illness in the light of contemporary debates in medical sociology and beyond. .. deviance model of illness, thereby over-simplifying the paradigm and result- . and informal sense then, Parsons argues, the doctor–patient relationship. 'has to . In the s, a founding father of medical sociology, Talcott Parsons, the model immediately flipped the doctor-patient relationship on its. Doctor-patient relationship is a special kind of social relationship where Parsons' model of the sick role has a few weaknesses. In the modern.
Whereas once it seemed reasonable to expect physicians to combine technical expertise with emotional sensitivity and skill, and nurses to complement them in both, now the patient gains equality and independence but with increasing emotional distance from caregivers. Under the current conditions of healthcare, social workers would seem to have a strategic role. They are, after all, uniquely trained in the skills of interpersonal relations, and professionally are intended to function as the patient's advocate for well-being, both within the period of illness and in preparation for the recovery period.
Yet, here, too, the pressures for professional status take an ironic toll. A trend toward private practice with fee-for-service financial rewards attracts social workers toward professional status on the medical model and away from the team model in which their function is to balance the technical with the social.
The same value dilemma confronts all the healing professions.
A polarization has developed between two orientations, one centered on the what of healthcare and the other on the how. The former has been called a reductionistic approach, emphasizing biomedical knowledge and technology; the latter is the "social ecology" or "humanistic" approach. The values of these two approaches are significantly different. The more traditional, reductionistic approach is dominated by faith that all problems of health and illness have rational solutions, and by a dedication to competence in practice and to a community of science that transcends personal interest.
Patient, societal, and ethical issues are seen as matters of opinion not susceptible to rational discourse Pellegrino; Fox, The approach of social ecology, on the other hand, rests on a very different set of values. The social and behavioral sciences and even the humanities are here as pertinent as the biological sciences; students are selected on the basis of social concern and interest in people and their problems; emphasis is on caring as much as on curing.
The community, not the university hospital, is the proper locus for the education of health professionals. Although one can say that neither of these approaches has sought or gained exclusive dominance, their differences are important enough to generate partisan claims from each about the failures of the past, the needs of the future, and the implications for patients and society.
Both the value of modern science and the critical need for enlightened social and ethical orientations can be found in the way national commissions are addressing the problems of today's healing professions Marston and Jones. Summary and Conclusions The definition of the professions is the foundation of sociological analysis of the professional—patient relationship. Uniquely among modern occupations, a profession has been seen as an activity that requires extensive training based upon a continuously developing knowledge base coupled with the application of such knowledge for the general welfare of society.
Therefore, although the rewards of professional life have been substantial, it is assumed that the professional is not free to exploit such skills and knowledge for personal gain alone, as other entrepreneurs may—the socalled principle of caveat emptor let the buyer beware.
On the contrary, the professional is granted unusual privileges involving access especially to the personal and biological privacy of patients, but only on an implicit contractual premise that such professional rights will conform to general rules of the welfare of society.
Medicine has been the primary subject of such analysis because it is seen as the archetype of professions.
Virtually every person needs the help of healing occupations; the other classic professions, the law and the clergy, are not so ubiquitous. Therefore, a large sociological literature grew out of the study of medicine as a profession. However, the practice of medicine has changed radically in modern times and continues to change.
Research in the biomedical sciences is usually considered the major driving force of this transformation, but changes in the social organization of the delivery of health services, the application side of the medical profession, have been no less dramatic.
In the wake of both the bioetchnological and application developments, new ethical issues have appeared and earlier ones have deepened.
Bioethics as a separate discipline has grown significantly, very likely as a direct consequence of these changes. Sociology, meanwhile, has spawned its own forms of interest in medical ethics. In part, sociologists have followed the tradition of individualism, which interprets behavior as a social psychological process determined by the values individuals learn and carry with them into social encounters.
A different perspective emphasizes the material technologies and organizational constraints that dominate the therapeutic relationship. For example, the bureaucratization of medicine has advanced, creating a situation in which both doctor and patient meet less as individuals than as members of groups. The resulting formalization has altered the emotional quality of the exchange and the nature of responsibility and accountability for those involved therein.
Conventional wisdom has suggested that the ethical problems of current therapeutic relationships are driven mainly by technical imperatives.
Professional–Patient Relationship: II. Sociological Perspectives | acryingshame.info
Sociologists, in the main, however, have argued that bioethics is determined by the value context in which medical technology must be managed, not by the intrinsic qualities of the technology. The dilemmas—the extension of life at the sacrifice of quality of life, the increased efficiency of neonatology at the cost of disability—are seen as only part of the current medicoethical challenge. Equally important is the unequal access to the benefits of technological advancement for populations that are disadvantaged by poverty, by race, or by other sources of discrimination.
