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THE USES OF SOCIAL SCIENCE IN MEDICINE
Saturday THE USES OF SOCIAL SCIENCE IN MEDICINE* MERVYN SUSSER M.B. W’srand, M.R.C.P.E., D.P.H. SENIOR
LECTURER, DEPARTMENT
OF SOCIAL AND PREVENTIVE
MEDICINE,
UNIVERSITY OF MANCHESTER
of society is still sometimes required to " credentials establish its as science ". For the sceptics, science is experimental and the social world is not amenable to its methods. This is a timebound idea, derived from the great successes of experiment during the past two centuries. With more truth, a field of study can be classed as science once it has produced speculations, theories, and hypotheses of an order which can be tested. Such hypotheses’ abound in social science, although the work of testing may lag. The tests need not be experimental. Students of society can rarely make planned experiments; in lieu of experiment they use the natural contrasts between societies and opportune changes within them. But they do not ignore measurement, although they must often rely on verbal communication and direct observation of behaviour. Physicians should well understand the importance and validity of these methods (even THE
study
though they are beset with large margins of error) for they resemble those of medicine; the clinician uses direct observation, and the epidemiologist measures and compares groups. The social sciences are in their infancy. Their productivity is much less than that of the physical sciences, for the study of society is among the most difficult of scientific endeavours. At each level of observation in the study of human beings, through the molecular, the cellular, the organic, the individual, and the social, the
number of uncontrolled variables is successively multiplied. As with the whole of medicine, proved facts are relatively few, and must be linked by hypothetical constructions; in what follows I cannot pretend to scientific proof for all my assertions. None of this is a cogent reason for dismissing the study of society as non-scientific, or useless. We learn from social science to adopt a position of scientific detachment towards society; to analyse, classify, and generalise observations in terms of social groups; and to measure and define the objective, if intangible, regularities of social relationships. One can treat social science in medicine under four heads: 1. Social factors in health and disease. 2. Patients as social beings. 3. Doctors in relation to patients. 4. Systems of medical care.
Henry Sigerist, writing about the history of summed up these social relations of medicine:
medicine,
" In every medical action there are always two parties the physician and the patient, or in a broader sense, the medical corps and society. Medicine is nothing else than the manifold relations between these two groups. The history of medicine, therefore, cannot limit itself to the history of the
involved,
*
7357
From
a
lecture
to
the
Keppel Club.
29
August I964
science, institutions and character of medicine, but must include the history of the patient in society, that of the physician, and the history of the relationship between physician and.patient." (Sigerist 1955.) Social Factors in Health and Disease Epidemiology is the study of the distribution of health and disease in populations, and part of its province is the study of the related social factors. Indeed, every epidemiological variate is in some sense a sociological variate. The factors affecting the distribution of disease in populations may be biological or environmental, and both have social implications. The populations to whom
the biological dimension refers are not mere aggregates of discrete individuals. They comprise, as groups of people with some order of relationships between them, the elements of society. The environment which contains the populations is equally a facet of society in its physical and biological as well as its social components; civilisation, however primitive, is natural environment modified by human groups. Epidemiologists have tended to interpret such basic attributes as sex and age and marital status in biological terms. But these variates also have social meaning, and their distribution in a population implies a particular configuration of statuses in society; each of these statuses carries its own set of obligations and duties and social relations. Each marital status, for instance, has implicit in it distinctive expectations of support for the individual should he fall ill. We may therefore predict that an individual’s marital status will affect his decision to seek help from a medical agency, or to enter a medical institution. Such decisions give rise to unrepresentative populations which distort the view of disease obtained by any one agency, whether it is general practice, or a hospital, or a public health department. The forces which determine whether an individual or a group breaks through the surface of anonymity to recognised morbidity are thus not only pathological but psychological and social. They need to be interpreted in terms of psychology and sociology. Many doctors are agreed that social factors are important in disease. The significant question is whether they need to be equipped to handle the notions relating to these factors, or whether an empirical, amateur approach is sufficient. Sociological notions tend to be many-sided and unamenable to simple, finite definitions. One example with wide currency is the concept of social class. The phenomenon it describes is real enough, but even sociologists disagree about its fundamental nature. For the 1911 census Stevenson, chief statistical medical officer to the General Register Office, devised a method of measuring social class by arranging all occupations within a hierarchy of five classes. His classification, somewhat modified, has regularly come to be used in national statistics and in medical research. If it is to be used with confidence, however, some understanding of the assumptions and the criteria which divide the classes
426
is needed. Yet half a century after the classification was introduced it is not clear how far these are arbitrary, or theoretical, or empirical, and anomalies of classification ensue.
