The concept “patient career” as a heuristic device for making medical sociology relevant to medical students

Sot. Sci. & Med. 1971, Vol. 5, pp. 441-460. Pergamon Press. Prmted in Great Britam.

THE CONCEPT “PATIENT CAREER” AS A HEURISTIC DEVICE FOR MAKING MEDICAL SOCIOLOGY RELEVANT TO MEDICAL STUDENTS* JOHN B. MCKINLAY Research Fellow, Department of Sociology, Umversity of Aberdeen and Attached Worker, Medrcal Sociology Research Umt, Foresterhill, Aberdeen Abstract-Increasingly it IS being suggested that the behav~oural sctences can contribute to medical education and should be incorporated into the medical curriculum. Evidence for the development of this view in Great Britain can be found in the recommendations of the recent Royal Commission on Medical Education and the submissions of various bodies to it. Given that the behavroural sciences in general and medical sociology in particular, can contribute in a positive way to the medical curriculum this paper attempts to: (a) draw together and crystallize some of the major problems inherent m past attempts to organize and include the behavioural sciences in the medtcal curriculum; (b) devise some criteria for determming the behavioural science content of the medical curriculum; (c) outline and discuss one possible course m medical sociology uttlizlng. as an organizing framework, the concept “patient career”. “ . . . any reform of medical education should, in my view, be aimed at preparing a doctor to live with change-and rapid change at that.” Lord Todd, &it. Med. Jnl. (1968), p. 208 “Cheshire Puss”, Alice began rather timidly, “would you tell me, please, which way I ought to go from here 2” “That depends a good deal on where you want to get to”, said the cat. “I don’t much care where,” said Alice. “Then it doesn’t matter which way you go,” said the cat. “-So long as I get somewhere,” Alice added as an explanation. “Oh, you’re sure to do that,” said the cat, “if you keep going long enough.” Lewis Carroll, Alice in Wonderland INTERESTINGLY, it was a physician,

Dr. Charles McIntire who, in 1894, in a paper entitled “The Importance of the Study of Medical Sociology”, was one of the tist to draw attention to the potentialities of medical sociology in the field of medicine. [1] The development of these potentiahties has, however, been a slow process [2], and it appears that medical sociology first gained entrance to the medical curriculum by way of psychology, not general sociology. [3] A brief Report on Medical Education (1944) did hint at the relevance of a sociological type of training when it emphasized the importance of encouraging the student to “collect, analyse and interpret evidence for himself; to observe and understand what he observes”, but ventured no concrete suggestions regarding how this training could be effected. * Thus paper was developed out of a presentation at the Thirteenth AMII~I Meeting of i% Socrety for the University of Glasgow, September, 1969. I am indebted to a number of people for their comments on earher versions, but most partrcularly to Mr. Gordon Horobin and Professor Peter Musgrave (now of Monash University, Australia). Thanks are also due to Professor Irving Zola of Branders Umversrty for discussions of “career contmgencies” and to Professor Raymond Illsley for creating the type of environment which facilitated the thought behind this paper. 441 Sonal Medxine,

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At about this time there appears to have emerged within the medical profession itself, a general belief that the basic medical sciences were insufficient to train the doctor of the future to cope with, for example, the socio-cultural and personal components of medical care and to equip him to fulfil the role obligations and expectations incumbent upon him as a doctor. The Goodenough Report (1944) reflected this belief when it stressed the need for medical training to have “a definite bias toward the needs of the future general practrtioner”, and called for the inclusion of the social sciences to achieve this. [5] Implicit in this and other similar statements is a broadening awareness of the potential contribution of other disciplines allied to psychology. This awareness is apparent in the Report of the General Medical Council (1957) [6] the Malleson Reports (196344) [7], and the report of the General Medical Council (1967) [8]. Although the Society for Social Medicine, in its evidence to the Royal Commission on Medical Education, also recognized the value of contributions from the behavioural sciences as a whole, it made no attempt to determine the precise contribution of specific disciplines in the field [9]. However, while there are clearly advantages in these moves away from an exclusively psychological orientation towards the widespread use of the more embracing term “behavioural sciences”, a new problem arises-conveniently shelved by both the Society for Social Medicine and the Royal Commission. Terms such as “behavioural science” and “social science” have been allowed to serve as blankets to smother the problem of further clarifying the nature and extent of the contributions of specific disciplines such as sociology, psychology, anthropology and economics. It is not proposed in this paper to enter into the general debate on whether these disciplines have anything to contribute to medicine and should be incorporated into medical training. Indeed an overview of trends in this regard suggests that for the vast majority of medical educators in the United States and increasingly more in Great Britain consider that sociology, psychology and even anthropology and economics, have an acknowledged place somewhere in the medical curriculum. Given that the behavioural sciences in general and medical sociology in particular, can contribute in a positive way to the medical curriculum the remainder of this paper attempts to: (a) Draw together and crystallize some of the major problems inherent in past attempts to organize and include the behavioural sciences in the medical curriculum. (b) Devise some criteria for determining the behavioural science content of the medical curriculum. (c) Outline and dicuss one possible course m medical sociology utilizing as an organizing framework the concept “patient career”.

SOME PROBLEMS AND INCLUDE

ASSOCIATED WITH PAST ATTEMPTS TO ORGANIZE THE BEHAVIOURAL SCIENCES IN THE MEDICAL CURRICULUM

Numerous difficulties are encountered when, in order to present a cohesive course to university students, one attempts a meaningful systematization of the vast literature in the field of medical sociology. We will briefly review some of the attempts that have been made in order to highlight a number of the difficulties encountered. McIntire, in the paper already referred to, was probably the hrst to specify in any detail, what the study of medical sociology should involve. He argued that medical sociology should comprise: (1) The study of medical practice-(a)

medicine as a profession

or institution

and a

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segment of social history; (b) Medtcal status, roles and social mteractions in relatron to diagnosis, care, management and business activities. (2) Public Health-(a) Social epidemiology and aetiology; (b) The investigations and modifications of attitudes; (c) Supplementary narrow specialities with general knowledge

DOI. Again from the United States, Acker and Roemer suggested a not dissimilar range of areas which should be covered [l I]. Both of these early attempts at specification are typically broad and, hence, superficial in then coverage. Real progress in organizing the field was not made until Straus suggested the very broad logical division of medical sociology into the sociology ofmedicine and sociology in medicine. Straus maintained that the sociology of medicine is concerned with studying such factors as the organizational structure, role relationships, value systems, rituals, and the function of medicine, as a system of behaviour, and that this type of activity can best be carried out by persons operating from independent positions outside.the formal medical setting. Sociology in medicine, for Straus, consisted of collaborative research or teaching, usually Involving the integration of concepts, techniques and personnel from many disciplines [ 121. While reviewing the general field of medical sociology six years later, Kendall more or less adopts (but does not refer to) Straus’ logical division of the field. Utilizing this type of division, Kendall maintains that sociology in medicine places emphasis on the contributions of sociological knowledge to the diagnosis and treatment of disease while the sociology of medicine concerns itself with the sociological study of the medical profession [13]. While discussing the relationship between the medical and social sciences, and the role of the social scientist in teaching and research in medicine, Butler groups the range of medical topics which have been studied sociologically into four main categories [14]. These are, the sociology of illness, the sociology of health, the sociology of medical care and the sociology of healing. This alternative categorization, like those already outlined, is, however, too comprehensive to be pragmatically meaningful, and offers no help when deadmg between two rival topics for a particular course. Other equally all-embracing courses have been suggested by Badgley [I 51, the Society for Social Medicine [16], Martin et al. [17], and the Report of the Royal Commission [I 81. A review of these and various other attempts to systematize the field of medical sociology uncovers what the author believes to be seven major difficulties associated with most of the work to date. Clearly not all of these difficulties are inherent in every attempt to organize the behavioural science content of the medical curriculum. Nevertheless, it is suggested that any one attempt, almost inevitably, contains at least one of them.

