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Sickness and society
B o o k RE', IEV~s
181
SICKNESS AND SOCIETY by RAYMOND S DUFF and AUGUST B HOLLINGSHEAD Harper & Rot,. 390 pp $12 50 Sickness and Soetet i' is based on the study of 161 patients at "'Eastern" Untverslt~ Hospital The umt of study J~ a single illness experience tracing the career of each patient from admission untd he returns home and completes his convalescence, or dies The sample criteria were 40--64 years white, married and living w~th spouse within the state, conscious on admission, adrrutted Sunday through Thursday, estimated hospltahzatJon of at least two day~, equal numbers from Surgery and Medicine, and of males and females, with at least 20 from each accommodation No data were collected without permission of the phys~cmn, patient and spouse The stated focus of the study is five general questIons on health care but the findirlgs are not orgamzed in reference to these questions Data are generally analyzed m terms or the three structural varmbles built into the organization of the hospital (service accommodation. se~) but nowhere are the significant findings pulled together In a fashion to slmphfy the reader's ass~mdatlon of facts A final chapter presents some findings and conclusions but also speculations and recommendations for organizational and pohcy changes which often seem to go beyond the hard data presented and does not represent the summary we seek Nevertheless, the major findings may be grouped around three problem areas (1) the orgamzat~on of role relatxonshlps m medicine generally and this hospital particularly, (2) the relationship of disease (ItS symptoms, etiology and approprmte treatment) to certain socml and environmental factors of the patient, (3) the use of the ward model m teaching medical students to view the pauent as s~mply "the disease m the body on the bed" and the medically undesirable consequences of that view Data were collected from a variety of sources records (admssslon, discharge, financial, medical, nursing) mtervte~s (with phys~cmns, admmlstrator~, nurses, a~des, patients and families) and obserl'attons For certain ke5 measures the authors rely on a re-reading of the full set of data for each patient, ultimately de~smg a 48-item "assessment schedule" "Each question (item) is designed to gt~e us an answer derwed from a synthesis of all the data we had accumulated '" However th~s assessment schedule is not pubhshed m the book The author~ were the judges and scorers m all cases talking untd consensus was reached When measures have been derived from the same source (e g , the full data set) and high correlations obtain certam issues arise Are the measures independent 9 Considering Table 34 t,h[ch shot, s a positive correlation of 0 84 between the individual's pre-dlness mental status, and the degree of maladjustment m his family, we ask H o t ' much ~mpllcxt weight (m the rmnds of the judges) d~d having a psychotic m the family cast in earning that famdy a ' severely maladjusted" score, since no psychotic came from a less than "severely maladjusted" home '~ The quesuon is not whether in real life a psychotic can and does disrupt normal relauonshtps, but t h e t h e r on the basts of measurement alone a farmly has an equal chance of earning a ' none or shghr'. "moderately". or "severely" maladjusted label regardless of the patient's pre-dlness mental status score Related to the independence problem described above the famdy adjustment measure suffers from a lack of precise conceptual (or operauonal) definmon The authors" procedure suggests that none was used although case examples of each category are prox lded S]mtlar problems of independence and conceptttahzatton occur elsewhere what are the specific characteristics of a disease and a r a y of life that cause them to be coded as "'disease was a way of hfe' or "disease was unrelated to a x~a.v of hfe "''~ (Table 16) By what erlterm did
182
BOOK REVlEWS
the judges code the "mamfestatlon of a symptom ' as "little or no relation to mental statu~ or "identical to mental status"'~ (Table 22) These conceptual and operational deficiencies do not necessarily invalidate the findings, but the)' do lea,~e the reader and subsequent investigator without crucial reformation, since without precise conceptual defimtions or rmmmally, operational defimtlons, this study cannot be replicated nor its findings compared with others Key measures affected by the deficiencies of definmon and independence include family adjustment, hnks between disease and way of life. pre-tllness mental status diagnosis, and appropriate management After reviewing again the full data set the authors arrive at a dtagnosls for each patient which they use as the standard for e,,aluatmg the accuracy and completeness of the diag'noses