- Email: [email protected]
Contemporary health services
1402
Book
cutting edge with which to follow through her own misgivings. So. having pointed out the way in which disability policy has been instigated only in so far as it has fitted in with the broader economic rationality of capitalist society, thus placing the aggregative principle of utility before the distributive principle of justice, she concludes that nevertheless this is preferable to following the Utopian prescriptions of moral absolutists. But the problem of injustice remains, and it is a problem which many non-absolutist writers on disability policy have attempted to confront. The apolitical nature of the analysis is also reflected in the confused rendering of the meanings of disability and handicap; terms which Topliss employs interchangeably. This tactic may allow pleasant stylistic variation but it does not enhance conceptual clarity. If I were a student of social policy, I would be mightily confused by a sentence that began: “It is unrealistic to expect that people defined as disabled because their impairments handicap them m socially crucial spheres. .” (p. 113). There is really no excuse for this sort of linguistic trouble when an organization such as WHO has brought out a classification defining these different terms quite clearly. In that classification disability is an individual level concept referring to activity restrictions whilst handicap is the social disadvantage consequent on impairment and/or disability. The point about handicap is that it is seen to rise out of the interaction between individuals and the social contexts in which they live, where context is seen to include human and material resources which the person with disabilities may mobilise to mitigate the consequences of disability. Now. resources are a type of power which is unevenly distributed in the field of chronic illness and disablement I did not get much out of Eda Topliss’s book, but recognize that it may mentally political nature of handicap which Topliss’s functionalist perspective fails to encompass and leads her to gloss over the type of redistribution required for social justice. Are these books worth buying? I think the volume on the elderly presents some interesting information and will prove valuable to those working in the area. As someone working in the field chronic illness and disablement I did not get much out of Eda Topliss’s book, but recognize that it may be of value to students s long as its philosophical assumptions are recognized and counterbalanced, and the ambiguities in its language are pointed out and discussed. At a time when government ministers are particularly keen to obfuscate, it is tremendously important that policy issues should be clearly and penetratingly dealt with in academic work. ARC Epidemiology Research Unit Manchester Medical School University of Manchester, England
GARETH H. WILLIAMS
Contemporary Health Services, edited by ALLEN W. JOHNBERTRAM H. RAVEN. Auburn House, Boston, MA, 1982. 264~~. Sl9.95
SON. OSCAR GRUSKY and
Contemporary Health Services offers the reader a broad overview of the range of research presently being undertaken in the field of health services research. While some of the articles will be interesting only to individuals interested in a specific discipline, several will appeal to individuals from many fields. The book contains three levels of analysis: the relationship between patients and medical practitioners, relationships within the hospital, and the relationship between the community and the health care needs of its residents. Articles by DiMatteo. Rodin and Millman all address issues involving patient-practitioner relationships. In DiMatteo’s on a Science of the Art of article, “New Perspectives
Reviews
Medicine”. the emphasis on the importance of communication between physicians and their clients is supported by her research on the effective teaching to house officers the essential skills of the ‘art’ of medicine. While taking into account environmental effects on patient-practitioner interaction, such as the established social role of the physician, current physician education practices. the bureaucratic constraints imposed by the hospital and the chronic time insufficiency faced by most physicians, DiMatteo offers the suggestion that learning more efficacious communication skills may help physicians to communicate more effectively with their patients and may also enhance their ability to confront their own affective needs. Rodin’s article, “Patient-Practitioner Relationships: A Process of Social Influence” draws on the traditions of social psychology to discuss the interactive power relationships between physicians and patients. She notes that “referent power”-based on the patient’s feeling of communality with the physician-has been shown to be quite effective in producing satisfactory outcomes for both patients and practitioners but is “least used in health care at this time” (p. 60). Other more traditional forms of power include expert, coercive, reward, legitimate, and informational power. Rodin discusses some situations where other types of power may be more effective for patient care outcomes but stresses the usefulness of referent power in patient compliance, describing specific ways in which physicians can use referent power. In “The Ideology of Self-Care: Blaming the Victims of Illness”, Millman writes about the dangers of the growing popularity of self-care ideology. When people are encouraged to be responsible for their own health care, they are also deemed responsible for their health. Those who suffer from such health problems as obesity come to be seen as solely responsible for illnesses they contract and consequently are ‘blamed’ for becoming ill. Shifting the blame. to the victims releases the health care system from the responsibtlity of caring for people with certain illnesses and obscures other social and environmental causes of such conditions such as obesity. The second part of Contemporary Health Services is concerned with the relationship of the hospital with its clients and its personnel. The article by Taylor. “The Impact of Health Organizations on Recipients of Services”, addresses the problems of patients facing the seemingly monolithic hospital structure. Taylor finds that neither of two typical patient responses, reactance (anger) and learned helplessness, assists patients in receiving satisfactory medical care. In the article by Raven. Freeman and Haley, “Social Science Perspectives in Hospital Infection Control”, an analysis of problems in implementing infection control procedures, locates sources of resistance to federal regulation in actual implementation designs. Infection control committees, while under the titular head of a chairperson who is usually a male physician, are routinely run by infection control nurses who lack sufficient power, if not authority. to enforce their mandates. The current structuring of the infection control committee expresses an institutional ambivalence to federal regulation of health care. Raven, Freeman and Haley found if a specific hospital and its administraticn actively support infection control procedures, and a physician is appointed who is equally supportive, the infection control nurse has sufficient institutional support to implement the infection control procedures. Because the nurse typically has less power than the physicians in the hospital, the nurse needs physician support to enforce these policies. In hospitals where either the hospital administration or the physicians assign lower priorities to infection control policies. infection control nurses express much less job satisfaction and a lower evaluation of the effectiveness of the infection control programs themselves.