Anomalies also reside in the classification itself. Any method of stratifying society aims to reflect its real structure. But Britain is not a social pyramid divided into five horizontal layers, which is the model the classification suggests. The lines of cleavage are vertical as well as horizontal (Watson 1962). Moreover, social groups are not static; the movement of individuals between social groups, and the movement of whole social groups, obscures the pattern. We can hardly hope to understand the distribution of schizophrenia, or mental coronary heart-disease, or bronchitis, grasp both the cleavages in society and the constant reshuffling of social and genetic attributes that
subnormality, unless
or
we can
accompanies social mobility. To handle such material we need the most rigorous methods that social science can offer; studies of social factors in health and disease which do not use them neglect a vital dimension. Patients
as
Social
Beings
Value Systems Patients are social beings, and much of their response to disease and their behaviour with doctors is socially determined. Doctors can hardly avoid learning empirically, in day-to-day practice, a good deal about thisaspect of their patients. Such knowledge, however, is comparable to that which a priest might have about the prevalence of disease in his parish; it is usually not ordered and interpreted in a theoretical framework. Despite this deficiency, doctors often feel that they do command special competence in questions of behaviour. This feeling may take on the flavour of authority, for medical education in the past has not been prone to emphasise what the physician did not know. It could be argued that one task of medical education has been to breed confidence in the physician’s own judgments, and through this confidence to promote his authority and ability to act; for the practice of medicine is beset with uncertainty in diagnosis, in treatment, and in prognosis. In the times when medicine had little scientific basis personal authority was the more necessary to the doctor, and such authority may still have value in inducing compliance in patients. In recent times, advances in organic medicine have enabled doctors to abandon some of this personal authority and to practise scientific humility, because they could rely on the growing authority of scientific knowledge. The substitution of scientific for personal authority has not been easy; as late as the end of the 19th century Samuel Gee, whose surname is the eponym for coeliac disease, is said to have advised his students not to bother with physiology. The substitution of science for authority is even more difficult when judgments must refer to the psyche and to society. The objective study of society requires the examination of value systems. To do this the social scientist, in his scientific role, must stand outside society. But each of us is a product of society, of its mode of rearing children, of its moral beliefs, and of its assumptions about people and society. Each of us knows right from wrong according to the special values that obtain in our own culture. The social scientist must detach himself from these built-in attitudes and modes of thought; this is to stand outside himself. Social scientists share this task with students of the
mind; its magnitude is emphasised by the psychoanalytic doctrine that self-analysis is scarcely possible. Ernest Jones thought that the greatness of Freud’s achievement could be measured by his feat of self-analysis (Jones 1957). It is perhaps no accident that men like Marx and Freud, both in some ways marginal to the society in which they lived, helped to found the modern sciences of society and human behaviour. Men secure in society are not made to question their values and ways of life, and tend not to feel a need to study them. The Sick Role Many doctors have
accept that what causes a particular individual to present as a sick person should in part be interpreted in psychological terms. Whether a patient’s symptoms rise above the threshold of complaint depends on the way in which he perceives illness and in which he is moved to act about it. Perception and motivation, however, are determined by the particular social context in which the individual lives and in which he performs his social roles. During growth he learns the behaviour expected in the roles appropriate to each new stage of development, and what he learns becomes an integral part of his personality. All behaviour is to some extent a reflection of social roles, and of the duties and come to
expectations implicit in them. It follows that to be sick is a social phenomenon. The sick person, as Sigerist long ago pointed out, has a special position, a social role with implicit rules and privileges (Sigerist 1927). Sickness is not synonymous with disease although it includes it. Disease can be defined as a state of physiological or psychic dysfunction which affects the individual organism, whereas sickness is a state of social dysfunction which affects the individual’s relations with others. The conditions in which sick privileges are conferred therefore vary between societies, between cultures and between particular social situations. The relationship of the patient with the doctor is only one aspect of his total situation and derives from it, and an adequate assessment of the patient requires analysis of his social context. Social science enables the doctor to make the analysis systematic; this should be as much a part of medical history-taking as systematic inquiry about symptoms. The analysis would examine the structure and content of the patient’s relations in the home, in the wider community, and in his occupation, and consider the relevance of these various associations in the clinical settlng. The structure of the relationships is determined by the status of the interacting individuals-in terms of age and sex and social position-and by the ramification of formal and informal ties between them. The content of the relationships depends not only on the personality of those who interact, but on the nature of their ties, and on the expectations and sanctions attached to them by the culture. Interaction is mediated by what is right and proper in the appropriate system of values. Communication Analysis of this kind places the doctor in a better position to comprehend the problems of patients. It may also help him to communicate more effectively with them by supplementing intuition with intellectual appraisal. Effective communication in the face-to-face situation between doctors and patients is fundamental to diagnosis and treatment. Much evidence shows how frequently communication by doctors does not produce the hoped-for result in their patients.
427 In
Israeli study patients were asked, before the doctor and again afterwards, whether they
a recent
seeing
considered they had a dangerous or a minor illness; the doctors were asked to make a similar rating (Pridan and Navid 1964). 40% of those patients rated by the doctor as having minor illness had thought, before seeing him, that their condition was serious. After seeing the doctor, 1 in 10 of the 40% no longer thought their condition serious, but the original number was exactly restored by others who had come to think their illness serious. In the patients’ perception of their illnesses there had been hardly any shift which could be attributed to the consultation. Although the doctors had succeeded in communicating instructions to these patients, they had not succeeded in communicating either reassurance or information about illness. How much medical advice and exhortation is equally ineffectual in the face of values, beliefs, and social relationships that the doctor has not appreciated ? The study of the patient as a social being has something to contribute to clinical practice.
The Doctor’s Medical Situation Many other factors influence the doctor’s relations with patients and the quality of his performance. To take one example, Freidson’s study of the Health Insurance Plan in New York suggests that the situations in which doctors work, and the groups to whom they refer to approve their behaviour, exert a marked effect on their relations with patients (Freidson 1961). The general practitioner, who stands close to the community and is subject to many pressures from it through his practice, tends to be sensitive to the personal aspects of care. In contrast, the hospital physician is under little pressure from the surrounding community or from patients, and he tends to be sensitive to pressures from professional colleagues. While such pressures are likely to maintain the doctor’s technical competence, they do not promote attention to the personal needs of patients. In line with this we have found that the mistakes of hospital practice often seem to arise from failures of communication, and the mistakes of general practice from technical failures.
.Medical Education The clinical situation is immediate to the doctor’s Doctors in Relation to Patients The medical personality which reacts to the behaviour. The Doctor’s Social Situation situation is founded on more remote factors, and to search The doctor is the professional of the two parties them out one must examine the medical profession as a involved in the transaction of medicine, but he too is a its political and economic interests, its organisation, social being; his social situation influences the transaction. whole, and its values. At the heart of its values lies the system The ideal type or model of the doctor’s relationship with of medical education. Medical education is more than a the patient takes no account of this; as Talcott Parsons has put
"
it, his position is one of affective neutrality " (Parsons 1958). The doctor tries always, according to the medical ethic, to give priority to the patients’ interests and needs, but at the same time he must remain emotionally detached from him. Theoretically the doctor elicits the necessary information about the patient, collates it, and makes his judgments and decisions on dispassionate rational grounds. A major revision of this computer-like model of the doctor’s role took place when psychoanalysts began consciously to use the doctor’s relationship with the patient for therapeutic purposes. They first recognised and analysed the nature of the patient’s emotional involvement with the doctor. However, all relationships are reciprocal, and they were soon led to recognise the doctor’s involvement with the patient. These psychological insights had to be revised in their turn when sociological studies began. Since the primary aim of the doctor is to serve the best interests of his patients, the medical ethic must forbid discrimination against them according to colour, class, or creed. The doctor in the bygone charity hospital was probably firm in the belief that he was trying to do no less for his patients in the hospital than for those in his consultingrooms. But what he consciously believed was unlikely to be the same as what he unconsciously did. A study of psychotherapy in New Haven provides a notable example of such unconscious social bias (Hollingshead and Redlich 1958). In each of the psychiatric agencies, the treatment given was related to the social class of the patient in its type, frequency, and duration. Among private psychiatrists, for instance, the average time for the therapeutic session declined from the higher social classes to the lower. Clearly psychotherapy is not all a matter of psychodynamics. The gulf of class and culture between the doctor and his patients affected his ability or readiness to treat them.