of the lesponsible physician, and maintain that 62 per cent of the diagnoses ~ere correct. Surgery made more correct diagnoses (75percent) than Medicine (46 percent) the largest proportion o f errors (on both servtces) was concentrated ,n the "underdlagnosls of mental dzsturbance " (Table 15) Errors ~n appropriate management were also concentrated in the area of "under-&agnosls mentally" (Table 18) A physician falhng to consider the emotional component as heax fly as the authors could not earn a diagnostic score of "accurate" nor a management score of "appropriate'" It ,s likely, however, that the low scores observed for diagnosis and management are less an evaluation of physician competence and more the reflection of a system that trains ~ts physicmns to focus on the physical aspects of disease whde ignoring the socio-emottonal More power Is g~ven the argument that these deficienc~es are built ,nto the present system when we realize the extremely close relationship between accommodatton, phislclan sponsolship and social status, and the tmpact of their combined effects on the training rmheu Accommodation is a function of social 3tatus ward patients are from the lower third and private pat,ents from the upper third of the soc~o-economac scale Type of physician sponsorshtp is highly associated w~th accommodation Commattee (ward), Semacomm,ttee (semJpnvate). Casual (semlprlvate, some private), Committed (private) Only ward patients have cornm*ttee sponsorship, and the authors are sharply critical of the care these patients receive "Members of the comm*ttee, for the most part, were interested in the impoverished (ward) patient to the extent that his disease advanced their learning or their research opportumtles " (p 371) The authors crmcally question whether the practices on the wards are statable as a patient care model for students of the health professions, and reply declsl,ely, "We think not, for the very neglect of personal and social influences upon disease, diagnosis, and care found m all accommodations may be viewed as extensions of the ward model" (p 381) GERALDINE TATE CLAUSEN, PH D Department of Sociology, Umverstty of Wisconsin, Madison, Wisconsin, 53706
M I G R A T I O N , M E N T A L H E A L T H AND C O M M U N I T Y SERVICES. Proceedings of a conference convened by the American Jomt Distribution Committee, co-sponsored by the World Federation for Mental Health, and held m Geneva. Switzerland. November 28-30.
181
SICKNESS AND SOCIETY by RAYMOND S DUFF and AUGUST B HOLLINGSHEAD Harper & Rot,. 390 pp $12 50 Sickness and Soetet i' is based on the study of 161 patients at "'Eastern" Untverslt~ Hospital The umt of study J~ a single illness experience tracing the career of each patient from admission untd he returns home and completes his convalescence, or dies The sample criteria were 40--64 years white, married and living w~th spouse within the state, conscious on admission, adrrutted Sunday through Thursday, estimated hospltahzatJon of at least two day~, equal numbers from Surgery and Medicine, and of males and females, with at least 20 from each accommodation No data were collected without permission of the phys~cmn, patient and spouse The stated focus of the study is five general questIons on health care but the findirlgs are not orgamzed in reference to these questions Data are generally analyzed m terms or the three structural varmbles built into the organization of the hospital (service accommodation. se~) but nowhere are the significant findings pulled together In a fashion to slmphfy the reader's ass~mdatlon of facts A final chapter presents some findings and conclusions but also speculations and recommendations for organizational and pohcy changes which often seem to go beyond the hard data presented and does not represent the summary we seek Nevertheless, the major findings may be grouped around three problem areas (1) the orgamzat~on of role relatxonshlps m medicine generally and this hospital particularly, (2) the relationship of disease (ItS symptoms, etiology and approprmte treatment) to certain socml and environmental factors of the patient, (3) the use of the ward model m teaching medical students to view the pauent as s~mply "the disease m the body on the bed" and the medically undesirable consequences of that view Data were collected from a variety of sources records (admssslon, discharge, financial, medical, nursing) mtervte~s (with phys~cmns, admmlstrator~, nurses, a~des, patients and families) and obserl'attons For certain ke5 measures the authors rely on a re-reading of the full set of data for each patient, ultimately de~smg a 48-item "assessment schedule" "Each question (item) is designed to gt~e us an answer derwed from a synthesis of all the data we had accumulated '" However th~s assessment schedule is not