Pressures are increasing for comprehensive entitlement to medical care but, as in the past, the chances for such change remain in doubt.
As analysts have noted, the proportion of national income that will be invested in healthcare is both a value judgment and a product of the political process. As a result, David Mechanic writes: When faced with competing claims on national resources, government finds it easier to restrain growth in programs affecting the poor and disabled, who constitute relatively weak constituencies, than to reduce subsidies shared by large, articulate, and sophisticated segments of the larger American public.
At one extreme are those who view the system as basically sound and strongly support the conventional structure of medicine. At the other extreme are those "who view the delivery system as so flawed in its structure and priorities and so dominated by special interests that only major reorganization offers any promise of an equitable and effective delivery system in the future" Mechanic,p.
The struggle between these polar opposites will be strongly affected by the values that are basic to American thinking and that inevitably must be reconciled in the policy decisions that will be made. The trend at this time appears to be toward universal health insurance.
The methods reinforce organizational development that fosters large corporate structures. Those who cling to the right to choose one's personal doctor, and believe that no healthcare system can function effectively otherwise, feel they have been put on the defensive against pressures for cost-effectiveness, even rationing, but nevertheless persevere in a time-honored American belief in individualism. The contributions of sociologists, if they follow the patterns of the period since the s, will continue to focus on the microrelations of medicine, especially the doctor—patient relationship Stacey.
They will also explore the ethics of human research, and issues of public policy such as equality of access to care and the role of the professions in determining the availability of medical and healthcare services Sorenson and Swazey. Individualism, for Fox, is "the primary value-complex on which the intellectual and moral edifice of bioethics rests" Fox and Swazey, p.
It starts with a belief in the importance, uniqueness, dignity, and sovereignty of the individual. From this flows the assumption that every person has certain individual rights. Autonomy, self-determination, and privacy are fundamental. In addition, individuals are entitled to the opportunity to find, develop, and realize themselves and their self-interests. They are entitled to be and do as they see fit, so long as they do not violate the comparable rights of others.
II. SOCIOLOGICAL PERSPECTIVES
Can these values be reconciled with the changes in modern American society, especially those that foster large organizational structures? Sociologists will certainly devote themselves to such questions, and include the fate of microrelations such as the professional—patient relationship.
Examining the Social Construction of Medicine, pp. Peter Wright and Andrew Treacher. The Doctor, His Patient and the Illness, 2nd edition. The Doctor and His Patient: The Psychiatric Hospital as a Small Society. An Analysis of Clinical Reasoning. The History of Sexuality, tr.
Introductory Studies in the Sociology of Medical Education, pp. Reader, and Patricia L. Professionalization and Socialization There is also inter-cultural variation in physician roles, and variation among physicians in the success of their role socialization.LL04 - Jonny Marler on Talcott Parsons and the doctor-patient relationship
While Parsons' model of doctors' affective neutrality, collective-orientation, and egalitarianism towards patients did express the professional ideal, some physicians are more affectively neutral than others. Following Parsons' lead, sociologists began to focus on the socialization of physicians and the factors in medical school and residency that facilitated or discouraged optimal role socialization to doctor-patient relationships Merton, Reader, and Kendall, ; Becker, Geer, Hughes and Strauss, This work generally took the division of labor in medicine for granted, and painted a more or less heroic picture of medical self-sacrifice.
A few writers began to focus on aspects of the physician role and medical education that themselves militated against humanistic patient care. Critics suggested that medical schools and residencies socialized physicians into "dehumanization," and to place professional identity and camaraderie before patient advocacy and social idealism Eron, ; Lief and Fox, ; and more recently Anspach, ; Hafferty, ; Sudit, ; Conrad, Professional Power and Autonomy The most important weakness of Parsons' functionalist account of the doctor-patient relationship, however, arose from his poor understanding of the ecological concepts of dysfunction and niche width.
Social structures cannot be assumed to be functional for the social system simply because they exist, any more than an organic structure, such as an appendix, can be assumed to be functional for its organism. All that can be said about a structure, or in this case a role relationship, is that it has not yet pushed the organism outside its niche, causing its extinction. In other words, the study of doctor-patient relationships in one society does not indicate how much the particular structures and norms of the provider-patient relationship are simply the result of historical chance, rather than necessitated by the nature of illness and healing in industrial society.