of teaching the skills necessary to the practice of medicine. It is a chief channel through which the values of the profession are transmitted and their continuity ensured. The social sciences have done much to illuminate this process (Merton et al. 1957, Becker et al. 1961). To change medical education by changing the medical curriculum is notoriously difficult. The difficulties are analogous to those of achieving change in any large organisation, only made worse by the relative autonomy of academic departments. Even when the curriculum is altered, however, effective changes in medical values and practice may not have been achieved, as in the controlled trial in the teaching of comprehensive medical care conducted at Colorado (Hammond et al. 1959). In the senior year students attended a general clinic instead of the wards; they were given responsibility for patients and encouraged to make home visits. The results, on the whole, were negative. It was all the experimental curriculum could do to prevent the development of hostile attitudes to comprehensive care; such attitudes did develop in the control group. Some of the reasons for the failure of the teaching programme lay in the group relations of the participant teachers and students. What is taught in one section of the curriculum is subject to the judgment and attitudes of teachers in other sections; these are influential according to the prestige of those teachers (which in turn depends on a complex of social, economic, and traditional factors). Teachers, students, and the content of teaching in the control group influenced the experimental group adversely towards comprehensive care. means
Students, moreover, have a culture of their own. Their values and their views about the purpose of the curriculum and the objects of education can be quite discordant with those of their teachers. The attitudes of the main body of students about the curriculum derives from what they consider to be priorities; the need to pass examinations, for example, and the need to equip them-
428 selves as well as possible for the tasks which they believe lie immediately ahead. Their estimate of such tasks is based on what they see about them. In Colorado rewarding jobs of high prestige did not embody the principles of comprehensive medical care. Medical education makes a large contribution to the quality of the doctor’s participation in the medical transaction, as most of us believe; but it is a complex process the outcome of which is difficult to control. The social sciences are necessary to its study as well as to the elucidation of the many other social factors which influence the doctor’s behaviour with patients.
Systems of Medical
Care
The " efficiency engineer ", whose job was to eliminate inefficiency in organisations scientifically ", was discredited among industrial sociologists by the crudeness of his schemes. Medical care likewise does not respond to the simplicities of rational planning, and requires an appreciation of its social dynamics. Systems of medical "
be considered in terms of their external relations with the larger society, and in terms of their internal relations-that is, in terms of the structure and content of relations within particular medical organisations. External Relations of Medical Systems The actual functions of medicine in society extend beyond its avowed functions. In industrial societies its avowed function is at the organic level, to cure and prevent disease. But it is quite evident that medicine has an additional function at the personal level. This is to reassure, and to allay anxiety in individuals, whether healthy or diseased, who turn to the doctor to alleviate their distress. Work at the personal rather than the organic level is the standby of the traditional doctor of prescientific societies; his credits in this field balance his debits with organic disease. In all societies medicine has a third function, at the social level, by which it helps to absorb the social strains of sickness. I have noted above that sickness can be seen as a form of social dysfunction in which the individual’s relations with others deviate from the norm. This sick role is regularised by his relationships with the doctor. Hence the heavy commitment of doctors in all modern societies to duties of certification, whether for absence from work or school, or for deaths, or for a multitude of other matters. Society uses the doctor to legitimise departures from such -expected behaviour as continuing to work, or continuing to live. It has used him too to legitimise the custody of deviants such as the psychopath and the mentally ill, and to legitimise the support of dependent or disabled persons-for instance the severely subnormal and the victims of industrial accidents. The balance between these medical functions at the organic, the personal, and the social level varies between societies and social groups. In New York, for example, psychotherapy appears to serve functions different from those in Manchester or in Moscow. In a survey of the prevalence of mental illness in Manhattan 23-6% of the population were considered to be functionally impaired by mental disorder. Only 5% of this staggering proportion were in treatment at the time, but an equal number of persons not evidently impaired were also in treatment (Srole et al. 1962). One explanation for this is that treatment was related less to the anomaly " organic " level of severe psychiatric disorder than to personal or social needs. Despite such variations, doctors in all societies share care can
all of their functions with other agents and institutions whose part in absorbing the strains of sickness must be recognised. The social sciences offer a means by which medicine can comprehend its position in relation to other purveyors of care. Internal Relations of Medical Systems The formal structure of an institution and the quality of communication within it is likely to influence the effectiveness of its officers, including doctors, and the services they provide. Studies of the internal working of medical organisations are one aspect of the general study of organisations. They warn us of the ravelled nature of the problems of organisation, and of the difficulties to be expected in such apparently simple matters as achieving coordinated care for patients between the three branches of the National Health Service. In any attempt at coordination the forces within each organisation must be recognised and coped with. Each organisation has a life of its own, and the forces which generate this life may’be quite divorced from the ostensible purpose of serving the client. Some of these forces are concerned with the maintenance of the power, the prestige, and the stability of the organisation and its various sectors. Stable persisting organisations develop distinctive cultures and beliefs about their functions. An organisation tends to see its work in terms of its own culture, and any medical agency’s outlook is inevitably centred in its own functions. This centripetal view is limited by the world of the institution in which the medical transaction takes place. The patient in a hospital bed has extremely restricted roles and a narrow range of explicit needs. Consequently some of his needs-for instance, for resettlement in normal social roles-may not be recognised or they may not be thought quite proper to the sphere of the hospital doctor. In contrast the view of a publichealth department, which may recognise social needs, may yet be restricted in respect of technical needs. Because of the limits set on experience and perception by medical training and institutions, it cannot be assumed that doctors have common ends, even though they share a common training and the common motive of serving the patient. Medicine will be frustrated in its attempts to live up to its ethical ideals, and will fail to give its best service, until it can recognise and control the hidden forces that throw its house into disorder.
