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This paper reviews the author's experience in becoming a medical sociologist before the field had become formalized. The contributions to medical sociology of sociologist Selden D. Bacon and physician and medical educator William R. Willard are described. The relationship of medical sociology to medical behavioral science, as experienced at the University of Kentucky, is discussed. Finally, the thesis of the author's 1957 paper on the nature and status of medical sociology is re-examined. [ABSTRACT FROM AUTHOR]

The introduction to this special issue of the Journal expands the scope of research on "the sociology of medical education" to include studies of the institutions in which physicians are trained as well as studies of the socialization of the physician throughout the life cycle. Research since the 1960s is reviewed briefly and the papers in this issue are discussed. Studies of the macropolitics and micropolitics of academic medicine are called for as well as comparative analyses of the settings in which physicians are trained and research on the relative effects on physicians' attitudes and behavior of different sets of experiences, professional and nonprofessional, over the course of their life cycle-all in the context of massive changes in the organization of health care. [ABSTRACT FROM AUTHOR]

This paper addresses current contentions that medical sociology is handicapped as both a scholarly and a policy science by its subordinate relationship to the more powerful field of medicine. An analysis of all research articles published in the JOURNAL OF HEALTH AND SOCIAL BEHAVIOR which focus upon patients reveals the following: (1) the presence, in the majority, of implicit and explicit medical value assumptions influencing all stages of the research process, from the definition of problems and variables through the application of findings to health policy; (2) a tendency for cases of "medical bias" to be associated with collaborative research in which the sociologist is wholly or partly dependent upon medical sponsorship and definition of the research situation. Consequences of this situation for the human subjects of research as well as for the field are discussed. A conclusion is that both our subjects' interests and the theoretic and political integrity of the field are best served by maximizing professional autonomy vis-à-vis medicine. A proposal for studying the structure of working arrangements concludes the paper. [ABSTRACT FROM AUTHOR]

This paper contrasts economic and professional models of physician admitting behavior. Economic models emphasize physician convenience and income maximization, while professional models emphasize physician autonomy and independence. The paper examines the relative power of these models to explain two types of admitting decisions made by physicians: which hospitals to begin admitting patients to, and how many patients to admit to a hospital. Analyses of physician admitting patterns over a three-year period suggest that economic considerations outweigh professional considerations in both decisions. Results are interpreted in light of recent changes in the profession of medicine and physician-hospital relationships. [ABSTRACT FROM AUTHOR]

This paper probes two aspects of the medical profession in Singapore: its structure and its social position. The first section reviews the relevant concepts concerning the structure and the social position of the professions that may be applied to medicine in Singapore. The second section looks into the structure of the medical profession in Singapore from an historical perspective. The third section deals with the internal organization of the medical profession. The fourth section focuses on its social position. The paper concludes with a summary of the main points and a brief comparison of the situation in Singapore with that in other countries. [ABSTRACT FROM AUTHOR]

This paper utilizes a social constructionist perspective to examine the widespread belief among physicians during the early 1980s that an oversupply of doctors was either present or imminent. It was found that the timing and growth of physician beliefs in a "physician glut" during this period could not be adequately explained by net increases in the physician supply, either on an absolute level or relative to the growth of the general population. Rather, this "fact" of a physician surplus was found to be more fruitfully explored as an emergent social phenomenon grounded in the historical evolution of physician-supply themes and the particular clinical practice environment in which physicians found themselves in the late 1970s and early 1980s. [ABSTRACT FROM AUTHOR]

This article responds to the comments of Edward E. Brent on the article "Processes of Continuity and Change During Socialization for Medicine in Israel," by Judith T. Shuval and Israel Adler, in the 1977 issue of the "Journal of Health and Social Behavior". It seems the Brent misunderstands the nature of correlations and is therefore led to a further nonsensical conclusion. This concerns his criticism of the proposed strategy to induce change. His suggestion that influence should best be exercised over a long period of time is contradicted by the data which show that whatever change is induced at any early time is largely wasted, since it is unlikely to show much carry-over to later times, i.e., correlations between distant times are weak. On the other hand, recency shows that change introduced at any given time is best carried over the next subsequent time.

