I. Introduction
II. Theory and general practices of medical sociology
III. Analyzing the social causes of disease
A. Diseases with social dimensions
B. Medical technology and social implications
IV. Emphasizing an interdisciplinary approach
V. Exploring the doctor- (health worker-) patient relationship
A. Challenges to the ideal relationship
B. Need to reaffirm the "whole" patient
VI. Conclusion: Call to action
A. Medical Schools
B. Society
That the medical field is facing very difficult challenges, some of which are old and many which are new, is nothing new to the public. Issues such as the lack of health care coverage for everyone, the high cost of medical care and the growing distance between health care professionals and patients are only few highlights of this crisis. What is different about our current crisis is the approach that is taken in order to solve these problems. Present discussion of the health care crisis centers around economic and political issues, and moreover, many health care workers and sociologists are concerned that such a discussion has shifted the emphasis away from the people in the system--the patients and the medical staff. In response, sociologists are calling for the integration, or as some would prefer a re-integration, of medical sociology.
Late in the nineteenth century, medical sociology had begun to establish itself as a credible and important voice; however, with the coming of Abraham Flexner's report, "medical education became highly technological, with little room for teaching about medicine's ultimate social role" which must take into consideration the actual people involved (Roemer, 1986, p. 153). While medical sociology has continued to express itself in the more technological context, it has not been acknowledged as a qualified approach to solving the medical crisis--until lately.
The need for the re-integration of medical sociology is based on the observations that current approaches, attitudes, and values are not completely applicable to our changing society. The sociology of medicine allows for the study of the origins, evolution and laws of the medical profession with respect to the factors that affect this community. In order to understand the relevance of medical sociology, it is necessary to apply its particular style of thought to important aspects of the medical field: the change in the kind of diseases medicine faces today, an interdisciplinary approach to the medical crisis, and the doctor- (or health worker-) patient relationship.
Before applications of medical sociology are addressed, a look at the theory and general practice of medical sociology is appropriate. The theory of sociology concerns "understanding the meaning of social action" which comprises the subjective elements of human beings; it explores human beings and their relationship to social agencies and the hierarchical structures of society which determine the quality of that relationship; and it addresses questions of social order in the midst of disruptive and disorganizing elements in society (Turner, 1987, p. 3, emphasis added). When applied to medicine, sociology becomes the means by which health care personnel can see the whole picture, including historical, economical, cultural, and political forces.
There has been a controversy surrounding the authority of medical sociology as a critical voice of the current health system. First is the concern that most of the medical sociologists do not go to medical school; they are not trained professionals. However, many view this prejudice as a historical and social power problem. For instance, in the past, the doctor's word was not questioned or scrutinized as it is today. It appears that the late twentieth century has made a demand for accountability of the system (Heron and Zabel, 1994). Sociologists see the issue of accountability as centering on the issue of power, and the reality that usually a challenge to a long-held tradition is not easily accepted. In addition, sociologists link this rising mistrust of the medical society to the changing facets of disease (Heron and Zabel, 1994). An increase in infectious and chronic diseases plus a growing elderly population are only some of the changes that challenge our current approach to disease by the medical society.
On another level, medical sociology also addresses the enlarging gap between social classes. Socialized medicine--such as Medicare--has made efforts to supply care at lower costs by regulating fees and services and by subsidizing physicians and medical or cooperative projects with government funds (Flexner, 1987). However, there are many conflicts in allocating public funds for bridging this gap, especially when the middle-class, not the rich, seem to be taxed more in order to cover costs. One major reason for the lack of enough funds is the overall governmental and cultural emphasis on medical technology (Hastings, 1996). Sociologists may argue that the increase in medical technology is partly caused by a misconception that sees medicine as the sole fountain to complete health or by a desire to stay at the top of scientific discovery.
Thus medical sociology links many fragmented aspects of medical issues with what may be its roots. On practical terms, many people feel that sociology can help us understand the social causes of disease and the patient’s experience of illness, and help improve interviewing skills by health care workers and provide a new perspective on the health-care system (Turner, 1987). Therefore, re-integrating sociology into medicine will better prepare professional health care workers to meet the challenges of today.