(a) The failure to identifv needs, specifv objectives and devise criteria In general, medical educators, by failing to take account of such factors as trends in the age composition of the population and changes in the nature and distribution of disease, have hindered the development of a set of general medical educational objectives. This has, in turn, prevented the elaboration of a set of criteria for the selection of topics or areas for mclusion in any course. It now seems that an urgent objective in medical education itself must be the development and detailed specification of such objectives and criteria. Some possible criteria and objectives for a medical sociology course, in particular, are outlined in the following sections.

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(b) The failure to distinguish between perspectives Very generally, the behavioural sciences can be said to be concerned with the description and explanation of the health and illness behaviour of groups and social categories, whilst medicine (especially clinical medicine) aims at the understanding and successful treatment of individual patient cases. By working exclusively on the basis of (or failing to take account of) these separate perspectives, meaningful dialogue between behavioural scientists and medical students has been made extremely difficult. (c) The faiiure to distinguish the audience It was stated in evidence to the Royal Commission that: “The purpose of teaching statistics to medical students is not to produce statistlaans, the purpose of teaching them biochemistry IS to produce biochemists” [19].

any more than

This statement applies equally to the teaching by behavioural scientists of psychology, sociology and anthropology to medical students. It is uncommon for umversity lecturers m the behavioural sciences to discriminate between medical and behavioural science students. By not distinguishing between the teaching of behavioural science theory to medical students and the teaching of such theory to behavioural science students alone, lecturers tend to concern themselves with issues and problems which, for the former, are too general, and for the latter too narrow, or almost exclusive to only one discipline. (d) The failure to take account of temporal location In British universities, the behavioural sciences, if at all, are usually taught in the preclinical years. It has been suggested that at this time, however, medical students are preoccupied with such fields as anatomy and physiology, and, since they lack contact with patients, tend to be relatively unconcerned with the behavioural aspects of medical care. Hence, medical students may be confronted with the behavioural sciences at a time when they are least likely to appreciate their usefulness [20]. (e) The failure to provide a conceptual framework Most courses in the behavioural sciences either offered or proposed, to a greater or lesser extent, tend to ressemble a sort of shopping list. For example, the courses offered by Badgley, Martin et al., and those proposed by the Society for Social Medicine and the Royal Commission all reflect this “shopping list” characteristic. After working down the list it is assumed that students will have all the technical goods required. It is, of course, difficult for students undertaking these “shopping list” courses to reflect on where they have been, appraise their current position, or consider where they may be going. Two further general problems seem to be inherent m many of the attempts to systematize the field of medical sociology, and to some extent are associated with some of the problems already outlined. (f) The problem of trying to cover too much Regardless of the allocation of teaching time it aspire to a coverage of every topic or subject area give students a taste of everything usually results students tend to lose their appetites. Badgley, to

is obvious that no teacher can possibly withm his discipline. The temptation to in a course which is so superficial that take an illustrative example, has rather

The Concept “Patient Career” as a Heuristic Device ambltlously proposed followmg topics:

445

that his second year course for medical students should cover the

“(1) reylew of concepts presented durtng the previous year (these are society, group culture, social system and work); (2) methodology; (3) analysis of the health team as a group; (4) overview of the community and ecological concepts; (5) the family; (6) patterns of child rearing; (7) sex Merences; (8) the aged; (9) social class; (10) ethniaty; (11) religion; (12) voluntary health associations; (13) the role of the patient; (14) social concept of pain; (IS) career lines of physicians--student mtem, general practitioner and speciahst ; (16)the doctor-patient relationship; (17)pattems of hospital utilization; (18) the social structure of the hospital” 1211. And all this, plus illustrations from appropriate studies, in only ten hours! Clearly it is important to realize, especially with the restricted amount of teaching time available in the medical curriculum, the impossibility of total, or even near total coverage, and the need for a high degree of selectivity. (g) The problem of omitting Important areas

This problem is, of course, an obvious extention of the need for selectivity. And, unfortunately, the omission of subjects is often highly influenced by the lecturer’s individual interests. To date, most of the attempts to present a systematic course in a behavioural science for medical students have failed to take account of areas which, given normal pnorities, should receive intensive consideration. Such a failure is well-illustrated in the outline of the specimen conrse suggested in the Todd Report. While embracing a number of areas with which medical students should ideally be acquainted, this course omits consideration of others directly affecting a medical career. Some of these priority areas are: the doctor-patient relationship, the socialization and career lines of medical practitioners, hospital organization, and the sociology of both rehabilitation and death. “Shopping list” courses tend to compound this problem by failing to provide a framework on which the relative importance of subjects can be evaluated, and thus encouraging random or purely subjective selection. SOME CRITERIA FOR DETERMINING THE MEDICAL SOCIOLOGICAL CONTENT OF THE MEDICAL CURRICULUM This section is concerned primarily with devising criteria which, given the finite amount of teaching time available, will offer some guidance in determining what aspects or areas of medical sociology should be given priority for teaching in the medical curriculum. It is perhaps important to point out that not all of the criteria to be presented are wholly original, nor are they intended to be in any way definitive. However, given recent developments in the general field of medicine, and particularly in medical education, they appear either in combination or separately, as factors which at least deserve attention from those devising a course for medical students. The fist four criteria are suggested in a recent paper by Smith and Vaughan [22] and may be termed the medical criteria, the remaining three can broadly be termed the sociological criteria. (a) Demographic changes in the population The most striking postwar demographic changes in developed countries have been the slowing up and stabilization of the birth rate and changes in the age structure towards the older ages [23]. The former is, to a large extent due to socio-cultural changes and developments with regard to contraception. Population ageing has been partly a result of this decline in the birth rate combined with an overall decline in mortality rates. Associated with these

