolation it has enjoyed over the past half-century, ever since medicine attained its present status as a dominant profession.

Essentially, Straus “suggested that the sociology of medicine is concerned with studying such factors as the organizational structure, role relationships, value systems, rituals, and functions of medicine as a system of behavior and that this type of [study] can best be carried out by persons operating from independent positions outside the formal medical setting. Sociology in medicine consists of collaborative research or teaching, often involving the integration of concepts, techniques, and personnel from many disciplines. . . . Research in which the sociologist is collaborating with the physician in studying a disease process or factors influencing the patient’s response to illness are primarily sociology in medicine.”²

In this book I shall examine medicine in general, but most particularly the medical profession and the institutions providing medical care from the point of view of the sociology of medicine. I shall attempt to show how, by adopting that point of view, one can better evaluate the nature of medical institutions in a way that is useful to the formulation of practical social policy. Indeed, I believe that only by adopting the perspective of a critical outside observer of medicine can one approach it in a way closely attuned to the public good, for while medicine has a foundation in scientific knowledge, its characteristics as a social institution lead it inevitably to have a distorted view of itself, its knowledge, and its mission. Collaborating with medicine in its institutionalized tasks requires adopting that distorted view with all its deficiencies. Studying it as an outsider allows one to see medicine as one of a number of human institutions, reflecting merely one of many intellectual points of view, one of many moral standpoints, and expressing the material interests and ideological commitments of only one of many organized groups in our society. Once one sees medicine that way, one is in a good position to evaluate how far social policy should allow the profession to determine for itself the terms of the medical care it provides the public, and how far not.

The Present Position of the Sociology of Medicine

The development of a sociology of medicine is a task that has barely been attempted in any serious and coherent fashion until recently.³ The field itself is very new. It is true that the word “sociology” has been associated with medicine by one writer or another for many years. A book entitled Medical Sociology was published more than fifty years ago.⁴ But the association was more one of good intent or rhetoric than of analytical significance. Until recently, the association of “medicine” with “sociology” meant merely that the writer believed that illness was not a purely biological phenomenon, that he recognized that social life formed the context for the practice of medicine, and that he was interested in the social and economic context of health and health institutions. But there were no distinctive concepts employed and usage was essentially unsystematic. For example, the stance of such a gifted scholar and admirable humanitarian as Henry Sigerist was essentially that of a humane physician with a keen eye for the social aspects of medicine. His marvelous analyses of tarantism and of homesickness⁵ rested on his perceptive common sense, not on any special concept of illness, including that recognized by modern medicine, as a social construct.⁶ And his trenchant and revealing commentary on the Hippocratic oath rested on his opposition to some of the conventional shibboleths of his guild, not on any special effort to arrive at some detached notion of the nature of medical practice.⁷ This stance takes the essential premises of medicine for granted and seeks to reform medicine by showing that social factors play a part in it; the stance does not, however, seriously question or evaluate either the concepts of medicine or its conception of its place in human affairs. The approach is that of sociology in medicine.

Until recently, a sociology of medicine was not possible. Sociology had to become more a discipline than a brave program of positivist philosophers, and it had to develop tools of analysis as capable of dealing with the humble and concrete as with the grand. And the occupation of sociology had to grow to the point of producing trained practitioners rather than gifted amateurs. In fact sociology developed slowly over the nineteenth century, but its impetus gradually increased during the twentieth. The past several decades have seen marked developments in the discipline and the conditions of its exercise. Not many absolutely new concepts have been created, but many old ones have been refined and systematically elaborated. A tradition of empirical study developed and became routine. And the absolute number of trained sociologists has increased to the point where whole aggregates can focus on special areas of study and so begin the accumulation of information and awareness of problems which underlies a specialty. A reciprocal process has developed whereby general sociological concepts are applied to a special field and in the test of application are almost invariably found wanting. They are then reviewed, revised, and refined so as to be applicable to that special field and the revision is transmitted back to the mother discipline. On application to still other special fields, the concepts are revised more, in the hope of attaining at some time a dignified stability. However, while it has been prominent in many areas, this process has rather lagged in the area of medicine and health affairs.