One major application of medical sociology is its analysis of the social causes of disease and of the types of diseases prevalent in a society through time. Medical sociology challenges the Flexner-derived ideology which asserts that disease is a result of physiological and biochemical factors only. It has been suggested that the traditional reductionists view is partly a result of Social Darwinism and an increased emphasis on scientific knowledge (Turner, 1987). However, a new set of diseases is prevalent in today's society and the current model for treatment is not efficient--mainly because these diseases have many social dimensions.
As some would say, the success of medicine in technology and research has brought about this change of how professionals treat disease. In the past, health care workers faced, on a large-scale, diseases like pneumonia, tuberculosis, gastroenteritis and influenza (Turner, 1987). As medical research and technology improved, these diseases slowly became less prevalent. However, today, chronic diseases like heart disease, cancers, and vascular tension to the central nervous system, present a two-faced problem: first, the problem of not understanding the disease in complete biochemical terms, and secondly, the problem of not knowing how to deal socially with these new kind of diseases (Turner, 1987). In other words, the new picture is quite the opposite to the previous situation: acute diseases have been well studied so that reasonable treatments can be employed and acute diseases are dealt on a temporary basis so that the meetings between the doctor and patient are usually brief.
A major cause of this shift in the prevalent diseases is the increasingly aged population. By 1992, more than 31 million Americans were over the age of 65 (Heron and Zabel, 1994). Also, life expectancy today has greatly expanded. It is in this population that diseases of the heart, dementia and cancers are dominant. Much research is being undertaken in the area of gerontology and on its economical impact on the health care system. In addition to health care personnel, both kinds of researchers must deal with the newness of the problem (or maybe its obvious presence) and its particular challenges.
Diseases with social dimensions
Some of the new disorders observed today require a bigger picture than the traditional model proposes. For example, RSI (tenosynovitis) is observed in workers who do repetitious work with their wrist muscles. However, this syndrome is different in that variation among patients exists widely. A study showed that people exposed to the same conditions that caused RSI in some people, did not cause it for others (Turner, 1987). In this case, sociologists ask, "How does stress and anger influence RSI? How are work conditions and practices influencing RSI?" Another example of a disorder with strong social connotations is anorexia nervosa. Many sociologists see this disorder partly as a result of social stress on the individual from a society that sends contradictory messages about thinness and over-consumption. This sociological view accompanied by psychological and biological view can provide better treatment of disease. Thus, anorexia patients need to be approached on a different level, one that understands the disease in full.
In the same context of social dimensions, there is the cancer problem. Society's sexual and reproductive behavior appear to contribute to the spread of cancer in the younger generation (Remennick, 1998). For instance, some forms of reproductive technology--in vitro fertilization--lead to an increased risk of cancer (Remennick, 1998). These are grounds for concern in the medical society.
Medical technology and social implications
Medical technology has brought about great changes in the medical community. It comes into the context of disease and death because technology has social (or anti-social) implications. For example, health care workers have been asked to reflect on what some people call the technological death in a hospital setting. One response concerned the objectivity of the "work" that was being done and not the "care" that should have been given because technology allowed for more control of the dying process; other responses centered around the insecurity of not knowing how to use technology without totally altering with "natural" processes (Harvey, 1997). In this case, medical sociology, while acknowledging the advantages of technology, seeks ways to use technology appropriately and/or to understand the social impact of medical technology so that the "whole" person is taken into account and not simply his/her anatomical/physiological mass.
In view of the complexity of the diseases that the medical society faces, an alliance of the social and medical aspects of disease is needed in order to provide relevant treatment.
In response to this all-encompassing approach to disease, a question about the interaction between different disciplines rises. Can psychologists, social workers and physicians really work together to address the overall problem of these and other disorders? While many sociologists believe they should, they are realistic about the lack of interdisciplinary communication among fragmented professions of society. Some effort has been made towards interdisciplinary action; however, many of those who participate in the effort are not satisfied with the relationship that exists.
One problem is that there is little faith in the credibility, especially from the part of the physician, in regards to the other professions (Heron and Zabel, 1994). For example, Dr. Roemer argues that one response to the need for social responsibility in medicine was the creation of the nurse practitioner and the physician assistant. It is Roemer’s opinion that such new professions actually reduce the quality of health care (Roemer, 1986). However, in rural areas and many heavily populated metropolitan areas it appears that these middle-level roles have improved accessibility and affordability of health care (Heron and Zabel, 1986).