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demographic changes, a variety of social and medical needs, although clearly not new, have assumed unforeseen proportions. Ideally it would seem important, in the training of medical and public health workers, to consider some of the medical, social, economic and cultural concomitants of demographic change and, if possible, to anticipate future developments and their probable effects on, for example, the family, social groups and major social institutions. (b) The changing pattern of disease We are frequently reminded of the fact that, over recent years, acute illness has been controlled to a remarkable degree and that deaths from infectious and parasitic diseases have all but been eliminated in developed societies [24]. There has also been a sharp decrease in certain diseases which are complications or sequelae of infectious processes (e.g. rheumatic heart disease or nephritis). These earlier major hazards to the public health are today replaced by such phenomena as coronary heart disease, hypertension, malignant neoplasms and ephysema. Such overall increases in the incidence of chronic and degenerative disease are obviously also partly due to the greater number of people living to older ages, as pointed out above. Whereas previously the patient with infectious disease, in the majority of cases, either died or recovered fully, now and increasingly in the future, a large proportion of patients ~111have to adapt to a life with a chronic disease and/or often have to adjust to long-term functional loss [25]. It is clear that future generations of medical practitioners and health workers will have to be sensitized to the particular needs of this type of patient. Bloom has suggested that this need to prepare future physicians for a deeper understanding of these factors is one of the greatest challenges facing medical education. He believes that : “the requirements of medicine appear to have shifted in emphasis from questions of knowledge about discare to questions about fk pclticnt, the patient’s feelings and the environmental context of his illness” 1261.

That the Society for Social Medicine was aware of these changing needs is reflected in its submission to the Royal Commisston when it stated: “ . . . the nature of the health problem with which medicine in Great Britain is increasingly concemedthat is, the prevention and long-term management of chronic dii of middle and old age-makea its practice more not less dependent on understanding human behaviour and social institutions and on applying that understanding in the treatment of patients*’[27].

(c) Changes in medical technology The last hundred years has witnessed a phenomenal expansion in the range of technical innovations in health and medical care. Breakthroughs in organ transplants and chemotherapy, advances in surgical techniques, developments in population screemng and the vast array of rehabilitative procedures are almost perennial events transforming our capacity to control the course of illness or disability. These developments may, of course, have negative side effects, or, in certain situations, promote more anxiety than they were onginally intended to relieve. It would seem important, therefore, that the future employers of modern technics be aware of the possibility of social and emotional problems created by their use and to be concerned with the minimization of them [28]. (d) Changes in the organization of medical care Britain has witnessed over the past twenty years an impressive expansion and improvement of health and welfare facilities. I have pointed out elsewhere that, almost without

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these improvements have involved increasing bureaucratization and the erosion of an individualistic, person-onented service. This in turn has necessitated much more knowledge and organizational expertise on the part of the client if he is to obtain the medical care to which he is entitled [29]. Perhaps we should ensure that medical students are aware of various side effects of such ratronalizations of medical and social servrces both on themselves, as the prime operators, and on patients, as the utilizers of those services. So far we have been concerned with what we have broadly termed the “medical” critena which may help in the determination of topics for a course in the behavioural sciences preparing students for future careers in the various branches of medicine. There are in addition three factors which we have loosely termed “sociological”, which should perhaps also be given consideration when attempting to design a realistic and useful course. exception,

(e) The state of knowledge in the behavioural sciences The rapid expansion of the behavioural sciences in both the United States and Great Britain has been noted in a number of places [30]. Many of these sciences are at present undergoing considerable ferment and debate. Traditional concepts are being discarded, reworked or extended, established research strategies are being questioned and new concepts and perspectives are emerging. Most commentators would regard this as a healthy actrvrty for any discipline. This phenomenal expansion and development in the area of medical sociology is reflected m the voluminous hterature appearing, firstly from the United States, and to a lesser extent in Great Britain [31]. Sociology, for example, has come a long way from and has much more to contribute than the consideration of only social stratification, the concepts of status, role and culture, the family or the community and demographic theory. A number of these developments will be highlighted in the next section where one possible course in medical sociology will be presented along the lines of the criteria being devised. Suffice it to say that in planning and implementing a course in any behavioural science which is to be both relevant and attractive to medical students and appeahng to staff, serious consideration must be given to these recent and promising developments. This, of course, places on behavioural scientists the responsibility of keeping abreast of changes and extensions in their own field, and relating these to the area of medicine. (f) What we know about students and their preferences There is now available a considerable amount of information concerning the views of medical students while they are undergoing training. This material, which takes two main forms, may furnish additional information with which to arrive at decisions on realistic undergraduate courses for medical students. We have firstly, from a number of studies of medical student socializatron, reliable information on, for example, the social-emotional stresses and role ambiguities of student life [32]. So far, unfortunately, all of these studies have been conducted in the Umted States, and one is never sure of the extent to which these findings have relevance to the British scene. There have been in Britain, and this is the second source of information, several studies of subject popularity and career preferences among medrcal students [33]. These investigations clearly point to the general unpopularity of both the behavroural sciences and social medicine durmg medical training, and the unattractiveness of public health as a career. One would have thought that these “inside” evaluative studies could provide us with valuable information to be used in decrdmg on

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both the nature, content, and timing of these courses in the medical curriculum, and methods by which any unattractiveness can be minimized. (g) The needfor a systematic approach

Martin et al., the Society for Social Medicine, and the recent Royal Commission-among others-have drawn attention to the urgent need for the teaching of the behavioural sciences to be systematic. System and organization should, of course, be a requisite of any course, but in the behavioural sciences there may be added reasons for it being so. There seems to be at least two levels on which a course should be systematic. In the first place, it should itself reflect a systematic approach in its clear specification of objectives, course content and what is expected at different points from the student. Secondly, and perhaps more importantly, a systematic approach should be manifest in the consistency with which individual teachers on the same course report findings and develop perspectives. This is not to suggest or recommend the imposition of some artificial consensus, but simply to emphasize that nothing can be more disillusioning or bewildering than for students, undertaking a single introductory course, to be confronted with diametrically opposed positions from representatives of the same or allied disciplines. Awareness of these kinds of issues, it is suggested, may help us to design courses which reduce the disorientation and role stress which we know to be the average student’s lot.

ONE POSSIBLE COURSE IN MEDICAL SOCIOLOGY CONCEPT “PATIENT CAREER” AS AN ORGANIZING

UTILIZING THE FRAMEWORK

The author’s experience (and that of some of his colleagues) while teaching medical sociology to medical students was one of dissatisfaction through a feeling that what was being taught was of low priority in relation to certain other areas, and a feeling that precious teaching time could be more profitably utilized. This dissatisfaction led the author to initiate a series of casual discussions with both students and staff in departments of sociology and social medicine. The course to be outlined is, to a large extent, the result of these discussions and represents one attempt to devise a course in medical sociology which takes account of as many of the above problems as possible by utilizing the criteria we have outlined. It is clearly not suggested that the course to be described takes account of all of the deficiencies of past courses, or that it fulf3s all seven criteria. It is, however, claimed (perhaps optimistically) that by following as closely as possible the criteria outlined in the selection of topics, most of the problems raised are taken account of. After outlining the general objectives of this course there will be a description of the “patient career” strategy and a specification of some of the topics to be included in each stage of the course. Following this is a discussion of how and when the “patient career” course might be presented to students along with a consideration of some of the advantages and disadvantages of such a course. 1. The course objectives The course aims to :

(a) Sensitize students to a sociological (as distinct from psychological or anthropological) perspective, which will serve as a framework for future and possibly more detailed investigation. (b) Provide an integrated, systematic introduction to selected areas of the field of medical

449

The Concept “‘Patient Career” as a Heuristic Device

sociology which will enhance understanding and, perhaps, facilitate the solution of present and future medical and social needs. (c) Help the student understand some of the social processes in which he is and may be involved, and some of his likely reactions to them. (d) Take account of some of the recent conceptual and methodological developments m medical sociology (within the framework provided) and, as far as possible, the ideal criteria for inclusion previously outlined.

