SOC 5510 / 5 The purpose of this assignment is to demonstrate your understanding of the role of paternalism in the patient-doctor relationship. For this as

SOC 5510 / 5 The purpose of this assignment is to demonstrate your understanding of the role of paternalism in the patient-doctor relationship. For this assignment, write reflection entry in which you apply the concepts you learned this week in Chapter 11 of the Weitz text to an interaction with a health or medical practitioner you have recently had. It can be related to the issue you discussed in your Week 2 reflection journal entry or a different issue. You should focus on reflecting on the patient-practitioner interaction, and include discussion of the concepts of medical dominance, paternalism, and the doctor-patient relationship as it pertains to the interaction. “LEARNING OBJECTIVESAfter reading this chapter, students should be able to:•Understand how the medical profession gained professional dominance.•Assess the current threats to medical dominance.•Describe medicine’s core cultural values.•Critique the consequences of medical values for patients.•Provide a sociological analysis of doctor–patient relationships.To become a doctor, students must spend long years studying biology, chemistry,physiology, and other subjects. In addition, students must learn the way of think-ing about medicine, patients, and medical care that characterizes medical culture.Michael J. Collins learned this culture during four years as a surgical resident atthe Mayo Clinic. After a particularly brutal day of surgery in which he watched ateenager die, Dr. Collins found himself emotionally traumatized, questioning themeaning of his work and the effect it had on him. Although he wished he coulddiscuss his feelings with B. J. Burke, the director of his residency program,Dr. Collins knew from experience how B. J. would respond. As he wrote in hismemoir:BJ Burke was not interested in what I thought or understood. He was interestedin what I did.“If you want to learn to be sensitive and introspective,”he would say,“doit on your own time.”I imagined myself being called into his office. As I enter the room he isseated at his desk, reading the report in front of him. He makes certain I know Iam being ignored.At length he looks at me over the top of his glasses.“Dr. Collins, what is your job?”“My job, sir?”“You have a job, don’t you? You get a paycheck, don’t you?”“Yes, sir.”“Well, what do you do?”“I’m a second-year orthopedic resident at the Mayo Clinic.”“Do you want to be a third-year resident someday, Dr. Collins?”“Yes, sir.”“What is an orthopedic resident supposed to do?”Where was this going?“Follow orders?”I venture.“An orthopedic resident is supposed to practice orthopedics, Doctor. He isnot supposed to go around asking patients if they have ever considered theontological implications of their fragile, mortal state.”” ““I didn’t exactly—”He jumps to his feet and points his finger at me.“We fix things. Do youunderstand that? We don’t analyze things. We don’t discuss things. We don’twring our hands and cry about things. We fix them! If somebody wants to beanalyzed they can see a shrink. When they come to the Department of Orthopedicsat the Mayo Clinic they want only one thing: they want to be fixed. Now get thehell out of here and go fix things. And I better not get any more reports of touchy-wouchy, hand-holding sessions in this department”(Collins, 2005:152–153).Dr. Collins’s story illustrates two basic elements of modern-day medicalculture—emotional detachment and a belief in medical intervention. In this chap-ter, we look at how these and other aspects of medical culture and training evolvedand at the consequences for both doctors and their patients. We begin by lookingat how doctors became the dominant profession within health care and at theforces that now threaten their dominance.AMERICAN MEDICINE IN THE NINETEENTHCENTURYWhen confronted by disquieting illness, most modern-day Americans seek carefrom a doctor of medicine. Little more than a century ago, however, that wouldnot have been the case. Instead, Americans received most of their health carefrom family members. If they required more complicated treatment, they couldchoose from an array of poorly paid and typically poorly respected health carepractitioners (Starr, 1982:31–59). These includedregular doctors(the forerun-ners of contemporary doctors) as well asirregular practitionerssuch as mid-wives; patent medicine makers, who sold drugs concocted from a wide variety ofingredients; botanic eclectics, who offered herbal remedies; and bonesetters, whofixed dislocated joints and fractured bones.Regular doctors were also known asallopathic doctors, or allopaths (fromthe Greek for“cure by opposites”) because they sometimes treated illnesses withdrugs selected to produce symptomsoppositeto those caused by the illnesses. Forexample, allopaths would treat patients suffering the fevers of malaria with qui-nine, a drug known to reduce fevers, and treat patients with failing hearts withdigitalis, a drug that stimulates the heartbeat. Their main competitors werehomeopathic doctors, or homeopaths (from the Greek for“cure by similars”).Homeopaths treated illnesses with drugs that produced symptomssimilarto thosecaused by the illnesses—treating a fever with a fever-producing