Another major important professional role has been that of the family physician. Many sociologists view this role as integrative health care or more holistic (Hokenstead, 1992). Ideally, the many aspects of the whole person are not fragmented in this setting. However, there are times that patient referral to other disciplines where a certain need may be met is very unlikely (Hokenstead, 1992). The general opinion is that the different disciplines believe that the solution for the problem is found within the discipline itself and not any other (Hokenstead, 1992). The victims of this conflict are the patients themselves; the same ones these professionals are supposed to be helping.
In addition to continuing effort towards an interdisciplinary approach, sociologists have studied the situation on a historical level and on a power-relation level. Researchers argue that there is a great issue over knowledge and power as determinants of prestige and status (Turner, 1987). The doctor’s opinion has gone uncontested for a long time. The assumption was the physician’s knowledge includes a different sort of language which requires a different sort of interpretation which no one else but the doctor was qualified to understand (Turner, 1987). It is obvious that medical school students undergo tough training in their field and that this training seems to qualify physicians in this "higher" role. However, it is not ethical for a profession to not be held accountable or to be considered as absolute authority. The reality is that sometimes doctors are wrong, unable to find the disease, and uncertain about prognosis and diagnosis (Turner, 1987). Legal actions such as mal-practice have been taken; however, social action is needed in battling the constant marginalization of opinions outside of the medical school context.
In a capitalist society, it appears that ruling by the privileged few should be the norm. Most doctors come from these privileged classes, and a judgmental view suggests that doctors are not totally willing to share their status or to allow less individualistic and more teamwork attitude into the field (Turner 1987). In a confessional mode, Milton I Roemer says that the society of physician susually does not advocate social responsibility and seeks more personal self-interests (Roemer, 1986). In a special report by The Hastings Center, one of the goals of medicine stated that "a solid health care system will respect and make wise use of those health professionals and fields that bring richness, diversity, and needed skills to the care of the sick" (Hastings, 1996, p. S20). Of course, any such change will deviate from the traditional response of doctors and other health care workers. However, if "richness, diversity and needed skills" are essential elements of a more stable and sustainable health care system, then people must adopt and adapt to a team concept.
While the interdisciplinary approach to medicine needs more exploring, medical sociology has studied the doctor-patient relationship in depth. The standards and values of such a relationship can be considered universal: the bond between the doctor and the patient is central to meet the need to heal, help, care and cure (Hastings 1996). However, application of these values is not easy when there is an "evolving fund of knowledge and a changing range of clinical practices that have no fixed essence" (Hastings, 1996).
Challenges to the ideal relationship
Sociology of medicine takes a look at the ideal situation of the doctor-patient relationship and challenges the ideas that base their approach on this ideal situation. Ideally, a real sick person seeks for the concerned doctor who suggests treatment to the sick person who in complete trust and understanding follows the doctor’s order. Reality is that there are many complications to this ideal situation. First, there is the idea of the "bad patient" who may bring trivial concerns to the doctor or who in being uninformed and unaware of his/her symptoms does not communicate well with the doctor.
Also, there is an obvious problem in the area of universal treatment in terms of class, gender, status and race. Studies show that doctors spend more time with members of higher classes (Turner 1987). The assumption is that the doctor takes more time to explain the situation to these people not necessarily for preferring people of these class, but more than likely, because the doctor assumes, maybe unintentionally, that members of the lower class will not understand medical explanation. Sociologists argue that doctors need to come down to the level of the patient and not portray him or herself as the god of interpretive wisdom in the realm of medicine, using language that does not enhance the relationship.
In terms of gender, it has been observed that there is a difference of treatment among patients treated for migraine headaches. When females reported the complaint, most of the time they were approach as neurotic patients; however, when the patient was male, it was presumed that demands and stress of the job was the cause for the migraine (Turner, 1987). Obviously, such treatment has its roots on the suppositions of gender roles. Much improvement has occurred in this area, partly because of complaints from the feminist community, but the differences still exists. In addition, other studies show that many doctors used their moral judgement in treating their patients. For example, when deciding whether to try to resuscitate a patient or not, doctors in the emergency room were more willing to treat sober patients rather than alcoholic patients (Turner, 1987). In matters of gender and moral judgement, sociologists play a major role in pointing out these inequalities so that the doctor-patient relationship is what is meant to be.