2. Decription of the “‘patient career” strategy Outlined below are a few of the results of some of the author’s thinking, reading and drscussions on the teaching of medical sociology which represents a possible approach to the general field-one which may provrde a useful conceptual framework for teaching purposes. This approach, termed “the patient career”, orders material in a natural sequence which corresponds to various stages which may be passed through by individuals with a sickness episode [34]. The “patient career” strategy commences with the conceptron and distribution of health and illness in society, proceeds through the processes of referral, utilization, patienthood and the sick role to variously organized therapeutic encounters, and concludes logically with either rehabilitation or death. This particular conceptual approach may be diagrammatically represented as follows:

I

ConceptIon deftnltlon ond dlstrlbutaon of health ond illness

Illness

The potlent 5 healer relotlonshlp

FIG.

1.

/ _

3

behovlour,

The sick role ond potlenthood

4

Heolers

8

Rehobllltotton

-

9

The potlent heollng agency relotlonshlp

7

Deoth

Diagrammatic representation of “patient career” strategy.

A

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JOHNB. MCKINLAY

Some aspects of the “patient career” strategy should perhaps be highhghted for clarificatory purposes. Firstly, the strategy begins at a very general level with such broad issues as the definition and distribution of health and illness between and within societies over time, and accumulates detail until, at the end of the career, one is concerned with very specific areas of medical sociology. SecondIy, each area in the strategy is exponentially linked to every other area. That is, in terms of the overall formulation, each step is a sequential pre-requisite for all that follow. Thirdly, each step or area m the patient career can be considered as analytically distinct and amenable to more detailed and separate consideration (perhaps at a later date). Fourthly, the career, as it is outlined, has a logical beginning (the definition and distribution of legitimate health and illness m a particular society at a particular time) and ending (the sociology of death). The advantages of this patient career strategy are obvious. It allows lecturers and students to break down the subject matter of medical sociology into more manageable parts, to relate these parts to one another in a relatively systematic and meaningful way, and, in general, to bestow a semblance of analytic order on the chaotic state of knowledge in the field of medical sociology. In these very advantages, however, lies the chief disadvantage of this approach; for the natural exponential, sequential framework tends to suggest that more order and coherence exist in the field than is actually the case. A POSSIBLE COURSE IN MEDICAL SOCIOLOGY UTILIZING THE CONCEPT OF “PATIENT CAREER”

Specification of topics 1. Health and illness in a historico-cultural context. changing conceptions of health and illness-over time -between societies -within societies the distribution of health and illness in the community-age -sex -social class some problems in measuring moribidty and mortality-incidence and prevalence relationship of increased knowledge and technological advances to changing conceptions of illness the normality of medical and social pathology-emphasis on why is A. healthy? Not why is B. sick? Suggested reading (a) E. H. ACKERKNJXHT,Natural diseases and rational treatment in primitive medicine, Bull. Hist. of Med., 19,467497, 1946. (b) T. PARSONS,Definitions of health and illness in the light of American values and social structure, in Patients, Physicians and Illness, pp. 165-187 (edited by E. G. JACO), Free Press, New York, 1958. 2. Illness behaviour and the processes of referred and utilization. the concept of “illness behaviour” and “at risk” behaviour with critique models of health behaviour-Hochbaum-Rosenstock model -Mechanic model -Suchman model

The Concept“PatlentCareer”as a HeuristicDevice

the family, the lay referral system and utilization self medication the concept of “cues” or “tnggers to action” some factors influencing utihzation-symptom perception -proximity of servtces -sociocultural milieu -economtc and emotional cost -stigma and fear -the form in which services are delivered research approaches in the study of utilization. Suggested readings (a) D. ROSENBLATTand E. A. SUCHMAN, Blue collar attitudes and information towards health and illness, In Blue Collar World (edited by SH~STAK and GOMBWG) Prentice Hall, 1963. (b) ELIOT FRJZIDSON, Client control and medical practice, Am. J. Social. 65,374-382,196O 3. The sick role and patienthood. Parsonian formulation of the sick role and critique social class variations in sick role expectations the patient role how the sick view their world-effects of sickness on thinking, perception and remembering the stigma of particular conditions. Suggested readings (a) J. B. MCKINLAY, The sick role, illness and pregnancy. In Problems of Medical Care (edited by P. J. M. MCEWAN,) Tavistock Press, 1971. (b) H. D. LEDERER,How the sick view their world, J. Sot. Issues, 8,445, 1952. (c) F. DAVIS, Deviance disavowal: the management of strained interaction by the visibly handicapped, Social Problems, 9, 120-132, 1961. 4. Healers. the decision to study medicme the socialization of doctors-the death of idealism -training for uncertainty -the concept of “detached concern” the doctor as culture hero-charisma and its functions the concept of “trained incapacity” the birth and death of specialties. Suggested reading (a) JOHN KOSA, Entrepreneurship and charisma m the medical profession. In Problems of Medical Care, ibid. (b) H. I. L~F and R. Fox, The medical student’s training for deatched concern, In The PsychologicalBasis of Medical Practice (edited by H. I. LIEFet al.), Harper 8z Row, 1964.

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5. The patient-healer relationship. appraisal of Parsonian formulation of this relationship factors influencing interpersonal perception the negotiation of a medical reality the effects of changes in the organization of medical care on the patient-healer healers’ patient type preferences patients’ healer type preferences medical vocabulary knowledge among patients problems in studying the healer-patient relationship.

relationship

Suggested readings (a) T. J. SCHEFF,Decision rules, types of error and their consequences in medical diagnons, University of Wisconsin Psychiatric Institute Bulletin, 2, 1-21, 1962. (b) T. S. SZASZ and M. H. HOLLANDER,A contribution to the philosophy of medicine: the basic models of the doctor-patient relationship, Arch. Intern. Med., 97, 385, 1956. (c) L. PRA-~T,A. SELIGMANand G. READER,Physicians views on the level of medical information among patients. In Patients, Physicians and INness (edited by E. G. JACO),Free Press, 1958. (d) E. FREIDSON, Dilemmas in the doctor-patient relationship, Chap. 11 in Human Behaviour and Social Processes (edited by A. Ross), Routledge 8c Kegan Paul, 1962. 6. Healing agencies. the ideology and social structure of a general medical hospital the hospital in the community humour in stressful milieux ritual on a hospital ward problems characteristic of hospital doctors--alienation nurses, orderlies and auxilliaries the health centre the participant observer technique in the study of healing agencies. Suggested readings (a) R. N. WILSON,The social structure of a general hospital, Ann. Am. Acad., 340,67-76, 1963. (b) ROSE L. COSER,Authority and decision-making in a hospital, Amer. Sot. Rev., 23, 56-63, 1958. 7. The patient-healing agency relationship. admission procedures-the mortification of the self communication with the patient the functions and dysfunctions of the patient society the prestige system on the ward patient techniques for gaining information. Suggested readings (a) E. L. BROWN, Meeting patients’ psychosocial needs in the general hospital, Ann. Am. Acad., 346,117-125,1965.