drug, for exam-ple. Although in retrospect the homeopathic model might seem odd, it drew onthe same logic as smallpox inoculation, the one successful inoculation available atthat time: People who developed a mild form of cowpox after inoculation witha few cowpox cells somehow became immune to the related but far more” “serious smallpox. Homeopaths, therefore, concluded that patients who received aminiscule amount of a drug that mimicked the symptoms of a given illnesswould become better able to resist that illness. Modern science now tells usthat drugs given in such small quantities can’t biologically affect patients. How-ever, we also now know that belief in a drug’s effectiveness will lead about30 percent of patients to experience at least temporary benefit from the drug—even if in reality they only receive sugar pills. This process is known as theplaceboeffect(Evans, 2003). It seems likely, therefore, that homeopathic drugs did notharm patients and sometimes helped them, if only through the placebo effect.That Americans before the twentieth century placed no greater trust in allo-pathic doctors than in any others who claimed knowledge of healing should notsurprise us. Although by the nineteenth century, science—the careful testing ofhypotheses incontrolledexperiments—had infiltrated the curricula of Europeanmedical schools, where many of the wealthiest Americans trained, it had gainedbarely a foothold in US medical schools. Moreover, the United States licensedneither doctors nor medical schools (Ludmerer, 1985). Instead, and until about1850, most doctors trained through apprenticeships lasting only a few months.After that date, most trained at any of the multitude of uncertified medicalschools that had sprouted around the country, almost all of which were private,for-profit institutions, unaffiliated with colleges or universities and lacking anyentrance requirements beyond the ability to pay tuition (Ludmerer, 1985). Norwere standards stricter at the few university-based medical schools. For example,in 1871, Henry Jacob Bigelow, a Harvard University professor of surgery, pro-tested against a proposal to require written graduation examinations on thegrounds that more than half of Harvard’s medical students were illiterate(Ludmerer, 1985:12). Training averaged far less than a year and depended almostentirely on lectures, so few students ever examined a patient, conducted anexperiment, or dissected a cadaver. Any student who regularly attended the lec-tures received a diploma. This situation began to change significantly only in the1890s and only in the better university schools.Lacking scientific research or knowledge, allopathic doctors developed theirideas about health and illness either from their clinical experiences with patientsor by extrapolating from abstract, untested theories. The most popular theory ofillness, from the classical Greek era until the mid-1800s, traced illness to animbalance of bodily“humors,”or fluids. Doctors had learned through experi-ence that ill persons often recovered after episodes of fever, vomiting, or diar-rhea. From this, doctors deduced—in part correctly—that fever, vomiting, anddiarrhea helped the body restore itself to health. Unfortunately, lacking methodsfor testing their theories, doctors carried these ideas too far, often inducing life-threatening fever, vomiting, purging, and bloodletting. Consider, for example,the following description of how Boston doctors in 1833 used what wasknown asheroic medicineto treat a pregnant woman who began having con-vulsions a month before her delivery date:The doctors bled her of 8 ounces and gave her a purgative. The nextday she again had convulsions, and they took 22 ounces of blood. After” “90 minutes she had a headache, and the doctors took 18 more ounces ofblood, gave emetics to cause vomiting, and put ice on her head andmustard plasters on her feet. Nearly four hours later she had anotherconvulsion, and they took 12 ounces, and soon after, 6 more. By thenshe had lapsed into a deep coma, so the doctors doused her with coldwater but could not revive her. Soon her cervix began to dilate, so thedoctors gave ergot to induce labor. Shortly before delivery she con-vulsed again, and they applied ice and mustard plasters again and alsogave a vomiting agent and calomel to “THE RISE OF MEDICAL DOMINANCEDespite the few benefits and many dangers inherent in allopathic medical care,by 1900, doctors had eliminated most of their competitors and gained controlover health care (Starr, 1982:79–112). In this section, we will see how thischange came about.From its inception in 1847, theAmerican Medical Association (AMA)had worked to restrain the practices of other health care occupations. State bystate, the AMA fought to pass laws outlawing their competitors or restrictingthem to working only under allopathic supervision or to performing only certaintechniques, such as spinal manipulation.Most of these efforts met with little success initially because nineteenth-century Americans considered health care an uncomplicated domestic matter,unrelated to science, and requiring no special training (Starr, 1982:90–92). Bythe beginning of the twentieth century, however, as improvements in publichealth and in living conditions ended scourges such as cholera and typhoid, andas Americans