some
or
Conclusion
A growing disjunction has arisen between the content of medical training and the needs of practising doctors. When in 1920 Lord Dawson of Penn, as chairman of a consultative council, advocated a national system of medical care based on health centres, he saw the crucial problem as the distribution of the benefits of medical science among the people (Dawson 1920). At that time medical education seemed to incorporate most of what was useful, but the trained doctor was not serving those who needed him. The National Health Service solved this question of distribution. The problem which now faces us is to train doctors who can meet the needs and expectations of the patients they serve by bringing to bear the new skills that have become available. Scientific and technical advances in medicine have engendered the dominance in medical care of the large specialised hospital with its concentration of equipment, technical skill, and power. Medical education, centred on hospitals, has therefore been able to absorb the technical disciplines which medicine has developed.
’
429
ELECTROCARDIOGRAPHIC CHANGES During the past century or more, pathology, physiology, histology, and lately biochemistry have joined anatomy ASSOCIATED WITH A CEREBROVASCULAR and pharmacology among studies basic to medicine. ACCIDENT None of these disciplines rises above the organic level MICHAEL T. HARRISON nor flows naturally beyond the bounds of the hospital. M.D. Belf., M.R.C.P. Bacteriology did force the attention of medicine on to LECTURER the relationship of human disease with other living things in the environment, and for a period the environmental BRYAN H. GIBB studies of epidemiology and public health flourished. In M.B. Cape Town the shade of the modern hospital, however, their apparent RESEARCH ASSISTANT UNIVERSITY DEPARTMENT OF MEDICINE, WESTERN INFIRMARY, potential in medical education withered. The newer GLASGOW sciences that deal with patients as individuals in a social environment have also failed to develop within the CEREBROVASCULAR accidents may be associated with a hospital sphere. This is not only the result of their Jgrossly abnormal electrocardiogram (E.C.G.), even in newness and of their use of data that are difficult to Jpatients without heart-disease. This association is not measure. The hospital envelops patients totally, and can widely recognised, and it may cause problems in diagnosis more or less dictate what is offered them. The doctorif J it is not appreciated. Operation on an intracranial in hospital can therefore focus on the patient’s disease ;aneurysm may be postponed or an unduly grave prognosis rather than on his sickness without being made to feel a given if it is wrongly believed that the E.C.G. indicates a 1fresh want of skills in personal medicine. Practice outside the myocardial infarct. As cerebrovascular accidents has until now where the want is felt, hospital, beenare most common in old patients, ischaemic heart-disease peripheral to medical education.must coexist in many cases; and, if a patient survives, one The result is that the practitioner must meet his :may be in doubt whether an abnormal E.C.G. should be patient’s demands at the personal and social level without special preparation. All patients make such demands and they may have sophisticated expectations of the doctor. A first step in redressing the imbalance in the doctor’s education must be to give him the best available means of handling the social and personal context of medicine in a systematic and scientific way. For this purpose he requires a grasp of the social sciences. They should now take their place in the array of theoretical sciences basic to the study of medicine, and to make them meaningful the student should have the opportunity to use them. This learning through use can be done in any medical situation, but is likely to be best done in those situations where the personal and social aspects of medicine press ..
upon the doctor. REFERENCES
Becker, H. S., Geer, B., Hughes, E. C., Strauss, A. L. (1961) Boys in White: Student Culture in Medical School. Chicago. Lord Dawson of Penn (1920) Future Provision of Medical and Allied Services. Interim Report. H.M. Stationery Office. Freidson, E. (1961) Patients’ Views of Medical Practice. New York. Hammond, K. R., Kern, F., Crow, W. J., Githens, J. G., Groesbeck, G., Gyr, J. W., Saunders, C. H. (1959) Teaching Comprehensive Medical Care. Cambridge, Mass. Hollingshead, A. B., Redlich, F. (1958) Social Class and Mental Illness. London.
Jones, E. (1957) Sigmund Freud: Life and Work; vol. III. London. Merton, R. K., Reader, G. G., Kendall, P. L. (1957) The Student Physician.
Cambridge,
Mass.
Parsons, T. (1958) Essays in Sociological Theory. Glencoe. Pridan, D., Navid, H. (1964) Health Education in a Clinic. J. Coll. gen. Practit. 7, 222. Sigerist, H. E. (1927) Reprinted in Henry E. Sigerist on the Sociology of Medicine (edited by M. I. Roemer). New York. (1955) A History of Medicine; vol. I. New York. Srole, L., Langner, T. S., Michael, S. T., Opler, M. K., Rennie, T. A. C. (1962) Mental Health in the Metropolis. London. Watson, W., quoted by Susser and Watson (1962) Sociology in Medicine.
Fig. I-E.C.G. taken 2 days after the cerebrovascular accident.
-
London.
"
I often recall the phrase used by the late Henry Quastler, expert in the application of quantitative methods in biology -we are living in a period of neo-Pythagorean numerology’. We seem to have followed so zealously the advice attributed to Galileo—’ What is not measurable make measurable’-that many people have come to think that if they attach a number to something they must necessarily know more about the thing than they knew before. They seem to forget that a number is an abstraction, and may be much farther removed from the thing itself than is a qualitative description."-D. MAINLAND. Notes from a Laboratory of Medical Statistics; note 73, p. 6, 1964. (New York University Medical Center, 112, E. 19th
of heart-disease or cerebrovascular accident or a combination of both conditions. We describe here abnormal E.C.G. findings in a young girl with a cerebrovascular accident in whom there is little doubt that the heart was normal.
explained on the basis
an
Street.)
Case-report A 17-year-old girl was admitted to hospital in a state of stupor. She had complained of headache the previous night but had otherwise been well. She had been delivered of a normal child 4 months before, after an uneventful pregnancy and labour. On the morning of admission she awoke confused and disorientated, and she staggered and fell on trying to get out of bed. She
was
well nourished and afebrile. The pulse-rate
90 per min. and
regular: blood-pressure was 120/80
mm.
was
Hg.