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(b) R. A. SCOTT,The selection of clients by social welfare agencies: the case of the blind, Social Problems, 14248-257, 1967. (c) J. L. WALSH and R. H. ELLMG, Professionalism and the poor-structured effects on professional behaviour, .J. Hlth Sot. Behav. 9, 16-28, 1968. 8. The sociology of rehabilitation. changing patterns of disease and rehabilitation rituals associated with leaving the sick role the concept of “residual deviance” the social acceptance of the condition types of families and rehabilitation sickness, rehabilitation and shifts in family dynamrcs work and rehabilitation. Suggested readings (a) S. Z. NAGI, Some conceptual issues in disability and rehabilitation, Chap. V, Sociology and Rehabilitation, Amer. Sot. Assn., 1965. (b) THOMASJ. SCHEFF,Typification in the diagnostic practices of rehabilitation agencies, In Sociology and Rehabilitation (edited by M. B. SUSSMAN),pp. 139-144, American Sociological Association, 1965. 9. The sociology of death and dying. death and social values attitudes towards death, funerals and funeral directors death and hospital organization death and the family the social uses of funeral rites ethical problems in research on death. Suggested readings (a) B. G. GLASSEX and A. STRAUSS, Dying trajectories, In Awarenessof Dying, Aldine Press, 1966. (b) B. G. GLASSER and A. STRAUSS,Temporal Aspects of dying as a nonscheduled status passage, Amer. J. Social. 61, 1965. (c) G. NETTLER, On death and dying, Social Problems, 14,335-344, 1966. 10. Review of the course. Havmg briefly outhned the objectives, characteristics and general subject content of the “patient career” course, one should perhaps consider a number of pragmatic questions regarding its presentation and scheduling. Firstly, attention will be given to the question of how it is proposed that this course should be taught-how both in terms of teaching methodr and presentation, etc., and in terms of how much time (for both students and staff) the course is likely to consume. Having considered these issues attention will be directed to the important but separate question regarding when, during the medical student’s years at university, he should be confronted with the proposed course. The recommendations for teaching the course are only one set of suggestions (devised by the author). The course quite clearly could assume many different forms and is amenable

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to extension or shortening. Assuming that lecturmg will continue as the major form in which knowledge is presented in British universities, there could be one lecture delivered each week for ten weeks on each of the stages or areas in the patient career model. This lecture could consist of an overview of the pertinent literature and research findings in each of the ten areas as well as touching on the topics specified in the outline. Such an overview would, of necessity, have to be perfunctory but would serve as an introductionto the main issues and the latest work in each area. It would also provide a broad framework for further investigation, by the student, of selected areas. This review could be followed by detailed consideration of aspects of one or two selected studies; for example, the research designs employed, the way m which data are handled and interpreted, and possible alternative approaches, etc. Because only one lecture would be delivered on each of the ten stages in the model, it would seem important to present students with a rather detailed lecture note hand-out with the main points of the lecture clearly outlined, with a few pertinent references attached for the student to follow up if interested. Furthermore, depending on the time and the staff avadable, an associated seminar would prove a useful supplement to each lecture, to enable further, detailed consideration of the lecture topic. Ideally, these seminars should be conducted by the lecturer so that, on the one hand, students could question that person on any points of interest or uncertainty and, on the other, the lecturer could gain some indication of the efficacy or otherwise of his teaching. If adequate hand-outs were distributed, of course, it might not be so important for the actual lecturer on the course to conduct these tutorial groups. Again, each supporting tutorial should be held after, and preferably in the same week, as its lecture is delivered. This precaution would minimize informational loss through problems of recall. Another way of utilizmg tutorial group time profitably might be to set students the task of familiarizing themselves with one or two papers which illustrate some of the main conceptual and methodological problems in each of the main areas covered in the course. Assuming that students are thoroughly acquainted with these papers tutors-or perhaps students+ould lead a discussion on selected areas in them. It would be essential that these tutorial discussions were both informal and problem-oriented-that is, purposely directed at the specific andfuture needs of medical students. One point should perhaps be added about the size of these proposed tutorials. There is now a considerable amount of information regarding the effects of group size on member satisfaction, participation and problem solution. This evidence, and the author’s experience, would suggest that a membership of ten must be an absolute maximum in any tutorial group if every participant is to contribute with benefit and without feelings of threat or dissatisfaction. In terms of formal student time (that is, time actually spent in class) the course of lectures and tutorials proposed should take no more than twenty hours. This course length is in accordance with that suggested by the Society for Social Medicine [35]. In terms of formal staff time, the course would be relatively inexpensive. Let us take a hypothetical situation and calculate the number of formal teaching hours required. Assuming a class of one hundred students at one lecture per week, plus ten supporting tutorials (no tutorial group having more than ten members) the course outlined would involve eleven formal teaching hours per week. These eleven hours per week multiplied by ten (the length of the course in weeks) results in a total teaching time of one hundred and ten hours. This averages out at just over one hour per student for this course, but excludes informal contact, the frequency of which we have no means of assessing.

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One further question, probably more important and practical and certainly more thorny than the what and how question, remains. When during a medical student’s years at umversity should he be confronted with medical sociology and, indeed, the other behavioural sciences. The view is increasingly being advanced that medical students emerge from their university courses with an unbalanced view of medicine [36], and it has been suggested that, to counteract the “disease orientation”, the behaviour sciences should be introduced at an early stage in the preclinical years. It IS argued that medical sociology, at a time when medical students are relatively unsophisticated with regard to medical knowledge, and not m regular contact with patients, would both increase students’ awareness of their own participation in and contribution to blocks m patient/doctor commumcation and focus their attention directly on the doctor/patient relationship rather than on orgamc aspects of the patient’s disease [37]. There are, of course, a number of other reasons why students should be confronted with the behavioural sciences at an early date, not the least of which is the student’s own frequent complaint regarding the boredom resulting from the intensive laboratory based study of pre-clinical sciences. It should, of course, be noted that points used to argue m favour of early mclusion in the curriculum can also be used as the basis for an argument against it, as was suggested earlier m this paper. We do not yet know whether the claims being made for the very early mclusion of the behavioural sciences in the medical curriculum are valid, as there have been no reported attempts to experiment along these specific lines. The claims, however, appear reasonable a priori and worth only serious investigation by medical educators. Evidence is clearly needed on the impact of different courses at different points of the medical curriculum. It is, of course, one thing to talk about when medical sociology should be inserted in the medical curriculum and another to find a place for it. When listening to the claims of behavioural scientists, medical educators must view with dismay the already overcrowded medical curriculum-especially the pre-clmical part of it. Given, however, that recognition of the need for the behavioural sciences in medicine is increasing and that the protagonists for them will not be silenced, it seems that some traditionally sacred subjects will have to move over, and perhaps others even move out. SOME COMMENTS