Book Scott’s article, “Health Care Organizations in the 1980s: The Convergence of Public and Professional Control Systems”, is one of the most interesting contributions to this book. Scott discusses the burgeoning administrative structures which have continued to spring up to allow the hospitals to comply with government regulatory bodies. Because of the growing need for fund-raising and cost containment in health care, Scott shows where the public and professional control systems begin to approach each other. Scott finds that the PSROs show physician acceptance of government influence. The third level of analysis of health services research deals with the community and its role and responsibility for health care. A report of a study by Evans, “Deterring Smoking in Adolescents: A Case Study from a Social Psychological Research Program”, discusses the direct application of social science research findings to intervention in the beginning of smoking among teenagers. An example of applied research, this study also highlights the value of and methodological problems in carrying out valid, reliable research within a specific community. The last two articles in this section deal with the effects of the deinstitutionalization of the retarded (“Deinstitutionalizing the Mentally Retarded: Values in Conflict”, by Edgarton) and the decarceration of the mentally ill (“Community Care of the Mentally Ill: Current Realities in the Context of Past Developments”, by Scull). From Edgerton’s point of view, attempts to integrate the retarded into their home communities and maximize the “least restrictive alternative” environments for the mentally retarded have to be judged as successes or failures from the perspective of the mentally retarded. Using middle class standards of living neglects the reality of cultural diversity in our society and imposes the value judgments of one group on the lives of different groups. According to Edgerton, many mentally retarded adults are relatively satisfied with their deinstitutionalized lives and have become integrated into their own communities in ways that are satisfactory to them. Scull, however, focusses on the plight of the decarcerated mentally ill who have not been structurally integrated into their communities. Scull views deinstitutionalization of the mentally ill as a form of dumping of the mqntally ill on local communities. These people had previously been considered the responsibility of the state or the federal government. Decarceration has resulted in disastrous family situations. protests from angry community residents, exploitative custodial enterprises which have sprung up to warehouse the frequently homeless mentally ill (e.g. in abandoned Victorian beach houses on the New Jersey shore) and much misery among the mentally ill themselves. Scull argues for a more realistic, structural assessment of the problems of the mentally ill and calls for more research on their treatment. These three levels of analysis and sections of the book-of the patient-practitioner. the hospital and the communityare supplemented by thorough. if somewhat repetitive, introductory essays by the editors. The concluding chapter of the book by Lewis (“Interdisciplinary Health Services Research: A Physician’s Perspective”) contributes an informative history of the development of health services research and the problems facing it. He discusses its multidisciplinary nature, its past emphasis on academic research topics, the current pressures on it to produce clinically usable findings. and the presently restricted funding opportunities which confront it. Lewis suggests that. in spite of these problems. the 80s will still offer some “fascinating opportunities.. to examine the Impact of deregulation. competition in the marketplace. the effects of a surplus of physicians” (p. 263): he advocates a continuing mandate for health services research. While there are some particularly interesting articles in this reader. the most significant problem of this book is the difficulty of discerning its intended audience. It offers a few interesting articles on studies of relationships between pa-
1403
Reviews
tients and practitioners (DiMatteo and Rodin). The article (Raven, Freeman and Haley) which analyzes the structural contradictions in infection control where lower status individuals (nurses) are invested with the job of policing higher status players (doctors) would have been interesting to follow with more studies from the perspective of health care management. Another very interesting article discusses the occupational caste system of the hospital and the changing power relationships within the health care system itself (Scott). The result of the collection, however, is that none of the three areas is adequately covered in terms of describing the state of research in each of these areas, and yet the selection of topics offered in the book is too specifically focussed to interest a general public. The book, in its attempt to give an overview of health services research, underscores the need of this field for the development of a coherent theory which can integrate the various disciplines now contributing to it. Deparrmenl qf Sociolog) Boston College Chestnut Hill, MA, U.S.A.