LECTURER, DEPARTMENT
OF SOCIAL AND PREVENTIVE
MEDICINE,
UNIVERSITY OF MANCHESTER
of society is still sometimes required to " credentials establish its as science ". For the sceptics, science is experimental and the social world is not amenable to its methods. This is a timebound idea, derived from the great successes of experiment during the past two centuries. With more truth, a field of study can be classed as science once it has produced speculations, theories, and hypotheses of an order which can be tested. Such hypotheses’ abound in social science, although the work of testing may lag. The tests need not be experimental. Students of society can rarely make planned experiments; in lieu of experiment they use the natural contrasts between societies and opportune changes within them. But they do not ignore measurement, although they must often rely on verbal communication and direct observation of behaviour. Physicians should well understand the importance and validity of these methods (even THE
study
though they are beset with large margins of error) for they resemble those of medicine; the clinician uses direct observation, and the epidemiologist measures and compares groups. The social sciences are in their infancy. Their productivity is much less than that of the physical sciences, for the study of society is among the most difficult of scientific endeavours. At each level of observation in the study of human beings, through the molecular, the cellular, the organic, the individual, and the social, the
number of uncontrolled variables is successively multiplied. As with the whole of medicine, proved facts are relatively few, and must be linked by hypothetical constructions; in what follows I cannot pretend to scientific proof for all my assertions. None of this is a cogent reason for dismissing the study of society as non-scientific, or useless. We learn from social science to adopt a position of scientific detachment towards society; to analyse, classify, and generalise observations in terms of social groups; and to measure and define the objective, if intangible, regularities of social relationships. One can treat social science in medicine under four heads: 1. Social factors in health and disease. 2. Patients as social beings. 3. Doctors in relation to patients. 4. Systems of medical care.
Henry Sigerist, writing about the history of summed up these social relations of medicine:
medicine,
" In every medical action there are always two parties the physician and the patient, or in a broader sense, the medical corps and society. Medicine is nothing else than the manifold relations between these two groups. The history of medicine, therefore, cannot limit itself to the history of the
involved,
*
7357
From
a
lecture
to
the
Keppel Club.
29
August I964
science, institutions and character of medicine, but must include the history of the patient in society, that of the physician, and the history of the relationship between physician and.patient." (Sigerist 1955.) Social Factors in Health and Disease Epidemiology is the study of the distribution of health and disease in populations, and part of its province is the study of the related social factors. Indeed, every epidemiological variate is in some sense a sociological variate. The factors affecting the distribution of disease in populations may be biological or environmental, and both have social implications. The populations to whom
the biological dimension refers are not mere aggregates of discrete individuals. They comprise, as groups of people with some order of relationships between them, the elements of society. The environment which contains the populations is equally a facet of society in its physical and biological as well as its social components; civilisation, however primitive, is natural environment modified by human groups. Epidemiologists have tended to interpret such basic attributes as sex and age and marital status in biological terms. But these variates also have social meaning, and their distribution in a population implies a particular configuration of statuses in society; each of these statuses carries its own set of obligations and duties and social relations. Each marital status, for instance, has implicit in it distinctive expectations of support for the individual should he fall ill. We may therefore predict that an individual’s marital status will affect his decision to seek help from a medical agency, or to enter a medical institution. Such decisions give rise to unrepresentative populations which distort the view of disease obtained by any one agency, whether it is general practice, or a hospital, or a public health department. The forces which determine whether an individual or a group breaks through the surface of anonymity to recognised morbidity are thus not only pathological but psychological and social. They need to be interpreted in terms of psychology and sociology. Many doctors are agreed that social factors are important in disease. The significant question is whether they need to be equipped to handle the notions relating to these factors, or whether an empirical, amateur approach is sufficient. Sociological notions tend to be many-sided and unamenable to simple, finite definitions. One example with wide currency is the concept of social class. The phenomenon it describes is real enough, but even sociologists disagree about its fundamental nature. For the 1911 census Stevenson, chief statistical medical officer to the General Register Office, devised a method of measuring social class by arranging all occupations within a hierarchy of five classes. His classification, somewhat modified, has regularly come to be used in national statistics and in medical research. If it is to be used with confidence, however, some understanding of the assumptions and the criteria which divide the classes
426
is needed. Yet half a century after the classification was introduced it is not clear how far these are arbitrary, or theoretical, or empirical, and anomalies of classification ensue.