began reaping practical dividends from scientific advances such aselectric lights and streetcars, public faith in science swelled. Increasingly,Americans defined health care as a complex matter requiring expert intervention,assumed the superiority of“scientific”medicine, and turned to allopathic doctorsfor care (Starr, 1982:127–142).Like the public, homeopaths and botanic eclectics (allopathic doctors’twomajor groups of competitors) also came to recognize the benefits of science andtherefore to realize that a lack of scientific foundation could doom their fields.However, they still received considerable popular support. Moreover, because,like allopaths, most were white men, homeopaths and botanic eclectics generallyheld social statuses similar to those of allopaths. Thus, homeopaths and botaniceclectics retained sufficient influence to pressure allopaths to accept them intomedical schools and licensing programs, and their fields eventually faded away.Other health care workers could bring far less power to their dealings withlegislators and with allopathic doctors. Newly emerging occupations such as chi-ropractic (described in Chapter 12) lacked the long-standing history of popularsupport that had allowed homeopaths to push for incorporation with allopathy.Older occupations, meanwhile, such as midwives and herbalists, lacked the socialstatus, power, and money needed to fight against doctors’lobbying. Becausemost of these practitioners were women or minorities, they were assumed tobe incompetent by both legislators and doctors (Starr, 1982:117, 124).The Flexner Report and Its AftermathThese differences between allopathic doctors and other health care practitionersincreased during the early twentieth century. Since the 1890s, the better medicalschools had begun tightening entrance requirements and stressing academic stan-dards, scientific research, and clinical experience. These changes increased thepressure on other medical schools to do the same. Those pressures increased fol-lowing publication in 1910 of theFlexner Reporton American medical”purge her bowels. In six hours shedelivered a stillborn child. After two days she regained consciousness andrecovered. The doctors considered this a conservative treatment, eventhough they had removed two-fifths of her blood in a two-day period,for they had not artificially dilated her womb or used instruments toexpedite delivery (Wertz and Wertz, 1989:69).As this example suggests, because of the body’s amazing ability to heal itself,even when doctors used heroic medicine, many of their patients survived. Thus,doctors could convince themselves they had cured their patients when in realitythey either had made no difference or had endangered their patients’lives.By the second half of the nineteenth century, most doctors, responding tothe public’s support for irregular practitioners and fear of heroic medicine, hadabandoned their most dangerous techniques. Yet medical treatment remainedrisky. Allopathic doctors’major advantage over their competitors was their abil-ity to conduct surgery in life-threatening situations. Unfortunately, until thedevelopment of anesthesia in the 1860s, many patients died from the inherentphysical trauma of surgery. In addition, many died unnecessarily from post surgical infections. Dr. Ignaz Semmelweis had demonstrated in the 1850s that because midwives (whose tasks included washing floors and linens) had rela-tively clean hands, whereas doctors routinely went, without washing their hands, from autopsies to obstetrical examinations and from patient to patient, more childbearing women died on medical wards than on midwifery wards. Yet not until the 1880s would hand washing became standard medical practice. Until well into the twentieth century, then, doctors could offer their patients little beyond morphine for pain relief; quinine for malarial and other fevers; digitalis for heart problems; and after 1910, Salvarsan for syphilis—each of which presented dangers as well as benefits. According to the 1975 edition of Cecil’s Textbook of Medicine, one of the most widely used medical textbooks, only 3 percent of the treatments described in the 1927 edition of the textbook were fully effective, whereas 60 percent were harmful, of doubtful value, oroffered only symptomatic relief (Beeson, 1980). Doctors’ effective pharmaco-peia did not grow significantly until the development of antibiotics in the1940s. Similarly, surgery in the early nineteenth century relied on only a few basic technologies and remained rare and dangerous, if nowhere near as danger-ous as it had been before the development of anesthesia and antiseptic techniques” “education (Ludmerer, 1985:166–90). The report, which was written by AbrahamFlexner and commissioned by the nonprofit Carnegie Foundation at the AMA’sbehest, shocked the nation with its descriptions of the lax requirements and poorfacilities at many medical schools. The Flexner Report increased the pressures onall medical schools to improve their programs and accelerated the changesalready underway. In the next few years, responding to pressure from both thepublic and the AMA, all US states began enforcing stringent licensing laws formedical schools (Ludmerer, 1985:234–249). These laws hastened the closure ofall proprietary and most nonprofit schools, many of