Managed care is cultivating a variety of new work careers within the medical profession, and it is worth asking whether they will function as long- or: shorter-term career options for the individuals who participate in them. This paper uses the specific case of hospitalist physicians to explore how the surrounding social and economic work contexts contribute to two individual-level outcomes that inform the issue of career longevity: the concepts of burnout and intent to stay in the career. The findings of a national survey of hospitalists reveal that job burnout and intent to remain in the career are more meaningfully associated with favorable social relations involving colleagues, co-workers, and patients than with negative experiences related to the economically induced pressures of the job, such as reduced autonomy and the use of financial incentives. In addition, career longevity is enhanced by the extent to which individual physicians pursue intrinsic and extrinsic rewards through their choices to become hospitalists. These findings demonstrate that sociologists should pay greater attention to the career trajectories of contemporary doctors in order to understand larger scale professional stratification within medicine. They also offer empirical support for redirecting our focus towards the relational dynamics that shape these trajectories. [ABSTRACT FROM AUTHOR]

This paper examines the social construction of diagnosis and illness in several ways. First, I discuss the centrality of social construction in medical sociology. Next I discuss the major role of diagnosis in social construction, leading to the need for a sociology of diagnosis. I emphasize controversial and conflictual diagnoses, as a first step toward a more general sociology of diagnosis. Then I put forth a typology of social construction, involving four combinations based on whether a condition is generally accepted and whether a biomedical definition is applied. Next I detail a series of stages in the social construction of a condition. In that process, my primary concern is the initial social discovery, which is essentially a matter of diagnosis, with a secondary emphasis on illness experience. This is followed by stages of treatment and outcome, which recursively affect social construction. I conclude by noting the health policy implications of the social constructionist perspective. [ABSTRACT FROM AUTHOR]

This paper is a revision of the address given by Professor Becker in connection with his receipt of the Leo G. Reeder Award for distinguished service to medical sociology. The address was given August 22, 1992, to the Medical Sociology Section of the American Sociological Association during its annual meeting, held in Pittsburgh, PA. [ABSTRACT FROM AUTHOR]

This paper explores the effects of computerized medical information systems on the occupational communities of health care professionals in hospitals. Interviews were conducted with informants from the pharmacy and nursing departments at two hospitals currently using medical information systems for communicating physicians' medication orders from the nursing station to the pharmacy. Results showed changes in tasks for both pharmacy and nursing, resulting in increased interdependence between the two departments. This interdependence was accompanied by improved communication and cooperation, providing an opportunity to encourage better working relationships between departments. The use and maintenance of the common computerized data base became a superordinate goal for the two groups, with the computer system itself as the topic of communication. [ABSTRACT FROM AUTHOR]

This paper examines a segment of medical social life that has not been studied extensively: formal presentations of case histories by interns, residents, and fellows. Because they are presented by physicians in training to their status superiors, who are evaluating them, case presentations are exercises in self-presentation which serve as a vehicle for professional socialization. This analysis of the language of case presentation is based on case presentations collected in two intensive care nurseries and an obstetrics and gynecology service. Four features of case presentation are identified: 1) the separation of biological processes from the person (de-personalization); 2) omission of the agent (e.g., use of the passive voice; 3) treating medical technology as the agent; and 4) account markers, such as "states," "reports," and "denies," which emphasize the subjectivity of patients' accounts. The language of case presentation has significant, if unintended, consequences for those who use it. First, some features of case presentation eliminate the element of judgment from medical decisions and mitigate responsibility for medical decision making. Second, some are rhetorical devices which enhance the credibility of the findings that are presented. Third, the language of case presentation minimizes the import of the patient's history and subjective experience. Finally, case histories socialize those who present them to a culture or world view which may contradict the explicit tenets of medical education. [ABSTRACT FROM AUTHOR]