ON THE “PATIENT

CAREER”

FORMULATION

One must admit that the “patient career” strategy, as it is outlined, has a number of deficiencies. These are, as I see it, threefold; but those more intimately associated with the training of medical students could probably uncover others. The first deficiency takes the form of an omission. Nowhere in the course outline is consideration given to the orgamsation and functioning of the Health Service or to comparative systems of medical care. Clearly these are important areas and, if possible, should be Included, but there are several factors which result in their deliberate omission. For one thing, bemg an essentially individuahstic framework, the patient career formulation would find the imposition of a sectron with an organizational orientation too much of a burden. Moreover, there is the sheer impossibility of total coverage. Medical care organization is one area which consumes an enormous amount of teaching time. Rather than cover it superficially and Inadequately it was thought best to omit it entirely, and give more detailed consideration to other important areas. The author of this paper is of the opmion that social administrators are more proficient than medical sociologists in this particular area. SSMS/J-c

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Certainly the most influential work to appear to date has come from social admuustrators [38], and it might be wiser for medical sociologists not to appear as jacks-of-alltrades but to become masters of a few. One further point should be added. The Health Service is clearly at present in a state of flux and uncertainty. A danger m the present situation is that medical sociologists might devote a considerable amount of time to impartmg knowledge which may, m the very near future, become redundant. Sociologists should be more concerned with studying the processes of and factors in change, within and without the Health Service, rather than merely the structure and functioning of the present Health Service itself. In addition, Departments of Social Medicme are increasingly concerned with the teaching of medical care organization. A second criticism of the course may be that there is no treatment of the methodological problems which sociologists encounter, including topics such as research design, questionnaire construction, interviewing, and elementary statistics. There are a number of sound reasons, however, for omitting such a focus. Apart from often being a painful experience for many students, methodology and statistics, as they are traditionally presented, frequently appear to be of limited value and unrelated to the mainstream of medical practice. In these circumstances, rather than offering an artificially separated “cook book” course in methodology, it would be more valuable if such considerations were built into the patient career strategy itself. There are clearly a number of conceptual and methodological problems associated with the study of each stage in the patient career, and it would seem that such problems would have greater relevance and impact if linked to their own substantive areas. Lectures could be used to review a number of illustrative studies emphasizing their research design, the way in which data is handled and interpreted, and possible alternative research approaches. A separate section on methodology, like a separate section on the health and welfare services, would find no easy place in the patient career as conceptualized above. This leads to the third, and probably most serious criticism of the patient career course. Nowhere in the outline is consideration given to important work in the field of mental health. This field is at present probably engaging the attention of some of the most creative and insightful sociologists, and promises rich rewards. It is possible to argue once again the impossibility of total coverage in any field; but, given the substantial amount of work in this area, it is undoubtedly a flaw in the conceptualization. It should be asserted, however, that the contributions of sociology to the area of human growth and reproduction are also not given consideration in the proposed course-a serious omission for an Aberdeen researcher! This area now appears, however, well worked out, and in relation to the former, attracts the attention of few sociologists. Given these, and perhaps other deficiencies in the formulation, I believe it has a number of distinctive advantages over most courses as they are currently formulated and I will state these briefly. Firstly, the patient career strategy does provide and, I think, meet the need for a systematic conceptual framework. Secondly, by being oriented towards medical problems it does distinguish the needs of the medical student from those of sociology students. Thirdly, by being essentially individualistic and “patient centred” it differentiates the contribution of sociology from that of, say, social medicine. Hopefully, it has other secondary advantages, for example, counteracting to some extent the narrow biological orientation and pre-clinical boredom. CONCLUSION

This paper has attempted to accomplish three tasks. In the first place it draws together and distinguishes some of the major problems inherent m past attempts to organize and

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include the behavioural sciences in the medlcal curriculum. Secondly, it suggests some criteria which may help in determining the behavioural science content of the medial curriculum. In the third place, it outlines and discusses one possible course in medical sociology which utihzes as an orgamzmg framework the concept of a “patlent career”. The author believes that the next few years will probably witness an increasing contribution by medical sociology to medicine generally, and medical education in particular. Given this possibility there remains the pragmatic question relating to sociology’s prospects of producing a sufficient number of properly trained medical sociologists to meet these needs. Some evidence on these prospects can be found in a report of a recent survey by Carter of the interests and research activities of British sociologists [39]. Sadly perhaps, this survey revealed that medical interests did not loom large among “main stream” professional sociologists. It appeared that only four per cent of all mam and special Interests and only six per cent of all current reported research were m the area of medicine. Respondents m this survey were also asked to comment on what areas of sociology they thought were either growth points or neglected topics. The sociology of medicine fell at an intermediate position as neither especially neglected nor overly promising. With regard to appointments it appeared that just over two-thirds of all respondents, who were engaged in work m the Sociology of Meddne, were m full time research posts. This is apparently a higher proportlon than for any of the other twenty hsted areas of interest, a statistic that has been used to Illustrate the apparent embryonic nature of the subject [40]. From Carter’s recent report on the survey it appears that the Sociology of Medicine is not a particularly promising position in relation to certain others areas of sociology. Nevertheless, it should be pointed out that Carter’s findings must be viewed with caution because less than half (42%) of those sent questionnaires replied-perhaps an inexcusable percentage for soclologlsts! There are, however, a number of promising indications such as the overwhelming response to the newly formed medical sociology group which has uncovered a number of sociologists from a variety of Institutions and colleges who are vitally interested in the field of medicine. The newly formed medical sociology group, like its brother in the American Sociological Association, promises to be one of the largest and most creative of all the study groups within the British Sociological Association. Also promismg in this regard is the development of a few postgraduate courses m medical sociology in a number of centres m Great Britain, although it is as yet too early to gauge their success, relative to courses in other areas of sociology. While the author is then, perhaps optlmistlcally, suggesting that sociology will probably be able to supply the researchers and teachers required to cope with the inevitable expansion m this area m the next few years, much will depend on developments in medical education and the willingness with which medical educators welcome the behavioural sciences. At least as far as medicine and medical education in Great Britain are concerned, the situation appears fairly promising. The situation IS equally promising for sociology. For example, it is not very often that sociology finds itself in such amiable company. In most areas sociologlsts find themselves at odds with the values of the people in the institution they are “invading”. Usually there is a resentment at being “studied”. Sometimes, when the results are not to the liking of those imvolved, there is an attack upon sociology as not being “scientific”. Researchers in the sociology of religion, the sociology of education or industrial sociology can testify to difficulties in commumcations, lack of willingness to co-operate, feelings of suspicion and threat, etc. It appears that these problems, in part, arise owing to

