Culture, health and illness: An introduction for health professionals

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This study examines several related aspects of this link between primary and secondary care, particularly how and why GPs refer their patients to hospital consultants for further investigations or treatment, and also their use of the hospitals for pathological or radiographic investigations. Dowie has conducted both a quantitative and qualitative survey of the referral behaviour of 65 GPs45 of whom were interviewed in some depth-in a 3-month period. Patients were referred to a local 400-bed district general hospital serving a population of 165,000 scattered over 4 small towns in south east England. She examined the stated reasons (in referral letters) for 2402 hospital attendancesby 1699 individual patients-during this period, of whom 370 had been referred by GPs. Her findings of the ‘referral decision making’-i.e. whether or not to refer a particular patient for a specialist’s opinion-make salutary reading for those health planners attempting to design a rational, cost-effective health care system, free of such messy influences as the personality, background or training of the individual GP. Many referral decisions were, predictably, found to be based on ‘non-scientific’ criteria, such as the desire to reassure the patient (and the GP!). Referral rates were found to vary by a factor of 25 among GPs. They differed particularly on the threshold at which referrals were made, and in the data included in the referral letters. Dowie relates these variations to other factors, such as the GP’s age, ideological preferences, personal values, styles of interaction, training, knowledge of the patient, knowledge of the resources available and knowledge of the reactive patterns of individual consultants. Much of this will not be news to any practising GP, but Dowie’s contribution is to quantify, as far as possible, the prevalence of these variations’in referral behaviour. She ascribes much of this variability to variations in the family doctors’ cognitive processes, especially differing confidence in their clinical judgement, and differing awareness of the “base rate probabilities of the occurrence of life-threatening events”. She utilizes Janis and Mann’s Conflict Model, a model of decisional conflict, to explain the cognitive processes underlying decisions to refer. However, much of this data can only be inferred, since she did not conduct detailed psychometric tests on GPs, nor make a comparison with appropriate control groups. Furthermore, the Conflict Model, while useful in describing the origins of referral decision making, offers little prescription for improving this process in real life. As Dowie convincingly makes clear, GPs are not computers and their decisions are frequently made on a seemingly irrational basis. Despite her assertion (p. 176) that “there is need for widespread experimentation with systematic programmes to teach medical students when to collect and how to evaluate information provided by investigations”, it is difficult for anyone experienced in the actuality of general practice to see how such educational efforts could produce decision making. Too many non-quantifiable variables, including the GP’s social class, cultural and religous background, as well as individual preferences and ‘pet theories’ all influence prescribing, treatment and referral behaviour. as several studies have shown. Although this book did not address many of these aspects of GP-patient and GP-consultant interactions, it nevertheless is a useful illustration, backed up by a large body of data, of how the individual, human element in GPs, consultants and patients may confound the designers of rational health care systems based on computer models of efficiency, rather than on the reality that Dowie so convincingly illustrates. Department of General Practice Middlesex Hospital Medical School England

CECIL G. HELMAN

Culture, Health and Illness: An Introduction for Health Professionals, by CECIL HELMAN. Wright, Bristol, England, 1984. 242 pp. $31.50