Using recent first-hand accounts by Klass (1987), Konner (1987), LeBaron (1982), and Reilly (1987), this paper examines "insiders' "experiences of medical school. Medical education emphasizes disease, technical procedures, and technological medicine, with scant attention to "caring" aspects of doctoring. Students struggle to learn medicine and to maintain a humanistic or patient-oriented perspective, but the social environment of medical training militates against humanistic doctoring. Toward the end of medical school, students undergo a transformation by adopting the medical-clinical perspective and shifting their identification from patients to doctors. The doctors who maintain a humanistic orientation to medical care appear to be individuals who had developed this orientation before they arrived at medical school. Thus, to increase the number of humanistic physicians, the best strategy may be to alter medical school recruitment and selection policies. [ABSTRACT FROM AUTHOR]

This paper is a revision of the address given upon receipt of the Leo G. Reeder Award for distinguished Scholarship in Medical Sociology. It was presented on August 19, 1987 to the Medical Sociology Section of the American Sociological Association during its annual meeting held in Chicago. [ABSTRACT FROM AUTHOR]

This paper describes how the structure and operational policies of the British National Health Service (NHS) affect the allocation of high cost medical technology. An exploratory case study of the technologies of dialysis and kidney transplantation provides the research focus. When relevant, the British and American experiences with these technologies are contrasted. In the U.K., intensive interviews were conducted with 43 medical and administrative personnel primarily in London. The study suggests that a fixed-budget system within a centralized NHS structure in an environment of scarce resources will be associated with shortages, less utilization of expensive technological options in treatment, greater ability of the government to change health priorities and ration care, conflict among interest groups, conflict among and within bureaucratic levels, and more effective cost-control. [ABSTRACT FROM AUTHOR]

This paper explores certain of the micro-processes of socialization for four health occupations (medicine, dentistry, pharmacy, and nursing) by means of a longitudinal, cross-occupational design. It presents additional findings of the Israel Study of Socialization for the Health Professions and describes changes during socialization in the image of the normative occupational role, which is structured in terms of People, Status, and Science components. Three types of change are examined through correlations between times and mean scores: primacy, continuity, and absolute emphasis on the role components. These changes are shown to be related to certain characteristics of the four occupations: their status, the timing and the length of clinical training, the clarity of the occupational role, and the extent of differentiation of periods during socialization. Parallel data were collected in all groups before the start of socialization and at several points during the process, the final time being close to students' entry into practice. [ABSTRACT FROM AUTHOR]

This paper examines processes by which the normative image of the physician changes and develops over time during socialization for medicine. Its primary focus is on the structure of transition from stage to stage. Data are drawn from a panel study of students in two medical schools in Israel who indicated their attitudes to a set of traits which clustered in three groups termed People, Status, and Science Components. Data were gathered at five times during socialization: before entry, end of years one, three, five, and six. Correlations of each component among different times are stronger than correlations among the three components at any given time. This is taken to indicate that socialization is differentiated in its focus on the three components. Recency is stronger than primacy for each specific component. Multiple regression analysis shows that the process of change can be described as a chain of lag 1 links. [ABSTRACT FROM AUTHOR]

In this thoughtful paper, Mechanic discusses the differences between quantitative and qualitative researchers, focusing on health-related issues. It should, of course, be evident to readers that the issues he discusses have applicability far beyond medical sociology. The same issues arise in all kinds of social research and the excellent examples he gives can be expanded easily to examples in areas including education, criminology, industrial relations, social stratification, and others. In my reading of his paper, Mechanic discusses both differences between methods at a single point in time and differences in measuring process across time. As a quantitative survey researcher, I will comment on my perceptions of the similarities and differences between observational and survey methods for cross-sectional research. I then discuss some methods for bridging the gap that do not involve diaries. Finally, I discuss procedures for measuring process using observational and diary methods. [ABSTRACT FROM AUTHOR]