HELEN MADFIS
City Hospitals: The Undercare of the Underprivileged, by HARRY F. DOWLING. Harvard University Press, Cambridge, MA, 1982. 245~~. $22.50 Dr Dowling reviews the history of “publically owned general hospitals in larger metropolitan areas of the United States” from colonial times to the present. These are city hospitals “because they function as the main public hospitals for the poor of the city”. The book is divided into four historical periods: (I) The Alms House Period-17th (2) The Practitioner Period-mid century (3) The Academic Period-early (4) The Community Period-post
to mid 19th century 19th to early 20th 20th century 1965.
to 1965
The best documented and most insightful treatment is accorded to the Practitioner and Academic Period. In the Alms House Period a blurring of the social welfare function of the state exists; health, welfare, prison and mental health services are commingled and represented institutionally by the Alms House, a place of terror. “Those who are most deserving objects of charity cannot be induced to enter it.. .death appears less terrible than residence in the Alms House”. During the Practitioner Period the institutional differentiation of the health function from other social welfare functions emerges. Both the voluntary hospital and the city hospital are controlled in the main by non-academic private practitioners. The Academic Period marks the emergence of the university-affiliated medical center and. its hospital-based staff. with the concomitant emergence of maior emphasis on teaching and research. It represents a periodof university control. “President Charles W. Elliott was astounded to find in 1888 that there was “not a single hospital infirmary or dispensary’ in which Harvard had the least control over appointments”. This was rectified. The Community Period, an epilogue of uncertain dimensions, on the one hand represents the revolt of the consumer and the revolt of the house staff “apprentice”. Although it is not a focus of the section, it is clear from the text that the “Community Period” is as much related to the “hours. wages and conditions” of the house staff apprentice as it is to any fundamental change in health delivery based upon concern for or control by the consumer.
Book
cutting edge with which to follow through her own misgivings. So. having pointed out the way in which disability policy has been instigated only in so far as it has fitted in with the broader economic rationality of capitalist society, thus placing the aggregative principle of utility before the distributive principle of justice, she concludes that nevertheless this is preferable to following the Utopian prescriptions of moral absolutists. But the problem of injustice remains, and it is a problem which many non-absolutist writers on disability policy have attempted to confront. The apolitical nature of the analysis is also reflected in the confused rendering of the meanings of disability and handicap; terms which Topliss employs interchangeably. This tactic may allow pleasant stylistic variation but it does not enhance conceptual clarity. If I were a student of social policy, I would be mightily confused by a sentence that began: “It is unrealistic to expect that people defined as disabled because their impairments handicap them m socially crucial spheres. .” (p. 113). There is really no excuse for this sort of linguistic trouble when an organization such as WHO has brought out a classification defining these different terms quite clearly. In that classification disability is an individual level concept referring to activity restrictions whilst handicap is the social disadvantage consequent on impairment and/or disability. The point about handicap is that it is seen to rise out of the interaction between individuals and the social contexts in which they live, where context is seen to include human and material resources which the person with disabilities may mobilise to mitigate the consequences of disability. Now. resources are a type of power which is unevenly distributed in the field of chronic illness and disablement I did not get much out of Eda Topliss’s book, but recognize that it may mentally political nature of handicap which Topliss’s functionalist perspective fails to encompass and leads her to gloss over the type of redistribution required for social justice. Are these books worth buying? I think the volume on the elderly presents some interesting information and will prove valuable to those working in the area. As someone working in the field chronic illness and disablement I did not get much out of Eda Topliss’s book, but recognize that it may be of value to students s long as its philosophical assumptions are recognized and counterbalanced, and the ambiguities in its language are pointed out and discussed. At a time when government ministers are particularly keen to obfuscate, it is tremendously important that policy issues should be clearly and penetratingly dealt with in academic work. ARC Epidemiology Research Unit Manchester Medical School University of Manchester, England