And second, such a study does not indicate whether the particular practices and norms are leading in a dysfunctional direction. A critical sociology of the doctor-patient relationship thus arose to challenge the internal contradictions of the Parsonsian biological metaphor: To the more critical 60's generation of social scientists, inspired by growing resistance to unjust claims to power, physicians' defense of professional power and autonomy appeared to be merely self-interested authoritarianism.
Physicians' battle-cry of the sacred nature of the doctor-patient relationship sounded hollow in their struggles against universal health insurance. Physicians' high incomes and defense of autonomy appeared to result in both bad medicine and bad health policy, and physician's unaccountable power appeared all the more nefarious because of medicine's intimate invasion of the body, In this context, Eliot Freidson's work,crystallized the notion that professional power was more self-interested than "collectivity-oriented.
Freidson's approach to the sick role was influenced by labeling theory Szasz, ; Scheff,and went beyond Parsons to assert that doctors create the legitimate categories of illness. Professionalization grants physicians a monopoly on the definition of health and illness, and they use this power over diagnosis to extend their control.
This control extends beyond the claim to technical proficiency in medicine, to claims of authority over the organization and financing of health care, areas which have little to do with their training. There are now many studies of the way that professional power has been institutionalized in the structure and language of the doctor-patient relationship. For instance, a recent study of medical students' presentation of cases demonstrated that physicians were being trained to talk about their patients in a way that portrayed the physician as merely the vehicle of an impersonal medicine acting on malfunctioning organs, rather than a potentially fallible human being interacting with another human being.
The more highly regarded presenters were found to 1 separate biological processes from the patient, 2 use the passive voice in describing interventions, 3 treat medical technology as the agent, and 4 mark patients' accounts as subjective the patient "states," "reports," "denies,". These devices make the physician more powerful by emphasizing technology and eliminating the agency of both physician and patient Anspach, Since its publication, Starr's The Social Transformation of American Medicine has quickly become the canonical history of the institutionalization of professional power, its effect on the organization of health care, and the profession's metastasized influence in the political sphere.
Though Starr draws on many theoretical sources, he paints a picture of the American doctor-patient relationship as a successful "collective mobility project" Parry and Parry,whose contours were not at all determined by the functional prerequisites of society. While Starr does not goes so far as to say that we do not need "doctors" at all, he argues that there are a range of possible structures that medicine could have taken in industrial society, and that American physicians are an extreme within that range.
Marxist and Feminist Approaches Drawing on, and extending the professional power analysts, the growing school of Marxist sociologists interpreted the doctor-patient relationship within the context of capitalism.
In the Marxist analysis, the American doctor-patient relationship is conditioned by the "medical-industrial complex" Ehrenreich and Ehrenreich, ; Waitzkin and Waterman, ; McKinlay, ; Waitzkin, ; profit-maximization drives the innovation of technologies and drugs and constrains physician decision-making.
The most orthodox advocate of this analysis, Vincente Navarro,rejects the analyses of those such as IllichFreidson and Starr who see professional power as having some autonomy from, and sometimes being in direct conflict with, capitalism and corporate prerogatives. For Navarro, physicians are both agents and victims of capitalist exploitation, engineers required to fix up the workers and send them back into community and work environments made dangerous and toxic by capitalism.
But the professions are anomalous for traditional Marxist theory; only those who own the means of production are supposed to accrue occupational autonomy and great wealth. Theorists of physician proletarianization point to the rising numbers of salaried physicians, the deskilling of some medical tasks, and the shifting of some tasks from physicians to less skilled technical personnel.
Parallel to, and often included in the Marxist account, has been the growing feminist literature on medicine. In particular, feminists have focused on the patriarchal nature of the male physician-female patient relationship, documenting the history of medical pseudo-science that has portrayed women as congenitally weak and in need of dubious treatments Ehrenreich and English, ; Arms, ; Scully, ; Mendelsohn, ; Shorter, ; Corea, ; Fisher, ; Martin, ; Todd, There is also extensive work done on the history of exclusion of women from medicine Walsh, ; Levitt, ; Achterberg,and the effects of the growing numbers of female doctors on the doctor-patient relationship.
Women physicians tend to choose poorly paid primary care fields over the more lucrative, male-oriented surgical specialties, are more likely to be employed as opposed to in private practice, and are less likely to be in positions of authority Martin, Women providers are also better communicators Weisman and Teitelbaum, ; Shapiro, Economic Approaches The growth of studies on cost-containment, and the economistic trend of 's social science, led to the rise of methodologically individualistic "rational choice" studies of the doctor-patient relationship.