which were already sufferingfinancially from the costs of trying to meet students’growing demand for scien-tific training. As a result, the number of medical schools fell from 162 in 1906 to81 in 1922 (Starr, 1982:118, 121).The Flexner Report, in conjunction with the changes already underway inmedical education, substantially improved the quality of health care available tothe American public and paved the way for later advances in health care. How-ever, these changes in medical education also had some more problematic results.The closure of so many schools made medicine as a field even more homoge-neous because only two medical schools for African Americans and one forwomen survived (Ludmerer, 1985:248; Starr, 1982: 124). In addition, few immi-grants, minorities, and poorer whites could afford the tuition for university-basedmedical schools or meet their strict educational prerequisites. Moreover, many ofthese schools openly discriminated against women, African Americans, Jews, andCatholics. Thus, even though the technical quality of medical care increased,fewer doctors were available who would practice in minority communities andwho understood the special concerns of minority or female patients. At the sametime, simply because doctors were now more homogeneously white, male, andupper class, their status grew, encouraging more hierarchical relationshipsbetween doctors and patients.Doctors and Professional DominanceBy the 1920s, doctors had become the premiere example of aprofession(Parsons, 1951). Although definitions of a profession vary, sociologists generallydefine an occupation as a profession when it has three characteristics:1. The autonomy to set its own educational and licensing standards and topolice its members for incompetence or malfeasance2. Technical, specialized knowledge, unique to the occupation and learnedthrough extended, systematic training3. Public confidence that its members follow a code of ethics and are moti-vated more by a desire to serve than a desire to earn a profitDuring the first half of the twentieth century, doctors clearly met this defi-nition of a profession (Timmermans and Oh, 2010). Most doctors worked inprivate practice (whether solo or group) and set their own hours, fees, andother conditions of work. Those who worked in hospitals or clinics were”
“typically supervised by other doctors, not by nonmedical administrators. Andeven in these settings, only doctors had the authority to review other doctors’clinical decisions, and this authority was rarely exercised. Similarly, only doctorsserved on boards that evaluated medical schools and granted or revoked medicallicenses. Finally, the public placed great trust in doctors, believed most doctorsworked selflessly to serve their patients, and routinely ranked medicine as themost prestigious occupation. These expectations were confirmed by doctors’adoption of a professional code of ethics.Ethical Debate: A Duty to Provide Care?explores one aspect of that code.As this suggests, as the leading profession in the health care world, doctorsenjoyed—and to some extent still enjoy—an unusually high level ofprofes-sional dominance: freedom from control by other occupations or groupsandthe ability to control any other occupations working in the same economicsphere (Freidson, 1994; Timmermans and Oh, 2010). Although doctors oftensupervised, taught, or set licensing standards for members of other health occupa-tions, those other occupations rarely had any say over doctors’work.THE THREATS TO MEDICAL DOMINANCEMore recently, however, this high level of professional dominance by doctors—otherwise known asmedical dominance—has come under threat.The Rise of CorporatizationUntil the 1960s, nonprofit or government agencies owned most hospitals andother health care institutions. With the initiation ofMedicareandMedicaid,however, the potential for profits in health care expanded tremendously, leadingmany for-profit corporations to enter the field, as we saw in Chapter 8 (Starr,1982:428–432; Timmermans and Oh, 2010). This growth of corporate medicineis known ascorporatization.Corporatization has substantially affected the work lives of American doc-tors. As Americans increasingly have obtained their insurance throughmanagedcare organizations, doctors have increasingly found employment within thoseorganizations. Passage of theAffordable Care Acthas also led doctors to takesalaried positions as a way of protecting themselves financially from whateverchanges that law may bring (Rosenthal, 2014a; Ruggieri, 2014). Meanwhile,hospitals increasingly are buying up private medical practices to expand theirposition in the market, increase their bargaining power with insurers, and thusgenerate more profits. Buying medical practices also increases hospitals’profitsbecause primary care doctors who work for a hospital are expected to refertheir patients to surgeons who work for the same hospital and who typicallyconduct surgery only in that hospital (Ruggieri, 2014). Currently, the majorityof primary care doctors and about two-thirds of surgeons work as paid employ-ees of hospitals or some other corporate institution, and most of the rest obtain” “typically supervised by other doctors, not by nonmedical administrators. Andeven in these settings, only doctors had the authority to review other doctors’clinical