Many theories about how to deal with patients assume a one to one, face to face, fee for service situation. This is not the case today. Patients often find themselves in large medical settings or as part of a relationship that is preferentially brief (JAMA, 1997). In view of this problem, sociologists emphasize the need to improve communication by the sharing of ideas and communication of feelings. As mentioned before, the idea that the physician has absolute authority and power in this situation is cause for miscommunication. In the role of power, some physicians do not take time to listen to their patients concerns and feelings. Studies have shown that when patients were reaffirmed in consultation, patients showed greater satisfaction as to the success of the meeting; however, those who were not reaffirmed were less likely to follow the doctor’s advice. Not surprisingly, the latter case dealt with people from minority ethical social groups, women bringing children and new patients (Turner 1987). While these members of society might not be as educated, it does not mean that they are not able to learn. Thus, the physician must also emphasize his or her role as educator, and the sociologist should make an effort to educate these outcasts of the learned society in order to improve the relationship.
Need to reaffirm the "whole" patient
The idea of reaffirmation is in the interest of understanding the "whole" patient, and of understanding that the patient defines his or her illness in terms of the cultural and societal concepts in which he or she lives. Sociologists are encouraged by the critique of the traditional patriarchal model set up for this relationship. It has made the relationship more open and democratic (Turner 1987). In short, it is believed that "a better understanding of the patient, and lay, perspective on medicine should be a key item to improve the mutual understanding between medicine and society" (Hastings, 1996, p. S8).
Many health care professionals who understand the needs of patients have made a public outcry in response to the pressures they feel from the large managerial and marketing voices in the medical system (JAMA, 1997). In this case, while health care professionals strive to fulfill their role, medical sociologists must study and address this economical and political issue.
Another point of pressure is the high expectation and high demand of the public. The media publicizes the latest technologies and insinuates the idea that soon medicine will solve all the health problems. Thus, patients with presently incurable diseases experience much anxiety, complain about prolonged treatment and begin to be skeptical of doctors, sometimes resisting further treatment (Heron and Zabel, 1994). In the absence of effective treatment, the relationship between the health care professional and the patient, and the need to be concerned with the "whole" person and not with the patient as a biochemical entity become more important.
Both social and medical structures need to communicate well the true goals of medicine. Medicine is a growing field and research and technology opens many avenues for promotion of health. However society must be realistic about their view, and accept disease and death as part of life. Most importantly, society must examine its value system and realize, in the medical sociological context, the effect that decisions and actions have on the whole society.
In view of the aspects of medical sociology discussed above, it is necessary to organize some kind of action. It has been suggested that medical sociology be of greater importance in the education of the physician. This does not mean forsaking traditional rules but it does mean revising them in order to apply them better to the present situation. Medical sociology will reject the reductionist view of the patient and incorporate the cultural context of the patient's problem. For example, medical students can be introduced earlier to nursing homes and home care in order to visualize social context of the elderly (Hastings, 1996) Also, medical sociology will emphasize the prevention of disease as well as its treatment. Preventive medicine should be easier (not easy) to implement by understanding the historical, cultural, social and economical factors associated with the disease. Medical schools should make effort to "skillfully organize the kind of interdisciplinary, interprofessional training necessary for students to understand, and work within, different and overlapping professional and educational systems" (Hastings, 1996, p. S22).
Moreover, it is necessary to not allow society to drown the influence of medical sociology in the midst of what is presented as the more pressing issues of medicine, politics and economics. Society as a whole must have a voice in the decision taken in the health care system. According to many physicians, profit-driven care occurs "largely hidden from public scrutiny and above citizen participation" (JAMA, 1997, p.1733). The Hastings Center Report believes that medicine should "find its direction by means of a continuing dialogue with society in which each seeks its legitimate sphere, duties and rights" (Hastings, 1996, p. S7).
Such action, both on the educational and on the societal level, has been taken and society as a whole should support and encourage these movements. Yet, so much more needs to be done and this will not be easy, but it is necessary in order to realize the actual purpose and goals of medicine: to prevent injury and disease; to promote and maintain health; to releive pain; to cure when possible, but care for all patients, curable or not; to prevent premature death but accept death when appropriate; and most important, to treat the whole person and not the disease (Callahan, 1997).
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