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differences in values between the researcher and the members of the researched mstitutions. There has been a suggestion, however, that the “metasociological” and the “metamedical” framework of values are highly compatible [41]. Health is thought to be a value m both disciplines and this enhances the possibilities of meaningful collaboration. However, some medical sociologists have doubts as to how a juncture of medicine and sociology can be brought about and, in fact, whether it should be achieved at all. There are those who regard medical settings as simply convenient places for the testing of general sociological theory. By contrast, others are dedicated to the principle of ‘%ociology in the service of medicine”, and their professional goal is to apply sociological theory and research to the solution of medical problems. There is, of course, no reason why one should not, and in fact some do, adhere to both positions simultaneously. While the chances for medical sociologists of providing beneficial knowledge for medicine and contnbutmg positively to medical education are good, equally, the prospects of testing, and even adding to, existing sociological theory through studies and teaching in medicine seem promising. Medical sociology in medical education is now in a similar position to that of pathology, bacteriology, biochemistry, physiology and pharmacology a decade ago, and a great deal can be learned from their development. In a similar manner, medical sociology has first had to establish its research contribution to medicine; and only after this is it becoming a meaningful and necessary part of the medical curriculum [42]. Even when such subjects as physiology, pathology, etc., became part of the medical curriculum they were first taught exclusively by physicians and this is often the case today for sociology [43]. Finally, it has been observed that when the natural sciences were first introduced in medical education, they had very low status [44]. This is, and will for some time remain, the experience of medical sociology [45]. Ultimately, however, the author believes that medical sociology will stand in relation to medicine as does physiology, endocrinology and biochemistry in that it is also a science which has emerged to describe and explain human functioning in the sphere of medicine, at the same time constituting a body of knowledge in its own right. REFERENCES 1. MCINTI~E,C. The

importance of the study of medical sociology, Jnl. of Amer. Acad. Med., 1, p. 423,

1894. See also The expansion of sociologic medicine, Jnl. of Soaologtcal Med. 16, l-3,1915. See for example Wxsr, L. J. Behavioural science tn the medical curriculum, Jnl. Med. Educ ,34,10701076, 1959. ROBERTSON,A. A commentary on sociology in the medical school, Canad. Med. Assn. Jnl., 84,703-704, 1961. KENDALL, PATRICIAL. Medical sociology in the Umted States, Sot. Sci. Znf., 11,20-34.1963. STRAUSS, R. The nature and status of medical sociology, Amer. Sot. Reo., 22,200-204,1957; FREEMAN, M. E., LEVPIE,S. and REEDER,LEO G. (edits), Hanabok of Medical Sociology, Prentice-Hall, NJ., 1963; HALL 0. Sociological research in the field of medicine, Amer. Sot. Rev., 16, 1, 1951. ATCHLEY, D. W. Science and medtcal education, Jnl. Amer. Med. A.m., 164,541-55, 1957. Reviewing the literature on the development of medical education in Great Britain and m the Umted States, it is difficult to foresee where and when the incorporation of new subjects is going to stop. The author recently uncovered, for example, a provocative paper arguing cogently for the inclusion of political science in medical training. After studying the paper it was disquietmg to find it not too difficult to take seriously Ideas regarding the need to establish University posts in clinical politics and political medicine. See LEPAWSKY, A. Medical science and political science, Jnl. Med. Educ., 42,905-917, 1967. 3. BROCKBANK,E. M. The Foundation of Provincral Me&Cal Ea?xatzon m England and of the Manchester School of Particular, Unrverstty Press, Manchester, 1936 and British Medical Association, The Traimng of a Doctor (The Cohen Report), London, 1948. 4. Royal College of Physrcians of London. Planning Commtttee (1944) Report on Medical Educatton, L.C.P., London. Committee on Medical Schools (Goodenough Report) Ministry of 5. Report of the Interdepartmental Health, H.M.S.O., London 1944.

2.