Anomalies also reside in the classification itself. Any method of stratifying society aims to reflect its real structure. But Britain is not a social pyramid divided into five horizontal layers, which is the model the classification suggests. The lines of cleavage are vertical as well as horizontal (Watson 1962). Moreover, social groups are not static; the movement of individuals between social groups, and the movement of whole social groups, obscures the pattern. We can hardly hope to understand the distribution of schizophrenia, or mental coronary heart-disease, or bronchitis, grasp both the cleavages in society and the constant reshuffling of social and genetic attributes that
subnormality, unless
or
we can
accompanies social mobility. To handle such material we need the most rigorous methods that social science can offer; studies of social factors in health and disease which do not use them neglect a vital dimension. Patients
as
Social
Beings
Value Systems Patients are social beings, and much of their response to disease and their behaviour with doctors is socially determined. Doctors can hardly avoid learning empirically, in day-to-day practice, a good deal about thisaspect of their patients. Such knowledge, however, is comparable to that which a priest might have about the prevalence of disease in his parish; it is usually not ordered and interpreted in a theoretical framework. Despite this deficiency, doctors often feel that they do command special competence in questions of behaviour. This feeling may take on the flavour of authority, for medical education in the past has not been prone to emphasise what the physician did not know. It could be argued that one task of medical education has been to breed confidence in the physician’s own judgments, and through this confidence to promote his authority and ability to act; for the practice of medicine is beset with uncertainty in diagnosis, in treatment, and in prognosis. In the times when medicine had little scientific basis personal authority was the more necessary to the doctor, and such authority may still have value in inducing compliance in patients. In recent times, advances in organic medicine have enabled doctors to abandon some of this personal authority and to practise scientific humility, because they could rely on the growing authority of scientific knowledge. The substitution of scientific for personal authority has not been easy; as late as the end of the 19th century Samuel Gee, whose surname is the eponym for coeliac disease, is said to have advised his students not to bother with physiology. The substitution of science for authority is even more difficult when judgments must refer to the psyche and to society. The objective study of society requires the examination of value systems. To do this the social scientist, in his scientific role, must stand outside society. But each of us is a product of society, of its mode of rearing children, of its moral beliefs, and of its assumptions about people and society. Each of us knows right from wrong according to the special values that obtain in our own culture. The social scientist must detach himself from these built-in attitudes and modes of thought; this is to stand outside himself. Social scientists share this task with students of the
mind; its magnitude is emphasised by the psychoanalytic doctrine that self-analysis is scarcely possible. Ernest Jones thought that the greatness of Freud’s achievement could be measured by his feat of self-analysis (Jones 1957). It is perhaps no accident that men like Marx and Freud, both in some ways marginal to the society in which they lived, helped to found the modern sciences of society and human behaviour. Men secure in society are not made to question their values and ways of life, and tend not to feel a need to study them. The Sick Role Many doctors have
accept that what causes a particular individual to present as a sick person should in part be interpreted in psychological terms. Whether a patient’s symptoms rise above the threshold of complaint depends on the way in which he perceives illness and in which he is moved to act about it. Perception and motivation, however, are determined by the particular social context in which the individual lives and in which he performs his social roles. During growth he learns the behaviour expected in the roles appropriate to each new stage of development, and what he learns becomes an integral part of his personality. All behaviour is to some extent a reflection of social roles, and of the duties and come to
expectations implicit in them. It follows that to be sick is a social phenomenon. The sick person, as Sigerist long ago pointed out, has a special position, a social role with implicit rules and privileges (Sigerist 1927). Sickness is not synonymous with disease although it includes it. Disease can be defined as a state of physiological or psychic dysfunction which affects the individual organism, whereas sickness is a state of social dysfunction which affects the individual’s relations with others. The conditions in which sick privileges are conferred therefore vary between societies, between cultures and between particular social situations. The relationship of the patient with the doctor is only one aspect of his total situation and derives from it, and an adequate assessment of the patient requires analysis of his social context. Social science enables the doctor to make the analysis systematic; this should be as much a part of medical history-taking as systematic inquiry about symptoms. The analysis would examine the structure and content of the patient’s relations in the home, in the wider community, and in his occupation, and consider the relevance of these various associations in the clinical settlng. The structure of the relationships is determined by the status of the interacting individuals-in terms of age and sex and social position-and by the ramification of formal and informal ties between them. The content of the relationships depends not only on the personality of those who interact, but on the nature of their ties, and on the expectations and sanctions attached to them by the culture. Interaction is mediated by what is right and proper in the appropriate system of values. Communication Analysis of this kind places the doctor in a better position to comprehend the problems of patients. It may also help him to communicate more effectively with them by supplementing intuition with intellectual appraisal. Effective communication in the face-to-face situation between doctors and patients is fundamental to diagnosis and treatment. Much evidence shows how frequently communication by doctors does not produce the hoped-for result in their patients.
427 In
Israeli study patients were asked, before the doctor and again afterwards, whether they
a recent
seeing
considered they had a dangerous or a minor illness; the doctors were asked to make a similar rating (Pridan and Navid 1964). 40% of those patients rated by the doctor as having minor illness had thought, before seeing him, that their condition was serious. After seeing the doctor, 1 in 10 of the 40% no longer thought their condition serious, but the original number was exactly restored by others who had come to think their illness serious. In the patients’ perception of their illnesses there had been hardly any shift which could be attributed to the consultation. Although the doctors had succeeded in communicating instructions to these patients, they had not succeeded in communicating either reassurance or information about illness. How much medical advice and exhortation is equally ineffectual in the face of values, beliefs, and social relationships that the doctor has not appreciated ? The study of the patient as a social being has something to contribute to clinical practice.
The Doctor’s Medical Situation Many other factors influence the doctor’s relations with patients and the quality of his performance. To take one example, Freidson’s study of the Health Insurance Plan in New York suggests that the situations in which doctors work, and the groups to whom they refer to approve their behaviour, exert a marked effect on their relations with patients (Freidson 1961). The general practitioner, who stands close to the community and is subject to many pressures from it through his practice, tends to be sensitive to the personal aspects of care. In contrast, the hospital physician is under little pressure from the surrounding community or from patients, and he tends to be sensitive to pressures from professional colleagues. While such pressures are likely to maintain the doctor’s technical competence, they do not promote attention to the personal needs of patients. In line with this we have found that the mistakes of hospital practice often seem to arise from failures of communication, and the mistakes of general practice from technical failures.
.Medical Education The clinical situation is immediate to the doctor’s Doctors in Relation to Patients The medical personality which reacts to the behaviour. The Doctor’s Social Situation situation is founded on more remote factors, and to search The doctor is the professional of the two parties them out one must examine the medical profession as a involved in the transaction of medicine, but he too is a its political and economic interests, its organisation, social being; his social situation influences the transaction. whole, and its values. At the heart of its values lies the system The ideal type or model of the doctor’s relationship with of medical education. Medical education is more than a the patient takes no account of this; as Talcott Parsons has put
"
it, his position is one of affective neutrality " (Parsons 1958). The doctor tries always, according to the medical ethic, to give priority to the patients’ interests and needs, but at the same time he must remain emotionally detached from him. Theoretically the doctor elicits the necessary information about the patient, collates it, and makes his judgments and decisions on dispassionate rational grounds. A major revision of this computer-like model of the doctor’s role took place when psychoanalysts began consciously to use the doctor’s relationship with the patient for therapeutic purposes. They first recognised and analysed the nature of the patient’s emotional involvement with the doctor. However, all relationships are reciprocal, and they were soon led to recognise the doctor’s involvement with the patient. These psychological insights had to be revised in their turn when sociological studies began. Since the primary aim of the doctor is to serve the best interests of his patients, the medical ethic must forbid discrimination against them according to colour, class, or creed. The doctor in the bygone charity hospital was probably firm in the belief that he was trying to do no less for his patients in the hospital than for those in his consultingrooms. But what he consciously believed was unlikely to be the same as what he unconsciously did. A study of psychotherapy in New Haven provides a notable example of such unconscious social bias (Hollingshead and Redlich 1958). In each of the psychiatric agencies, the treatment given was related to the social class of the patient in its type, frequency, and duration. Among private psychiatrists, for instance, the average time for the therapeutic session declined from the higher social classes to the lower. Clearly psychotherapy is not all a matter of psychodynamics. The gulf of class and culture between the doctor and his patients affected his ability or readiness to treat them.