Cross-functional teams (CFTs) play an increasingly important role in health care. However, despite their potential, CFTs often fail to function effectively. This paper contributes to the literature in medical sociology by examining how the steep and well-defined hierarchy characteristic of the health occupations proves to be dysfunctional in the CFT setting. Previous research has shown that status differences among members of work teams negatively affect their functioning. Yet the specific mechanisms that connect variations in status to poor team functioning remain unclear. We hypothesize that it is the suppression of participation among low status team members that leads to poor CFT functioning. Our theoretical model integrates status characteristics theory and the value attainment theory of job satisfaction to link team members' statuses to participation in team decision-making and, ultimately, to their attitudes about the job. We use causal modeling to test our hypotheses. Our results indicate that relationships between health professionals defined in broader social contexts affect status, roles, and functions within CFTs, and these, in turn, affect the team's interpersonal processes. We suggest changes in organizational structure and in team leadership styles that might make CFTs more effective. [ABSTRACT FROM AUTHOR]

This article comments on the article "Processes of Continuity and Change During Socialization for Medicine in Israel," by Judith T. Shuval and Israel Adler, in the 1977 issue of the "Journal of Health and Social Behavior". Shuval and Adler are concerned with the processes by which the normative image of the physician changes and develops over time during socialization for medicine. However, the authors have presented a groundless theory. It is a theory based neither on experience nor on some logical framework, having no explicit statements and having only one very vaguely understood concept, socialization, which functions as the guiding metaphor for their study.

This article evaluates how physicians draw upon scientific and other forms of knowledge in different professional communities. We argue that because physicians will draw upon clinical research findings to improve their reputation with colleagues, and because the terms for accruing esteem in an academic hospital may differ depending on the dominant task structure of the organization, the form of knowledge that is valued by a physician will vary with his or her hospital’s level of prestige. We use social network and multivariate analyses to test this theory in six U.S. hospitals with varying levels of prestige. We find that in lower-prestige hospitals, physicians can improve their reputation by reading a relatively broad range of scientific journals, whereas in higher-prestige hospitals, esteem is allocated to those with a more elite medical school pedigree. Statistically significant differences also exist between hospitals in terms of whether work with patients is valued, with physicians who engage in more clinical activity in the highest-ranked hospitals receiving less esteem from their colleagues. We finish by discussing how the functioning of higher- and lower-prestige hospitals is interconnected in ways that sustain both the development of innovations and their widespread adoption. [ABSTRACT FROM PUBLISHER]

Recent work on the sociology of the professions, in general, and on the profession of medicine, in particular, target dramatic changes in the organization of social institutions, "boundary work" among professionals, and the implications of both for professional power. However, public attitudes cited in theories as a critical linchpin of professional status remain relatively unexplored in the face of these changes and widespread contentions of public dissatisfaction. Using data from the 1976 National Survey of Access to Care (Aday, Andersen, and Fleming 1980) and the 1998 General Social Survey (Davis, Smith, and Mardsen 1998), we take advantage of a unique opportunity to compare the public's attitudes across a 20-year period. We examine individuals' evaluations of the way physicians do their work and their ability to confront health problems. Three findings support a complex view of public sentiments. First, while public confidence in physicians remains relatively high, we document a crystallization of attitudes reflecting greater negative and fewer positive sentiments. Second, while neither the structure of attitudes nor the role of sociodemographic characteristics in explaining attitudes has significantly shifted over time, in 1998 health status and insurance status are correlated with negative attitudes. Third, using General Social Survey time trend data on the confidence in medicine compared to other professions (science and education), we find support for a general public response to social institutions, with confidence in medicine tracking closely with confidence in science in level, and education in pattern. We end with four possible explanations of our findings, including and a general discussion of the role of the public in the professional status of physicians and its implications for social change in the institution of medicine. [ABSTRACT FROM AUTHOR]