GARETH H. WILLIAMS
Contemporary Health Services, edited by ALLEN W. JOHNBERTRAM H. RAVEN. Auburn House, Boston, MA, 1982. 264~~. Sl9.95
SON. OSCAR GRUSKY and
Contemporary Health Services offers the reader a broad overview of the range of research presently being undertaken in the field of health services research. While some of the articles will be interesting only to individuals interested in a specific discipline, several will appeal to individuals from many fields. The book contains three levels of analysis: the relationship between patients and medical practitioners, relationships within the hospital, and the relationship between the community and the health care needs of its residents. Articles by DiMatteo. Rodin and Millman all address issues involving patient-practitioner relationships. In DiMatteo’s on a Science of the Art of article, “New Perspectives
Reviews
Medicine”. the emphasis on the importance of communication between physicians and their clients is supported by her research on the effective teaching to house officers the essential skills of the ‘art’ of medicine. While taking into account environmental effects on patient-practitioner interaction, such as the established social role of the physician, current physician education practices. the bureaucratic constraints imposed by the hospital and the chronic time insufficiency faced by most physicians, DiMatteo offers the suggestion that learning more efficacious communication skills may help physicians to communicate more effectively with their patients and may also enhance their ability to confront their own affective needs. Rodin’s article, “Patient-Practitioner Relationships: A Process of Social Influence” draws on the traditions of social psychology to discuss the interactive power relationships between physicians and patients. She notes that “referent power”-based on the patient’s feeling of communality with the physician-has been shown to be quite effective in producing satisfactory outcomes for both patients and practitioners but is “least used in health care at this time” (p. 60). Other more traditional forms of power include expert, coercive, reward, legitimate, and informational power. Rodin discusses some situations where other types of power may be more effective for patient care outcomes but stresses the usefulness of referent power in patient compliance, describing specific ways in which physicians can use referent power. In “The Ideology of Self-Care: Blaming the Victims of Illness”, Millman writes about the dangers of the growing popularity of self-care ideology. When people are encouraged to be responsible for their own health care, they are also deemed responsible for their health. Those who suffer from such health problems as obesity come to be seen as solely responsible for illnesses they contract and consequently are ‘blamed’ for becoming ill. Shifting the blame. to the victims releases the health care system from the responsibtlity of caring for people with certain illnesses and obscures other social and environmental causes of such conditions such as obesity. The second part of Contemporary Health Services is concerned with the relationship of the hospital with its clients and its personnel. The article by Taylor. “The Impact of Health Organizations on Recipients of Services”, addresses the problems of patients facing the seemingly monolithic hospital structure. Taylor finds that neither of two typical patient responses, reactance (anger) and learned helplessness, assists patients in receiving satisfactory medical care. In the article by Raven. Freeman and Haley, “Social Science Perspectives in Hospital Infection Control”, an analysis of problems in implementing infection control procedures, locates sources of resistance to federal regulation in actual implementation designs. Infection control committees, while under the titular head of a chairperson who is usually a male physician, are routinely run by infection control nurses who lack sufficient power, if not authority. to enforce their mandates. The current structuring of the infection control committee expresses an institutional ambivalence to federal regulation of health care. Raven, Freeman and Haley found if a specific hospital and its administraticn actively support infection control procedures, and a physician is appointed who is equally supportive, the infection control nurse has sufficient institutional support to implement the infection control procedures. Because the nurse typically has less power than the physicians in the hospital, the nurse needs physician support to enforce these policies. In hospitals where either the hospital administration or the physicians assign lower priorities to infection control policies. infection control nurses express much less job satisfaction and a lower evaluation of the effectiveness of the infection control programs themselves.