of teaching the skills necessary to the practice of medicine. It is a chief channel through which the values of the profession are transmitted and their continuity ensured. The social sciences have done much to illuminate this process (Merton et al. 1957, Becker et al. 1961). To change medical education by changing the medical curriculum is notoriously difficult. The difficulties are analogous to those of achieving change in any large organisation, only made worse by the relative autonomy of academic departments. Even when the curriculum is altered, however, effective changes in medical values and practice may not have been achieved, as in the controlled trial in the teaching of comprehensive medical care conducted at Colorado (Hammond et al. 1959). In the senior year students attended a general clinic instead of the wards; they were given responsibility for patients and encouraged to make home visits. The results, on the whole, were negative. It was all the experimental curriculum could do to prevent the development of hostile attitudes to comprehensive care; such attitudes did develop in the control group. Some of the reasons for the failure of the teaching programme lay in the group relations of the participant teachers and students. What is taught in one section of the curriculum is subject to the judgment and attitudes of teachers in other sections; these are influential according to the prestige of those teachers (which in turn depends on a complex of social, economic, and traditional factors). Teachers, students, and the content of teaching in the control group influenced the experimental group adversely towards comprehensive care. means
Students, moreover, have a culture of their own. Their values and their views about the purpose of the curriculum and the objects of education can be quite discordant with those of their teachers. The attitudes of the main body of students about the curriculum derives from what they consider to be priorities; the need to pass examinations, for example, and the need to equip them-
428 selves as well as possible for the tasks which they believe lie immediately ahead. Their estimate of such tasks is based on what they see about them. In Colorado rewarding jobs of high prestige did not embody the principles of comprehensive medical care. Medical education makes a large contribution to the quality of the doctor’s participation in the medical transaction, as most of us believe; but it is a complex process the outcome of which is difficult to control. The social sciences are necessary to its study as well as to the elucidation of the many other social factors which influence the doctor’s behaviour with patients.
Systems of Medical
Care
The " efficiency engineer ", whose job was to eliminate inefficiency in organisations scientifically ", was discredited among industrial sociologists by the crudeness of his schemes. Medical care likewise does not respond to the simplicities of rational planning, and requires an appreciation of its social dynamics. Systems of medical "
be considered in terms of their external relations with the larger society, and in terms of their internal relations-that is, in terms of the structure and content of relations within particular medical organisations. External Relations of Medical Systems The actual functions of medicine in society extend beyond its avowed functions. In industrial societies its avowed function is at the organic level, to cure and prevent disease. But it is quite evident that medicine has an additional function at the personal level. This is to reassure, and to allay anxiety in individuals, whether healthy or diseased, who turn to the doctor to alleviate their distress. Work at the personal rather than the organic level is the standby of the traditional doctor of prescientific societies; his credits in this field balance his debits with organic disease. In all societies medicine has a third function, at the social level, by which it helps to absorb the social strains of sickness. I have noted above that sickness can be seen as a form of social dysfunction in which the individual’s relations with others deviate from the norm. This sick role is regularised by his relationships with the doctor. Hence the heavy commitment of doctors in all modern societies to duties of certification, whether for absence from work or school, or for deaths, or for a multitude of other matters. Society uses the doctor to legitimise departures from such -expected behaviour as continuing to work, or continuing to live. It has used him too to legitimise the custody of deviants such as the psychopath and the mentally ill, and to legitimise the support of dependent or disabled persons-for instance the severely subnormal and the victims of industrial accidents. The balance between these medical functions at the organic, the personal, and the social level varies between societies and social groups. In New York, for example, psychotherapy appears to serve functions different from those in Manchester or in Moscow. In a survey of the prevalence of mental illness in Manhattan 23-6% of the population were considered to be functionally impaired by mental disorder. Only 5% of this staggering proportion were in treatment at the time, but an equal number of persons not evidently impaired were also in treatment (Srole et al. 1962). One explanation for this is that treatment was related less to the anomaly " organic " level of severe psychiatric disorder than to personal or social needs. Despite such variations, doctors in all societies share care can
all of their functions with other agents and institutions whose part in absorbing the strains of sickness must be recognised. The social sciences offer a means by which medicine can comprehend its position in relation to other purveyors of care. Internal Relations of Medical Systems The formal structure of an institution and the quality of communication within it is likely to influence the effectiveness of its officers, including doctors, and the services they provide. Studies of the internal working of medical organisations are one aspect of the general study of organisations. They warn us of the ravelled nature of the problems of organisation, and of the difficulties to be expected in such apparently simple matters as achieving coordinated care for patients between the three branches of the National Health Service. In any attempt at coordination the forces within each organisation must be recognised and coped with. Each organisation has a life of its own, and the forces which generate this life may’be quite divorced from the ostensible purpose of serving the client. Some of these forces are concerned with the maintenance of the power, the prestige, and the stability of the organisation and its various sectors. Stable persisting organisations develop distinctive cultures and beliefs about their functions. An organisation tends to see its work in terms of its own culture, and any medical agency’s outlook is inevitably centred in its own functions. This centripetal view is limited by the world of the institution in which the medical transaction takes place. The patient in a hospital bed has extremely restricted roles and a narrow range of explicit needs. Consequently some of his needs-for instance, for resettlement in normal social roles-may not be recognised or they may not be thought quite proper to the sphere of the hospital doctor. In contrast the view of a publichealth department, which may recognise social needs, may yet be restricted in respect of technical needs. Because of the limits set on experience and perception by medical training and institutions, it cannot be assumed that doctors have common ends, even though they share a common training and the common motive of serving the patient. Medicine will be frustrated in its attempts to live up to its ethical ideals, and will fail to give its best service, until it can recognise and control the hidden forces that throw its house into disorder.