decisions, and this authority was rarely exercised. Similarly, only doctorsserved on boards that evaluated medical schools and granted or revoked medicallicenses. Finally, the public placed great trust in doctors, believed most doctorsworked selflessly to serve their patients, and routinely ranked medicine as themost prestigious occupation. These expectations were confirmed by doctors’adoption of a professional code of ethics.Ethical Debate: A Duty to Provide Care?explores one aspect of that code.As this suggests, as the leading profession in the health care world, doctorsenjoyed—and to some extent still enjoy—an unusually high level ofprofes-sional dominance: freedom from control by other occupations or groupsandthe ability to control any other occupations working in the same economicsphere (Freidson, 1994; Timmermans and Oh, 2010). Although doctors oftensupervised, taught, or set licensing standards for members of other health occupa-tions, those other occupations rarely had any say over doctors’work.THE THREATS TO MEDICAL DOMINANCEMore recently, however, this high level of professional dominance by doctors—otherwise known asmedical dominance—has come under threat.The Rise of CorporatizationUntil the 1960s, nonprofit or government agencies owned most hospitals andother health care institutions. With the initiation ofMedicareandMedicaid,however, the potential for profits in health care expanded tremendously, leadingmany for-profit corporations to enter the field, as we saw in Chapter 8 (Starr,1982:428–432; Timmermans and Oh, 2010). This growth of corporate medicineis known ascorporatization.Corporatization has substantially affected the work lives of American doc-tors. As Americans increasingly have obtained their insurance throughmanagedcare organizations, doctors have increasingly found employment within thoseorganizations. Passage of theAffordable Care Acthas also led doctors to takesalaried positions as a way of protecting themselves financially from whateverchanges that law may bring (Rosenthal, 2014a; Ruggieri, 2014). Meanwhile,hospitals increasingly are buying up private medical practices to expand theirposition in the market, increase their bargaining power with insurers, and thusgenerate more profits. Buying medical practices also increases hospitals’profitsbecause primary care doctors who work for a hospital are expected to refertheir patients to surgeons who work for the same hospital and who typicallyconduct surgery only in that hospital (Ruggieri, 2014). Currently, the majorityof primary care doctors and about two-thirds of surgeons work as paid employ-ees of hospitals or some other corporate institution, and most of the rest obtain”
“their patients largely through contracts with managed care organizations(Rosenthal, 2014a; Ruggieri, 2014).In all of these circumstances, doctors’autonomy has diminished. Administratorshave taken over decisions formerly made by individual doctors, such as settingdoctors’fees and work schedules, requiring doctors to obtain authorization beforescheduling surgeries or prescribing certain medications, and expecting doctors to fol-lowpractice protocolsthat establish treatment guidelines aimed at providing thebest—but also most cost-effective—treatment for different conditions (McKinlayand Marceau, 2002; Millenson, 1997; Vanderminden and Potter, 2010).Meanwhile, concern about costs has led corporations to replace doctors withradiation technologists, pharmacists, nurse practitioners, and other allied healthpersonnel. This shift has reduced both doctors’bargaining power with adminis-trators and their power over other health occupations.The Rise of Government ControlConcern about costs has also led the government to restrict doctors’professionalautonomy (Timmermans and Oh, 2010). Because the government pays the bills gen” “doctors’fees and treatment decisions. To do so, it has established programs such asthediagnosis-related groups (DRG)system and theresource-based relativevalue scale (RBRVS). The DRG system (described in Chapter 8) establishedpreset financial limits for each diagnosis for hospital care under Medicare (and insome states, Medicaid). Because hospitals are not reimbursed for any costs abovethose limits, they have a vested interest in making sure that doctors stay below thelimits. Consequently, hospitals may cut the wages or terminate the contracts of doc-tors who consistently exceed DRG limits, thus pressuring all doctors in theiremploy to stay within those limits. Doctors sometimes conclude that they haveonly two choices: to misreport a patient’s diagnosis on the DRG form so they canjustify more expensive treatments they believe are necessary or to ignore their ownclinical judgment and change their treatment plans to stay within DRG limits.Whereas DRGs were designed to control Medicare spending on hospitalcare, RBRVS was designed to control spending on doctors’bills. RBRVS is acomplex formula for determining appropriate compensation for medical careunder Medicare, based on estimates of the costs and effort required to providespecific services in specific geographic areas. Under this system, incomes of mostspecialists have declined, whereas those of generalists (other than pediatricians,who receive no Medicare funds) have increased.”

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