The Underdevelopment of a Sociology of Medicine

Not until the 1950s were there enough sociologists interested in illness and medicine to reach the critical mass required for the development of a specialty. From then on, an increasing number of sociologists, including for a time some of the most prominent, began to think seriously about the character of illness, the doctor-patient relationship, medical education, hospitals, and other institutions of medicine. Indeed, aggregation of the interested proceeded at such a great rate that by the 1960s the newly formed Section on Medical Sociology of the American Sociological Association was about one-tenth the size of the entire association. It is in 1970 still one of the largest and most active sections. Number alone suggests that a full-fledged specialty had arisen in less than twenty years.⁸

However, the field has remained a specialty of number, a collectivity joined by vocational interest in the broad “medical” subject matter. Aside from somewhat greater experience in applying available methodological techniques to the collection of empirical data and a ritual use of jargon, sociological workers in the field have, with some exceptions, been largely indistinguishable from other workers. It is difficult to discern a distinctive approach to the area, a limited set of strategic concepts around which the entire range of phenomena may be ordered. The cause of this failure, I believe, lies first of all in the relatively weak state of sociology itself, which, even though strengthened markedly these past twenty-five years and encouraged by being fashionable in the popular press, has hardly arrived at the status of one of the physical sciences. But since all sociologists in every specialty share this burden, it does not help us to understand the special weakness of medical sociology. What seems to be peculiar to sociologists working in the field of medicine (including psychiatry) is an inordinate reliance upon the approach of the professional practitioners in the field and a distinct reluctance to use the approaches suggested by sociology itself. The emphasis is predominantly on sociology in medicine rather than on the sociology of medicine.

This medical rather than sociological orientation is demonstrated by the topics that have been studied intensively, by those that have been virtually ignored, and by the approach usually adopted toward the topics investigated. By far the most frequent topic studied is the health of given populations and its relationship to variables like age, sex, occupation, income, education, religion, and ethnic background. More sophisticated research in this area concerns itself with the concrete variables underlying or implied by those gross characteristics—dietary and other health-influencing customs, for example, or special types of environmental stress. By and large, both types might be called social epidemiology. From the point of view of the medically defined mission, they are very useful in measuring the extent of given health problems in the population, a task that is essential for determining what resources are needed by the health sector of the economy. Other studies focus on the utilization of health services, and to the extent that the administrative fact of utilization or nonutilization is the prime variable, to be associated with simple socioeconomic and demographic characteristics, these share the logic of epidemiological studies. In both cases the concern is with the distribution in a population of an attribute, trait, behavior, or experience that medical men believe to be important to the public good. Insofar as those attributes, traits, behaviors, or experiences are not themselves considered to constitute analytical problems to be studied critically, such studies do not provide concepts or information that allows the evaluation of what medical men believe or claim is important to the public good. Medicine may only be served, not evaluated.

Aside from studies of the correlates of illness and utilization, by far the bulk of remaining studies focus on various aspects of patient or prospective patient behavior. Here falls a rather large variety of analyses of the beliefs about and attitudes toward illness and the medical profession-studies of special ethnic groups in the United States, for example, or of relatively self-sufficient and exotic cultures in contact with Western medical institutions. Here also fall studies of the process by which people come to believe themselves sick and to seek some kind of care. The orientation of such studies varies a great deal, from those that consider the social behavior of the sick to be a unique area of study to those that regard it as at best a special instance of a more general class of human behavior, from common-sense correlation of social or administrative variables with simple attitudes to analyses employing systematic, sometimes specifically sociological, schemes.

The studies mentioned thus far are not only the most numerous in the field, but were also the first to be undertaken in any quantity as the field itself grew. What unifies them is their preoccupation with the layman as a social problem—whether or not he should be under medical treatment and, if he is not, why not. There is comparatively little concern with the extent to which it is not the layman but the physician, not lay but medical institutions, which are problems. There is typically what Roth calls “management bias.”⁹ And even when they are scrutinized, medical personnel and institutions tend to be evaluated from the point of view of medical norms.