Book Scott’s article, “Health Care Organizations in the 1980s: The Convergence of Public and Professional Control Systems”, is one of the most interesting contributions to this book. Scott discusses the burgeoning administrative structures which have continued to spring up to allow the hospitals to comply with government regulatory bodies. Because of the growing need for fund-raising and cost containment in health care, Scott shows where the public and professional control systems begin to approach each other. Scott finds that the PSROs show physician acceptance of government influence. The third level of analysis of health services research deals with the community and its role and responsibility for health care. A report of a study by Evans, “Deterring Smoking in Adolescents: A Case Study from a Social Psychological Research Program”, discusses the direct application of social science research findings to intervention in the beginning of smoking among teenagers. An example of applied research, this study also highlights the value of and methodological problems in carrying out valid, reliable research within a specific community. The last two articles in this section deal with the effects of the deinstitutionalization of the retarded (“Deinstitutionalizing the Mentally Retarded: Values in Conflict”, by Edgarton) and the decarceration of the mentally ill (“Community Care of the Mentally Ill: Current Realities in the Context of Past Developments”, by Scull). From Edgerton’s point of view, attempts to integrate the retarded into their home communities and maximize the “least restrictive alternative” environments for the mentally retarded have to be judged as successes or failures from the perspective of the mentally retarded. Using middle class standards of living neglects the reality of cultural diversity in our society and imposes the value judgments of one group on the lives of different groups. According to Edgerton, many mentally retarded adults are relatively satisfied with their deinstitutionalized lives and have become integrated into their own communities in ways that are satisfactory to them. Scull, however, focusses on the plight of the decarcerated mentally ill who have not been structurally integrated into their communities. Scull views deinstitutionalization of the mentally ill as a form of dumping of the mqntally ill on local communities. These people had previously been considered the responsibility of the state or the federal government. Decarceration has resulted in disastrous family situations. protests from angry community residents, exploitative custodial enterprises which have sprung up to warehouse the frequently homeless mentally ill (e.g. in abandoned Victorian beach houses on the New Jersey shore) and much misery among the mentally ill themselves. Scull argues for a more realistic, structural assessment of the problems of the mentally ill and calls for more research on their treatment. These three levels of analysis and sections of the book-of the patient-practitioner. the hospital and the communityare supplemented by thorough. if somewhat repetitive, introductory essays by the editors. The concluding chapter of the book by Lewis (“Interdisciplinary Health Services Research: A Physician’s Perspective”) contributes an informative history of the development of health services research and the problems facing it. He discusses its multidisciplinary nature, its past emphasis on academic research topics, the current pressures on it to produce clinically usable findings. and the presently restricted funding opportunities which confront it. Lewis suggests that. in spite of these problems. the 80s will still offer some “fascinating opportunities.. to examine the Impact of deregulation. competition in the marketplace. the effects of a surplus of physicians” (p. 263): he advocates a continuing mandate for health services research. While there are some particularly interesting articles in this reader. the most significant problem of this book is the difficulty of discerning its intended audience. It offers a few interesting articles on studies of relationships between pa-
1403
Reviews
tients and practitioners (DiMatteo and Rodin). The article (Raven, Freeman and Haley) which analyzes the structural contradictions in infection control where lower status individuals (nurses) are invested with the job of policing higher status players (doctors) would have been interesting to follow with more studies from the perspective of health care management. Another very interesting article discusses the occupational caste system of the hospital and the changing power relationships within the health care system itself (Scott). The result of the collection, however, is that none of the three areas is adequately covered in terms of describing the state of research in each of these areas, and yet the selection of topics offered in the book is too specifically focussed to interest a general public. The book, in its attempt to give an overview of health services research, underscores the need of this field for the development of a coherent theory which can integrate the various disciplines now contributing to it. Deparrmenl qf Sociolog) Boston College Chestnut Hill, MA, U.S.A.
HELEN MADFIS
City Hospitals: The Undercare of the Underprivileged, by HARRY F. DOWLING. Harvard University Press, Cambridge, MA, 1982. 245~~. $22.50 Dr Dowling reviews the history of “publically owned general hospitals in larger metropolitan areas of the United States” from colonial times to the present. These are city hospitals “because they function as the main public hospitals for the poor of the city”. The book is divided into four historical periods: (I) The Alms House Period-17th (2) The Practitioner Period-mid century (3) The Academic Period-early (4) The Community Period-post
to mid 19th century 19th to early 20th 20th century 1965.
to 1965
The best documented and most insightful treatment is accorded to the Practitioner and Academic Period. In the Alms House Period a blurring of the social welfare function of the state exists; health, welfare, prison and mental health services are commingled and represented institutionally by the Alms House, a place of terror. “Those who are most deserving objects of charity cannot be induced to enter it.. .death appears less terrible than residence in the Alms House”. During the Practitioner Period the institutional differentiation of the health function from other social welfare functions emerges. Both the voluntary hospital and the city hospital are controlled in the main by non-academic private practitioners. The Academic Period marks the emergence of the university-affiliated medical center and. its hospital-based staff. with the concomitant emergence of maior emphasis on teaching and research. It represents a periodof university control. “President Charles W. Elliott was astounded to find in 1888 that there was “not a single hospital infirmary or dispensary’ in which Harvard had the least control over appointments”. This was rectified. The Community Period, an epilogue of uncertain dimensions, on the one hand represents the revolt of the consumer and the revolt of the house staff “apprentice”. Although it is not a focus of the section, it is clear from the text that the “Community Period” is as much related to the “hours. wages and conditions” of the house staff apprentice as it is to any fundamental change in health delivery based upon concern for or control by the consumer.