pubhshed m the book The author~ were the judges and scorers m all cases talking untd consensus was reached When measures have been derived from the same source (e g , the full data set) and high correlations obtain certam issues arise Are the measures independent 9 Considering Table 34 t,h[ch shot, s a positive correlation of 0 84 between the individual's pre-dlness mental status, and the degree of maladjustment m his family, we ask H o t ' much ~mpllcxt weight (m the rmnds of the judges) d~d having a psychotic m the family cast in earning that famdy a ' severely maladjusted" score, since no psychotic came from a less than "severely maladjusted" home '~ The quesuon is not whether in real life a psychotic can and does disrupt normal relauonshtps, but t h e t h e r on the basts of measurement alone a farmly has an equal chance of earning a ' none or shghr'. "moderately". or "severely" maladjusted label regardless of the patient's pre-dlness mental status score Related to the independence problem described above the famdy adjustment measure suffers from a lack of precise conceptual (or operauonal) definmon The authors" procedure suggests that none was used although case examples of each category are prox lded S]mtlar problems of independence and conceptttahzatton occur elsewhere what are the specific characteristics of a disease and a r a y of life that cause them to be coded as "'disease was a way of hfe' or "disease was unrelated to a x~a.v of hfe "''~ (Table 16) By what erlterm did
182
BOOK REVlEWS
the judges code the "mamfestatlon of a symptom ' as "little or no relation to mental statu~ or "identical to mental status"'~ (Table 22) These conceptual and operational deficiencies do not necessarily invalidate the findings, but the)' do lea,~e the reader and subsequent investigator without crucial reformation, since without precise conceptual defimtions or rmmmally, operational defimtlons, this study cannot be replicated nor its findings compared with others Key measures affected by the deficiencies of definmon and independence include family adjustment, hnks between disease and way of life. pre-tllness mental status diagnosis, and appropriate management After reviewing again the full data set the authors arrive at a dtagnosls for each patient which they use as the standard for e,,aluatmg the accuracy and completeness of the diag'noses of the lesponsible physician, and maintain that 62 per cent of the diagnoses ~ere correct. Surgery made more correct diagnoses (75percent) than Medicine (46 percent) the largest proportion o f errors (on both servtces) was concentrated ,n the "underdlagnosls of mental dzsturbance " (Table 15) Errors ~n appropriate management were also concentrated in the area of "under-&agnosls mentally" (Table 18) A physician falhng to consider the emotional component as heax fly as the authors could not earn a diagnostic score of "accurate" nor a management score of "appropriate'" It ,s likely, however, that the low scores observed for diagnosis and management are less an evaluation of physician competence and more the reflection of a system that trains ~ts physicmns to focus on the physical aspects of disease whde ignoring the socio-emottonal More power Is g~ven the argument that these deficienc~es are built ,nto the present system when we realize the extremely close relationship between accommodatton, phislclan sponsolship and social status, and the tmpact of their combined effects on the training rmheu Accommodation is a function of social 3tatus ward patients are from the lower third and private pat,ents from the upper third of the soc~o-economac scale Type of physician sponsorshtp is highly associated w~th accommodation Commattee (ward), Semacomm,ttee (semJpnvate). Casual (semlprlvate, some private), Committed (private) Only ward patients have cornm*ttee sponsorship, and the authors are sharply critical of the care these patients receive "Members of the comm*ttee, for the most part, were interested in the impoverished (ward) patient to the extent that his disease advanced their learning or their research opportumtles " (p 371) The authors crmcally question whether the practices on the wards are statable as a patient care model for students of the health professions, and reply declsl,ely, "We think not, for the very neglect of personal and social influences upon disease, diagnosis, and care found m all accommodations may be viewed as extensions of the ward model" (p 381) GERALDINE TATE CLAUSEN, PH D Department of Sociology, Umverstty of Wisconsin, Madison, Wisconsin, 53706
M I G R A T I O N , M E N T A L H E A L T H AND C O M M U N I T Y SERVICES. Proceedings of a conference convened by the American Jomt Distribution Committee, co-sponsored by the World Federation for Mental Health, and held m Geneva. Switzerland. November 28-30.