Reviews In attempting to teach the clinical relevance of anthropology to physicians-in-training, medical students and other health care professionals. I have searched far and wide for a concise, well-written and lively textbook which would introduce my busy colleagues to the burgeoning field of medical anthropology. Although many excellent multi-authored texts on this subject have appeared in recent years. I was most pleased and excited to discover Cecil Helman’s newlypublished Culture, Health and Illness: An Introduction for Health Professionals. Dr Helman, a British general practitioner-medical anthropologist, writes with his “health professional” audience in mind, and rather than attempt an encyclopedic review of the massive medical anthropological literature. he is thoughtfully selective in choosing key references to illustrate the major issues. Following a brief introductory chapter which provides an overview of the scope of medical anthropological inquiry, there are ten chapters which cover a variety of subject areas: ‘Cultural Definitions of Anatomy “Diet and Nutrition”, “Caring and and Physiology”, “Doctor-Patient Interactions”, “Pain and Curing”, “Culture and Pharmacology”, “Ritual and the Culture”, Management of Misfortune”, “Transcultural Psychiatry”, “Cultural Asoects of Stress” and “Cultural Factors in Epidemiology”. Dr Helman’s writing style is consistently interesting, entertaining, clear and relatively jargon-free. Particularly informative are his discussions of the British National Health Service, medical pluralism in Britain, the cultural dimensions of everyday medical encounters and the complex nature of healing rituals. Frequent use is made of illustrative case examples-an effective technique for transmitting pertinent knowledge to the reader. A final appendix outlines a very helpful series of clinical questionnaires which can serve either as a study guide to each chapter, a method for generating classroom and group discussion, or a starting point for students undertaking small medical anthropological research projects. As is the case with any introductory text, specific topics in each of the chapters could have been more fully developed. For example, the discussion of pain and culture draws heavily on Zborowski’s studies in the 1950s of ethnic differences in the experience of pain, but does not cover more recent work relating to the sociocultural determinants of acute versus chronic pain and subsequent illness behavior. “Hard-core” biomedical clinicians and researchers will appreciate the chapter on the “cultural epidemiology” of various diseases (e.g. cervical cancer, coronary heart disease, hypertension, parasitic infections, kuru), but will probably be disappointed that other contributions from the fields of biological and physical anthropology are not presented. Similarly, nursing health professions will miss reading about the important theoretical and research contributions made by nurse medical anthropologists. A number of important subject areas are also either omitted or just barely touched upon in the book. These include (I) the interface between medical anthropology, “community diagnosis” and the delivery of “communityoriented primary care”; (2) the implications of a crosscultural perspective for the emerging disciplines of family medicine, family therapy and family systems theory; (3) the historical roots and cultural dimensions of biomedicine and the various medical specialties; and (4) the political economy of health care and the socioeconomic forces which determine the production, distribution and exchange of medical knowledge, goods, and services. Finally, this reviewer would have liked to read more about Dr Helman’s personal views regarding future directions for medical and clinicallyapplied anthropological research. The book unfortunately ends rather abruptly and would have benefitted from a final summarizing chapter. Despite these minor limitations. I found Culture, Health and illness to be an absolutely marvellous and refreshing

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Book Reviews addition to the existing medical anthropological literature, and only hope that the publishers of this relatively high priced volume will come out with a less expensive paperback version so that a broader reading audience can be attracted. Dr Helman truly succeeds in making the case that an anthropological perspective is indeed relevant for the clinical practice of medicine. I plan to make extensive use of Culture, Health and Illness in my teaching of residents, medical students, and undergraduates, and I am pleased to be able to recommend the book without any hesitation to both the newcomer to the field of medical anthropology as well as the veteran scholar! Department of Family Medicine University of Medicine and Dentistry of New Jersey Rutgers Medical School New Brunswick, N.J., U.S.A.

ROBERT C. LIKE

machines, and the great prestige given to scientific mnovation in medicine make this critique valuable. This work widens our understanding of a basic force in health care and can help us to rethink and reshape our views and actions. The Vniversily qf Texas STANLEY J. REISER Health Science Center at Houston Program on Humanities and Technology in Health Care Houston, Tex., U.S.A.

Delivering In-Home Services to the Aged and Disabled, by FREDR~CKW. SIEDL, ROBERT APPLEBAUM, CAROL AUSTIN and KEVIN MAHONEY. Lexington Books, Lexington, Mass.,

1983. 197 pp. $23.95 Home Health Care: Its Role in tbe Changing Health Services Market, by ELI GINZBERG, WARREN BALINSKYand MIRIAM

The Culture of Technology,

by ARNOLD PACEY. The MIT Press, Cambridge, Mass., 1983. 210 pp. $17.50

&TOW.