The organization and delivery of health care in the United States is undergoing significant social, organizational, economic, political, and cultural changes with important implications for the future of medicine as a profession. This essay will draw upon some of these changes and briefly review major sociological writings on the nature of medicine's professional status to examine the nature of professional dynamics in a changing environment. To this end, we focus on the nature of medical work and how this work impacts on and is impacted by medicine's own internal differentiation and the presence of contested domains at medicine's periphery. We trace this dynamic through a number of issues including the multidimensional nature of medical work, the role of elites in that work, and how changes in the terms and conditions of work can exert changes at medicine's technical core. We close with some thoughts on the relationship of public policy to medicine's professional status, the role health policy might take in shaping a new professional status, the role health policy might take in shaping a new professional ethnic for medicine, and the role sociologists might play in this process. [ABSTRACT FROM AUTHOR]

The current situation in health care organizations, among providers and for people, dramatically challenges the "business as usual" roles of medicine, government, insurance companies, the community, and the university. Health care reform marks the first attempt in a century to consider a reconstruction of the social contract between society and medicine. While sociology stands as one of the earliest social sciences to systematically study the health care arena and create a health-focused subfield, there is a perception, not without support, of a desertion of identity from within, an encroachment by other areas from without, and abandonment by the parent discipline. We argue that these situations in medical arenas and in research fields require serious rethinking. The key lies in understanding how these phenomena are related to each other and to larger social forces, and how they offer opportunities, rather than signal limitations, to medical sociologists. We turn to the theoretical tools of sociology to help unravel the complicated challenges that face both policymakers and researchers. After framing these issues in a sociology of knowledge perspective, we use the case of "utilization theory" to illustrate the connections between society and systems of care (as well as studies of them) and to create a future agenda. We end by raising three basic questions: (1) Why is a sociological perspective critical to the understanding of change and reform in health care? (2) Why is medical sociology critical to the survival of the general sociological enterprise? and (3) Why is general sociology critical to the research agenda in medical sociology? [ABSTRACT FROM AUTHOR]

The relationship between physicians and physician extender occupations is considered in light of the stratification of medical care workers. Professional dominance between various medical occupations and professional competition among physicians are considered. Data from a national sample of physicians taken in 1981 are used to determine 1) under what conditions physicians are likely to consider the employment of physician extenders helpful for improving quality of care and 2) which characteristics and available resources are associated with the belief that the employment of physician extenders will improve medical care. Of four different service populations considered, physicians are most likely to think that the use of physician extenders to care for the urban poor will aid care and are least likely to think that their employment will improve care for obstetrics and pediatrics cases. The results indicate that physicians' beliefs regarding the employment of physician extenders are dependent on the clientele as well as on the relative position of the two occupational groups in the hierarchy of medical care occupations. [ABSTRACT FROM AUTHOR]

Why is it that quantitative and qualitative researchers on health issues often have divergent findings and conclusions? Exploration of such differences can be a useful way of bringing separate intellectual enclaves in medical sociology together and also can stimulate future inquiries. Some differences can be resolved by more precise definitions, by comparable frequency and timing of measurement, and by careful evaluation of meaning contexts. The triangulation of methods, using diaries as a bridge between surveys and qualitative measurement, offers particular promise. Improved theory on the relationships of method to data, and more attention to behavioral sequences and the social context of measurement, can serve as a stimulant to innovative solutions. [ABSTRACT FROM AUTHOR]

Although both gender and professional socialization determine physicians' values, attitudes, and behaviors, the relative importance of each varies. Physicians' career paths demonstrate gender differences: women tend to choose primary care fields and rarely enter surgery, they are paid less and are less likely to be self-employed, and they are underrepresented in positions of authority within medical organizations and in academia. Data on practice style reveal striking similarities in physicians' attitudes toward patient care, knowledge, and clinical behavior, but recent work on physician-patient communication reveals important gender differences. These differences suggest that although medical socialization determines most aspects of practice style, a physician's gender can have an important influence on medical practice. [ABSTRACT FROM AUTHOR]