some
or
Conclusion
A growing disjunction has arisen between the content of medical training and the needs of practising doctors. When in 1920 Lord Dawson of Penn, as chairman of a consultative council, advocated a national system of medical care based on health centres, he saw the crucial problem as the distribution of the benefits of medical science among the people (Dawson 1920). At that time medical education seemed to incorporate most of what was useful, but the trained doctor was not serving those who needed him. The National Health Service solved this question of distribution. The problem which now faces us is to train doctors who can meet the needs and expectations of the patients they serve by bringing to bear the new skills that have become available. Scientific and technical advances in medicine have engendered the dominance in medical care of the large specialised hospital with its concentration of equipment, technical skill, and power. Medical education, centred on hospitals, has therefore been able to absorb the technical disciplines which medicine has developed.
’
429
ELECTROCARDIOGRAPHIC CHANGES During the past century or more, pathology, physiology, histology, and lately biochemistry have joined anatomy ASSOCIATED WITH A CEREBROVASCULAR and pharmacology among studies basic to medicine. ACCIDENT None of these disciplines rises above the organic level MICHAEL T. HARRISON nor flows naturally beyond the bounds of the hospital. M.D. Belf., M.R.C.P. Bacteriology did force the attention of medicine on to LECTURER the relationship of human disease with other living things in the environment, and for a period the environmental BRYAN H. GIBB studies of epidemiology and public health flourished. In M.B. Cape Town the shade of the modern hospital, however, their apparent RESEARCH ASSISTANT UNIVERSITY DEPARTMENT OF MEDICINE, WESTERN INFIRMARY, potential in medical education withered. The newer GLASGOW sciences that deal with patients as individuals in a social environment have also failed to develop within the CEREBROVASCULAR accidents may be associated with a hospital sphere. This is not only the result of their Jgrossly abnormal electrocardiogram (E.C.G.), even in newness and of their use of data that are difficult to Jpatients without heart-disease. This association is not measure. The hospital envelops patients totally, and can widely recognised, and it may cause problems in diagnosis more or less dictate what is offered them. The doctorif J it is not appreciated. Operation on an intracranial in hospital can therefore focus on the patient’s disease ;aneurysm may be postponed or an unduly grave prognosis rather than on his sickness without being made to feel a given if it is wrongly believed that the E.C.G. indicates a 1fresh want of skills in personal medicine. Practice outside the myocardial infarct. As cerebrovascular accidents has until now where the want is felt, hospital, beenare most common in old patients, ischaemic heart-disease peripheral to medical education.must coexist in many cases; and, if a patient survives, one The result is that the practitioner must meet his :may be in doubt whether an abnormal E.C.G. should be patient’s demands at the personal and social level without special preparation. All patients make such demands and they may have sophisticated expectations of the doctor. A first step in redressing the imbalance in the doctor’s education must be to give him the best available means of handling the social and personal context of medicine in a systematic and scientific way. For this purpose he requires a grasp of the social sciences. They should now take their place in the array of theoretical sciences basic to the study of medicine, and to make them meaningful the student should have the opportunity to use them. This learning through use can be done in any medical situation, but is likely to be best done in those situations where the personal and social aspects of medicine press ..
upon the doctor. REFERENCES
Becker, H. S., Geer, B., Hughes, E. C., Strauss, A. L. (1961) Boys in White: Student Culture in Medical School. Chicago. Lord Dawson of Penn (1920) Future Provision of Medical and Allied Services. Interim Report. H.M. Stationery Office. Freidson, E. (1961) Patients’ Views of Medical Practice. New York. Hammond, K. R., Kern, F., Crow, W. J., Githens, J. G., Groesbeck, G., Gyr, J. W., Saunders, C. H. (1959) Teaching Comprehensive Medical Care. Cambridge, Mass. Hollingshead, A. B., Redlich, F. (1958) Social Class and Mental Illness. London.
Jones, E. (1957) Sigmund Freud: Life and Work; vol. III. London. Merton, R. K., Reader, G. G., Kendall, P. L. (1957) The Student Physician.
Cambridge,
Mass.
Parsons, T. (1958) Essays in Sociological Theory. Glencoe. Pridan, D., Navid, H. (1964) Health Education in a Clinic. J. Coll. gen. Practit. 7, 222. Sigerist, H. E. (1927) Reprinted in Henry E. Sigerist on the Sociology of Medicine (edited by M. I. Roemer). New York. (1955) A History of Medicine; vol. I. New York. Srole, L., Langner, T. S., Michael, S. T., Opler, M. K., Rennie, T. A. C. (1962) Mental Health in the Metropolis. London. Watson, W., quoted by Susser and Watson (1962) Sociology in Medicine.
Fig. I-E.C.G. taken 2 days after the cerebrovascular accident.
-
London.
"
I often recall the phrase used by the late Henry Quastler, expert in the application of quantitative methods in biology -we are living in a period of neo-Pythagorean numerology’. We seem to have followed so zealously the advice attributed to Galileo—’ What is not measurable make measurable’-that many people have come to think that if they attach a number to something they must necessarily know more about the thing than they knew before. They seem to forget that a number is an abstraction, and may be much farther removed from the thing itself than is a qualitative description."-D. MAINLAND. Notes from a Laboratory of Medical Statistics; note 73, p. 6, 1964. (New York University Medical Center, 112, E. 19th
of heart-disease or cerebrovascular accident or a combination of both conditions. We describe here abnormal E.C.G. findings in a young girl with a cerebrovascular accident in whom there is little doubt that the heart was normal.
explained on the basis
an
Street.)
Case-report A 17-year-old girl was admitted to hospital in a state of stupor. She had complained of headache the previous night but had otherwise been well. She had been delivered of a normal child 4 months before, after an uneventful pregnancy and labour. On the morning of admission she awoke confused and disorientated, and she staggered and fell on trying to get out of bed. She
was
well nourished and afebrile. The pulse-rate
90 per min. and
regular: blood-pressure was 120/80
mm.
was
Hg.