Medical technology is becoming a consuming force not only in modem medicine, but in our society. Its growth began to take on momentum in the early nineteenth century. By its end, an armory of diagnostic tools were in place that in outline represent those used today: tools of seeing into the body, and chemically and electrically analyzing its parts. In the twentieth century, therapeutic tools were added to these diagnostic agents. We entered an era in which surgical intervention and drug therapy grew rapidly. Up until the mid-1960s most discussion of these developments took place in the pages of medical journals. Occasionally, stories of dramatic medical findings reached newspapers and the lay literature. But since that time, social interest has become so intense that hardly a day passes without a story about medical technology and its effects reaching the newspaper’s front page. These events make Arnold Pacey’s book important reading. It seeks to place technologic change in general into a cultural context. It is a critique of the concept that technical capacities of a technologic innovation cause social change without social change crucially affecting the use of technology. He argues that innovation itself is an outcome of a complex interaction between social, cultural, as well as technical elements. New patterns of organization, for example. had to be invented before certain techniques would appear. Thus, television required a mass entertainment concept and organized media, not just a technological logic. Similarly, the presence of factory organization gave James Watt an opportunity to perfect his innovation. He notes: “If the advance of microelectronics now seem inevitable, we ought to ask what kind of organizational pressure lies behind it?’ @. 27). Pacey is also concerned with the place of values in the development and practice of technology. He sees a conflict between values of innovative creativity with their imperative to master nature wherever it may lead, with values asserting a concern with the user, in which innovations help people to care for selves and nature. Moreover, these two in turn are in conflict with economic values, whose priority is whether an innovation aids manufacture and economic growth. Such values determine the sorts of technology produced. Dangers arise when the pursuit of one of these values becomes obsessive. and the others become eclipsed. Pacey would like to see greater efforts on the part of those who use and invent technology to balance “need-orienting, nature-conserving, and virtuosity-related goals” @. 126). Although medical examples are used throughout this book. it is not a work about medicine directly but an analysis of technology as a scientific and social force. However, the interactions of patients. practitioners and

The unprecedented demographic phenomenon of large numbers of people in industrialized societies reaching old age is creating major problems for health planners, economists and social policy-makers. Already in the United States, 11%of the population is over 65, a percentage that will double within 50 years. The numbers of people over age 85 are rising even faster. Elderly patients are admitted to acute care hospitals two and a half times as often as younger people and stay almost twice as long. They presently occupy 85”/, of all nursing home beds. The elderly consume 40% of total health costs in the United States, of which two-thirds is paid by various government programs, chiefly Medicare and Medicaid. Although most elders are relatively healthy, about 20% are functionally impaired and require assistance with activities of daily living (ADLs). Providing long term care for the frail elderly is becoming increasingly expensive, although two-thirds of them continue to live in the community (as opposed to nursing homes) and to receive the bulk of their care from family and neighbors. Primarily in hopes of reducing health costs, expanded home care programs are receiving new attention as an alternative to long term institutional care and as a means of reducing the frequency and length of acute hospitalizations. In modern times home care has been much neglected. In 1979 only 2.1% of the total Medicare budget and 1.2% of Medicaid were allocated to it. In the mid-1970s several demonstration projects in various locations studied the costs and potential uses of increased home services, which were provided under waivers from Medicaid. One of these was the Wisconsin Community Care Organization (CCO), the subject of the work by Seidl et al. The CCO, begun in 1975, was a nonprofit corporation controlled by representatives of local community service agencies, funded by a private foundation and by a Medicaid waiver, and endorsed by the state government. It began with the hypothesis that providing personal care services (i.e. assistance with ADLs) to frail elders in the community could help preserve functional status and hopefully delay or prevent institutionalization. The CC0 used case managers to target services to clients who they felt were at high risk for entering a nursing home. The chief screening instrument was the Geriatric Functional Rating Scale (GFRS), which measures not only the functional status of the client but also assesses the available home support network. They operated in three separate locations, one rural, one urban and one mixed. Each experimental site had a matched control site. Patients in the control groups received usual home services, without case management and without the extra services available through the Medicaid waiver. Both groups were studied at entry, at six months, and at fifteen months by the

Rowman & Allanheld, Totowa, N.J. 1984. 186 pp.

$27.50