The emphasis of this analysis is on the social institutional history of medical sociology. This subfield is described as (1) closely connected with the patterns of development in its current discipline, (2) as containing a dual thrust between applied and basic science, and (3) as struggling with "insider-outsider" ambiguity involving the work of subgroups working either in medicine or from roles external to medicine but studying the sociology of medicine. Tracing a detailed historical fragment from the decade following World War II, it is predicted that the continuity of an accepted position for medical sociology is assured even though the style and quality of its professional life are full of uncertainty. [ABSTRACT FROM AUTHOR]

Changing approaches to conceptualizing professionalism are discussed. The utility of the more recent approaches, which are based upon concepts of power, autonomy, and dominance, is assessed through a case study of the development of Western medical education in Thailand over the past fifty years. Using archival data as well as data from other sources, we present evidence that, at least in this case, the newer approach to professionalization is vital to understanding (1) the process by which Western medicine was "exported'' to Thailand, (2) the full nature of technical assistance programs, and (3) the extent to which the creation of a small, powerful, autonomous, professionally dominant group of physicians in Thailand was a deliberate effort on the part of the technical advisors and the organization they represented. Finally, the importance of historical data for understanding current institutional patterns is discussed. [ABSTRACT FROM AUTHOR]

The effects of the reorganization of a medical practice on continuity of care were investigated in a case study of a changing pediatric practice. Continuity, which has often been conceptualized as one indicator of quality of care, was measured by an index of which the numerator was the number of visits with own pediatrician and the denominator was the total number of pediatric visits for the year. Increased number of pediatricians and incorporation of the practice into an academic setting resulted in a decline of continuity of care accompanied by a rise in the number of doctor visits for acute illness care. Patient satisfaction, although related in some of its aspects to continuity, was by and large unaffected by the change. The consequences of changes in practice size and goal complexity for interpersonal aspects of patient care and quality of care are discussed. [ABSTRACT FROM AUTHOR]

Societal practices and beliefs regarding the medicinal use of drugs recently have been widely cited as a source of non-medicinal drug use. We submit this "drug-oriented society" explanation of non-medicinal drug use to a test by surveying a sample of 500 university students. The data for each respondent include favorableness of attitudes toward medicine, amount of parental use of medicine, and amount of self use of medicinal and non-medicinal drugs during a two-week test period. Analysis showed parental use of medicine to have a small association with respondents' non-medicinal drug use. Otherwise, contrary to what the explanation would predict, no important links exist among these variables. This independence, along with marked differences in the usage patterns of the various types of drugs included in the study suggests that rather clear societal distinctions exist in practices and beliefs regarding medicinal and non-medicinal drug use. [ABSTRACT FROM AUTHOR]

The article is a rejoinder to comments regarding an article on the assessment of mental and emotional problems published in the "Journal of Health and Social Behavior". The claims equate assessment of a person's specific type of health problem categorical assessment. The authors believe that these errors are encouraged by the traditional concepts of medicine, in which symptoms are manifestations of specific, unseen organisms or lesions. There are few objective bases for the cut points and concatenation rules that define the categories of DSM-III and the DIS psychodiagnostic measures. Yet they insist that a categorical typology is essential for precise assessment. None gives a single reason why a uniform typology is superior to a uniform set of indexes representing the dimensions of interest, such as the degree of depression, paranoia, schizophrenia and social functioning.

In this article the authors acknowledge Kyriakos S. Markides and Fred P. Fiedler for their comments made for the article "Pathways to Medicine Use." The author of this article conclude that there was some programming or typographical error, or that the correlation became confused with the indirect effect. The authors noted that in path analysis the total effect of one variable on another is made up of three components: direct effects, indirect effects, and correlation due to common or correlated causes. The authors are agree with the respecification for decomposing the determinants for prescribed drug use, and have done the same for nonprescribed drugs. The indirect effects in the model are small in the case of the prescribed drugs and negligible for nonprescribed drugs. Moreover, the direct effects are not very impressive either. R2 is only .29 for prescribed and .06 for nonprescribed drugs. Clearly much more needs to be known about why people use drugs than is revealed by the usual social variables.