It is of course easily understandable why most studies focus on the patient, for he is not only officially considered a social problem but also is more of a captive to the researchers than are other participants in the health care system. Similarly, it is no accident that in studies of health personnel, captives (which is to say students in nursing, dental, and medical schools, and post-graduate students in teaching hospitals) have been studied more often than full-fledged professional practitioners, and among practitioners the lower status aides and nurses have been studied more often than physicians.

By and large, I would argue, medical sociology has focused on the areas that the medical practitioner himself has considered problematic, adopting the conception of what is problematic from the profession itself without raising questions about the perspective from which the problem is defined. This is, of course, what one may expect from the point of view of sociology in medicine. In addition, I may say, even when sociological studies have turned their attention to the health worker himself, they have adopted the perspective of the worker in that they have emphasized the health worker’s own conception of what is problematic about his own occupation and the other occupations with which he has worked. I refer here to a fairly exclusive focus on the attitudes of the worker—his personal commitment to his work and training, his professionalism, his conception of the patient—rather than on the way the worker’s work is organized. This tendency is in part produced by relying on the survey questionnaire as the prime method of collecting data—an occupational disease .of the sociologist that is present in all fields. But among sociologists of medicine, the tendency is accentuated by the primacy of a particular ideological emphasis in the field itself, The most prominent workers in the field of health are believed to be rather special kinds of people called professionals. By definition—and arbitrary definition—what is special about professionals is believed to be a stable set of ethical and other kinds of values which guide their behavior. The essential question asked is whether or not students have become professional by internalizing such values. Another question is whether or not attendants and nurses evidence such values and thus may be called professionals. In studies in this area, the tendency is not to question the value of the definition itself or to test its premise that professional behavior is contingent upon professional norms. Consequently, there has been little interest in studying the organized constraints upon individual behavior. Indeed, in the case of the physician we are extraordinarily ignorant of basic facts about the reality of medical practice—which is to say, the organization of medical care. Quite apart from the practical difficulty of study, part of that ignorance is a direct function of the assumption that attitudes and values—ethics and dedication—are more important than the circumstances in which they are tested. The assumption itself, while hardly illegitimate, is one espoused by the profession, which sees itself as a group with a special kind of knowledge and a special state of mind rather than as a group organized in a special way.¹⁰

In all, I would argue that while there are conspicuous and admirable exceptions, the bulk of the work of sociologists in the field of health has been medical and medical-professional rather than specifically sociological and independent in orientation. The premises underlying most work have been borrowed uncritically from the common sense of administrative policy, from the diagnostic categories of medicine, and from the ideology of the professional himself. The specialty of medical sociology has shown little of the ferment and independence now evident in the work of sociologists working in other areas, whether criminology, education, poverty, or other social problems. Why is this so?

Barriers to a Sociology of Medicine

Certainly one element explaining the sociologist’s lack of detachment is his own humanity. He would be a poor human being indeed not to recognize the genuine suffering surrounding illness and the real value of much of modern medicine in ameliorating that suffering. In some instances the sociologist has deliberately assumed the role of a paramedical worker, cooperating in facilitating case finding and treatment as they are defined by current medical policy. The seductiveness of such ameliorative possibilities constitutes a distinct problem that sociologists in ma...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Foreword
• Introduction: Substantive Issues in Medical Sociology
• Part 1. A Sociological Approach to Medical Care
• 1. The Present State of Medical Sociology
• 2. A Structural Approach to Medical Care
• Part 2. The Position of the Profession in the Medical Care Structure
• 3. The Profession—An Overview
• 4. The Structural Solution to the Problem of Professional Authority
• 5. Professional Dominance and the Ordering of Health Services
• Part 3. Problems of Organizing Medical Care
• 6. Organizing Hospital Care
• 7. Organizing Ambulatory Medical Care
• 8. Professional Dominance and the Reorganization of Medical Care
• Index