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6. General Medical Council, Recommendations as to the Medical Curriculum, 1957, p. 10. 7. MALL.ESON,N. (1963) Report on School of Medrcme and Human Biology (published privately), ctted m Report on a Comprehensive Medical School (1967), Institute of Social Research, London. 8. General Medical Council, Recommendations as to Basic Medical Education (1967), p. 15. 9. Society for Social Meddne, “Evidence Submitted to the Royal Commission on Medical Education”, Brat. Jnl. Prev. Sot. Med ,20, 159, 1966. 10. Op cu., see note 1, p. 423. 11. ACKER,M. S. and ROEMER,M. 1 Proposals for a department of social and preventive medicine in the university of Saskatchewan College of Medicine, Dept. of Health, Government of Saskatchewan, Regina, (Mimeographed) 1954. 12. STRAUS,R. The nature and status of medical sociology, Amer. Sot. Rev., 22,~204, 1957. 13 KENDALL, PATRICIAL. Medical sociology in the United States, Sot. Sci. Znf. 11,20-24, 1963. 14. BUIZER,J. R. Sociology and me&al education, Social. Rev. 87-96, 1969. 15. BALXXEY, R. F. Sociology m the medical curriculum, Canadian Med. Assoc. Jnl., &4,705-709, 1961. 16 Op. crt , seenote 9, p. 159-161. 17. MARX-IN, F. M. et al., A course in psychology and soctology for medical students, Lancer, pp. 411-413, 1967. 18. Report of Royal Commrssion of Medual Eiiucatron (Todd Report), Cmnd. 3569, H.M.S.O. London, 1968, Appendtx II, pp. 279-280. 19. Society for Social Medicine, op cu., see note 9, p. 156. 20. HYMAN,M. D. Medicme, Chap. 6 in LAZARSFELD, P. et al., The Uses of Sociology, 119-154, 1968. 21. Op crt., see note 15, p. IOtT. 22. Sm, A. and VAUGHAN, D. H. Education for practice and research in public health, Background paper for Arst Znt. Conf m Socral Science and Meakine, Aberdeen (Sept., 1969). 23. See in this connectton TWADDLE, A. C. Ageing population growth and chronic illness, J. Cluon. DIS., 21, 417-422, 1968. Comparable work does not appear to be available in Great Britain, but suggestions regarding changmg patterns of need are m TITMUSS,R. M. Essuys on the “Welfare State”, George Allen & Unwm, London, 1958 and Tm, R. M. Commitmen? to We&we, George Allen & Unwm, London, 1968, especially Chap. 8; BARRJE,W. D. Demographrc and social changes, In Mea&zalPractice and the Communzty (edited by BROWN,R. G. and WHYTE,H. M.), Australian National University Press, Canberra (1970), pp. 3-19. 24. In this connection see TERRY,L. L. Changmg patterns of disease, Jnl. Med. Educ., 41,305-310, 1966; MCKEOWN,T. Medrcine m Modern Society, George Allen & Unwm, London, 1965; BENJAMIN, B. Health and Vital Statrstics, George Allen & Unwin, 1968; CASSELL, J. Physical illness in response to stress, 1969 (unpublished paper). 25 The need for medical training to be oriented towards meeting future patient needs is discussed extensively m LEHMANN,J. F. Patient care needs as a basis for development of objectives of physical medicine and rehabilitation teaching in undergraduate schools. J. C/won. Dis., 21,3-12, 1%8. 26. BLOOM,S. W. The role of the sociologist in medtcal education, Jnl. Med. Educ., 667-673, 1957. 27. Op cu., see note 18, p. 159. 28. See for example KEMFX,J. P. et al., Kidney transplants and shifts in family dynamics, Am. Jnl. Psychratry, 125,39-U, 1969, and Fnamso~, E. Review essay: health factories, the new industrial sociology, Socral Problems, 14,493-500,1966-67; FLETCHER, JOHN,Human experimentation: ethtcs in the consent situatton, Law and Contemporary Problems, 32, 620-649, 1967. 29. MCKINLAY,J. B Better maternity and cluld care for whom . . . ? The MedIcal Officer, 15th Nov. 1968 See also in thts connectton SUCHMAN, E. A. Medical deprivation, Amer. Jnl. Orthopsych., 665672, 1967; FREIDSON,E. The organzatton of medical practice and patient behaviour, Am. Jnl. Pub. Health, 51, 43-52, 1966; STRAUSS, A. L. Medical ghettos, Transaction, 77f, May, 1968. 30. See for example MERTON,R. K. et al., Soczology Today, Basic Books, N.Y., 1959; LIPSET,S. M. and SMELSER, N. J. Sociology, The Progress of a Decade, Prentice-Hall, N.J , 1961. 31, From the United States, there have appeared: SUSSMAN,M. B. (ed.) Sociology and Rehabihtation, Amertcan Sociologtcal Association, 1965; MECHANIC,D. Medzcal Sociology, Free Press, New York, 1968; DUFF, R. S and HOLLINGSHEAD, A. B Szckness and Socrety, Harper & Row, London, 1968; KtNG, S. H PerceptIons of IlIness and Medical Practice, Russell Sage Foundation, New York, 1962; FREEMAN,H E. et al, Handbook of Medrcal Socrofogy, PrenticeHall, N.J., 1963; APPLE,D. (ed.) Sociological Studres of Health and Illness, McGraw-Hill, London, 1960; JACO,E. G. (ea.), Patzents, Physrciam and Illness, Free Press, Glencoe, Illmots, 1958; KNUTSON,A. L The ZndunduaI, Society and Health Behavrour, Russell Sage Foundation, N Y., 1965, SCOTT,W. R. and VOLKART,E. H. (eds.), Medrcal Care, Wiley, N Y., 1966 To a lesser extent, there have appeared 111Great Bntain C~-rwar~rrr, A. Human Relatrons and Hospual Care, Routledge & Kegan Paul, London, 1964; Sussna, M. W and WATSON,W. Sociology m Medrcine, Oxford University Press, 1962, CAR-IWR~GI~~, A. Patzents and Theu Doctors, Routledge & Kegan Paul, 1967; In addition there has been the appearana of new and the

460

JOHNB. MCKINLAY expansion of existing journals like Sot. Sci. & Med.; Medical Care; J. Hlth Sot Behav. and The Mdbank Memorial find Quarterly.

32. For e%amples, see MWTON, R. K. et al., The Student Physician, Harvard University Press, Cambndge, Mass, 1957.. especially the chapters by Rooo~~, NATALIE, The decision to study medrcme, pp. 109-129 and HWQRON, MARY,The development of a professional self image, pp. 179-187; BECKER,H. S et al., Boys in Whrte, Student Culture m Medical School, Umversity of Chicago Press, Chlcago, 1961; ERON,C. D. Effect of medical education of student attitudes, J. Med. E&c. 30,559-566, 1955, HALL,0. The stages of a medical career, Am. J. Social., 53, 327-336, 1948; LIEF, H. I. and Fox, RENEE,The medical students’ train& for detached concern, In The Psychological Basis of Me&Cal Tramrng (edltcd by LIEF, H. I. et al.) Harper & Row, N.Y.,; BLOOM,S. W. The process of becoming a physician, Ann. Am. Acad. Polit. Sot. Sci., 346, 77-87, 1963; Additional studies are reported in Medical careers in public health, The Milbank Memorial Fund Quarterly, 44,1966. F. M. and BODDY, F. A. Career preferences of medical students, The Sonologtcal Revrew 33. Mam, Monograph, No. 5,21-32, 1962; “Survey of Medical Students in 1966”, Appendix 19, In Report of the Royal Commission on Medical EXucatron, 1965-68, op. ctt.. see note 27. 34. A more extensive discussion of this “natural sequence” type of approach appears in SMELSER,N. J. Theory of Colkctive Behaviour, Routledge & Kegan Paul, London, p. 12, 1962. 35. Op cit., see note 9, pp. 160-161. P. R. An expenence in teaching the doctor-patient relatIonshIp to first 36. Po~cxc, S. and MANNXNG, year medical student, Jnl. Med. Educ., 42,X%774,1967. 37. Ibid. p. 770. A. J. The Creation of the National Health Service, Routledge 6 Kegan 38. w for example, WILLCOCKS, Paul, London. 1%7; ABEL-S-, B. 7’he Hosprtah Z8OfLZ948, Heinemann, London, 1964; TIT-, R. M. &ays on the Welfare State, Allen & Unwin, London, 1958; TX-, R. M. and ABEL-SMITH, B. Zhe Cost of the National Health Service, O.U.P., 1956; m, R. J. and KINNAIRD,J. Health Servrces A&ninistratton, E. & S. Livingstone Ltd., London, 1965; DONNBON, D. U. and CHAPMAN, V. Social Policy and AdminiJtratlon, Guxge Allen & Unwin Ltd., 1965. CARTER,M. P. Report on a survey of sociological reaearch in Britain, The Socaal. Rev., 16, 5-40, 1968. :: BUTLER,J. R. op. cit., see note 14. 41. Cuans, J. H. Sociology and medicine: some steps toward reapproachment, Amer. Cath. Sot. Rev., 21, 9-17, 1960. 42. Smom, J. The social scientist as researcher and teacher in the medlcal school, J. Hlth Human Behav., I, 42-46,1960.

43. STAINBROOK.E. and WEXTER,M. The place of the behavloural sciences in the medxal school, Psychiatry, 19,263-269,1956. 44. Bu)(IM, S. W. et al., The sociologist as medical educator: a discussion, Amer. Sot. Rev., 2!?$97, 1960. 45. The author believes. however, that there are a number of fundamental issues which require clariication and discussion befo& medical educators can request a widespread investment of sociological resources. See MCKINLAY,J. B. Before involvement: some questions for the attention of medical socioloqsts. Forthcoming in Br. J. Social., 1971.