These studies usually ignored the functionalists' interest in norms and roles, as well as the critical theorists' interest in power and exploitation. Instead, the economists' model starts from the assumption of a mutual "utility-maximizing" agency contract between the doctor and patient Dranove and White, ; Buchanan, The patient is interested in maximizing consumption of health, and the physician is interested in maximizing income.
The studies then focus on the effects of insurance, reimbursement and utilization control structures on doctor behavior, the doctor-patient relationship and the success of medical agency Eisenberg, ; Salmon and Feinglass, For instance, a number of studies have documented that patients without health insurance have less access to doctors, and receive less care from them when they have access Hadley, Steinberg and Feder, ; Kerr and Siu, Research has also demonstrated that different payment structures affect physician behavior Moreno, ; Rodwin, For instance, a recent study of Medicaid case-management found that pediatricians who received augmented Medicaid fees provided a higher volume of services to children than either a group receiving fees-for-service, or a group covered by capitation Hohlen, et al.
Another strain of economistic research picks up on the Freidson observation of physicians' power to define illness, and explores the degree to which physicians "induce demand. Communication and Outcomes Two trends led to the rapid growth of research on doctor-patient communication. The first trend was the interest of physicians and medical educators in improving their ability to elicit patient histories and concerns, and inform patients of their conditions and treatment needs, and thereby achieve successful diagnosis and treatment compliance.
Literally thousands of analyses of consultations have been done since the s to develop methods to teach and improve physician communication skills Stewart and Roter, A second trend, the rise of health consumerism, has encouraged more contractual and conflictual relationships between patient and doctor.
NHS England » The sick role
An increasingly well-educated population has begun to challenge medical authority, and treat the doctor-patient relationship as another provider-consumer relationship rather than as a sacred trust requiring awe and deference Reeder, ; Haug and Lavin, Opinion polls indicate a steadily declining faith in physicians, and in the American medical system in general Blendon, The consumer, women's health Ruzek,the holistic health movements, and the perception of physician indifference and greed, have also encouraged patients to distrust physicians.
These trends were often portrayed by medical sociologists as democratizing Haug, ; Haug and Lavin, but perceived by physicians with alarm, especially in light of the rise of malpractice litigation.
Encouraged by these two trends, symbolic interactionists Anderson and Helm, ; Strauss, and discourse analysts began detailed analyses of doctor-patient communication to tease apart the workings of power and authority within them. In particular, Howard Waitzkin,has drawn attention to the way that American medical communication reinforces individualistic, bio-medical interpretations of problems with social origins and social solutions, and thus reflects and reproduces social inequality and disenfranchisement.
Another example is the work of Hayes-Bautista who studied the bargaining between the patient and the doctor over treatment. The patients were observed using "convincing tactics" of a demands, b disclosure that the treatment has not worked, c suggestions, and d leading questions.
If these did not achieve the desired change in treatment, they turned to "countering tactics" of arguing that the treatment is too weak, too powerful or insufficient. To augment their authority, the doctors used tactics of a wielding overwhelming knowledge, b medical threats about the consequences of ignoring advice, c disclosures that the treatment may take longer to work for the patient; or d a personal appeal to the patient as an acquaintance.
The outcome measures of this game theoretic situation were a continuation of the relationship, b patient termination of relationship, c physician termination, and d mutual termination.
Health care marketing became a third major impetus for studies of doctor-patient communication, largely with the goal of identifying the kinds of interactions that improved patient satisfaction. Research found, not surprisingly, that people like to have doctors talk to them in an egalitarian way, listen, ask a lot of questions, answer a lot of questions, explain things in a simple way that the patient can understand, and allow patients to make decisions about their care DiMatteo, ; Hall, Roter and Katz, ; Roter, Hall and Katz,; Roter and Hall, ; Gerteis, Edgman-Levitan, Daley and Delbanco, Researchers also began to demonstrate that different patterns of communication have effects on the clinical outcomes of patient care.
The kinds of medical care that patients find satisfying tends to alleviate psychosomatic symptoms and make patients more compliant with their treatment regimes, and thereby produce better clinical outcomes Egbert, et al.
The Decline of the Professions and the Doctor-Patient Relationship To change the health system at all, much less to create a medical system which maximally utilizes self-help and mutual help and which encourages an active rather than a passive role for the patient, will require radical deprofessionalization.