S207 Week 6 6 February 2007   Cindy: medical professionals moving into administrative roles Janet: Freidson was taking

on the critique that his notion of professional autonomy = dated (see: corporations, etc.). his response was that, even when we have clinical guidelines and protocols, it’s physicians who are deciding what ends up in the protocol or guidelines, so it still maintains that kind of power within the profession. according to him, professional autonomy was not being eroded as much as other theorists argued. is professional autonomy/power eroding? one piece of evidence that certain scholars would cite = instances in which the content of medical work has changed, and physicians no longer control the boundaries of what defines that medical work. but some of you are bringing up: what if the definition of medical work in and of itself is changing? so what used to be this causal relationship between professional autonomy and the boundaries of medical work is no longer seen as causal. maybe the fact that physicians are doing other kinds of things is redefining the boundaries and reconstituting the grounds upon which we judge professional autonomy to exist or not exist. thus far, a lot of scholars have been saying: one follows from another.. professional autonomy/power follows from being able to define the boundaries of work. but what happens when the boundaries themselves are changing? then maybe that definition of professional autonomy no longer holds. it’s an empirical question to ask. physicians getting into the business of administration and protection of private interests – physician entrepreneurs – may in fact be an expansion of professional power. it’s a different kind of profession for sure, but.. Cindy: it’s a conflict of interest Janet: what defines conflict of interest? ---Cindy: in a different society, would Parsons even have an application? Janet: seems a lot of you are interested in the sick role and how it can be applied. so to what extent do other things in modern medicine undermine what we’ve learned so far? are physicians still dominant? Jonathan: secondary gains Cindy: Jonathan’s definition is different from Parsons’ definition Jonathan: patients demanding MRIs instead of CTs. fear re: health/morbidity/disability/death Beth: not everyone worries just cuz we talk about the emergent culture of the worried well, doesn’t mean everyone is a worried well re: public fear: is there also something else that’s going on? a lot of observers would argue there’s this new culture – whether you call it postmodern culture, similar to the remission society Frank talked about – where fear is qualitatively different, and much more pervasive. not just fear of being ill, but fear of risk of being ill, and the risk of being at risk. for example, Pescosolido.. is it just that the public is becoming more assertive/directive.. is this stemming from generalized fear about illness and health? Elena: fear that doctors are acting only in self-interest. it’s not really care. alternative care.

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what would neo-Marxists and political economists say about it? Krista: organic produce as opposed to genetically modified foods. you could say alternative medicine is just another attempt to make money on a health product. but it’s also a challenge to the hegemony of capitalist medicine. people like Navarro had a lot to say about science as an ideology. the way Western medicine works now, it’s not a coincidence.. it emanates from system of class relations in Western society. division between expert and lay knowledge. the assumption in medicine of a mechanistic ideology (body is a machine).  this is an opportunity to mimic the kinds of things you could be doing in your paper. Erica: another reason we might have this fear might relate to the compartmentalization of knowledge. eye doctor told me I need to see the retina specialist. you start to question how much knowledge doctors actually have, if they can’t even talk about something that seems like it would be in their purview. and it does make the public question the ability/knowledge/autonomy of physicians. but if that specialization already exists, isn’t that what you would want – to go to the specialist? Cindy: is it just passing the buck? shift the burden? Erica: makes you feel like a commodity, like everyone is very different.. when in fact people are a lot more similar than different. but that’s the presumption of evidence-based medicine, right? we’re not one-size-fits-all people, and you can’t apply a formula. ---changing status of physicians and other professions. somewhat different interpretations of what those trends mean. what are some of different interpretations and implications theorists draw? is it an example of increasing professional dominance, or is it the erosion of the unity of the profession in its ability to pursue its own interests? ---we’re supposed to be sociologists of medicine. what are the implications of evidence-based medicine? why is it that this notion of there being variability in medicine – why is that now a social problem? Beth: b/c of costs. Hafferty: sense you can have increasing scope/dominance on a macro level that would undermine your scope/dominance on a micro level. physicians going out into wider roles/occupations vs. what that does on the individual level. doesn’t the observation that evidence-based medicine is in part motivated by concerns about cost (paying for things we don’t need) – does that problematize the whole phenomenon at all? Cindy: I think it started w/ DRGs.. started as cost, then became issue of quality John: we need to question this myth of altruism. Stone: if you’re middle class, get insurance so you don’t have to get treated like a poor person. people don’t like to deal with uncertainty. believe doctors knew a lot more than they actually did; they acted based on intuition. things are getting revealed for what they have been for a much longer time than we’ve been willing to admit. Elena: the relationship between diagnosis and prognosis (Death Foretold by N. Christakis) for some things, there’s a “truth” (tonsillectomies don’t help you w/ sore throats). as sociologists, that’s not our question to adjusticate. what we can say is: EBM didn’t just pop

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up. it became important and it became seen as useful b/c of a confluence of different social trends. it’s our job to interrogate this rise of EBM and say it’s a historically contingent thing. certain things had to be in place for us to be able to say that the problem looks like this. e.g., the “right” interpretation of this problem is one of quality. these are all socially constructed things we’re doing here. none are “well, of course we’d see it this way.” all these are historically and socially contingent things that unfold. the question is not whether one guideline got it right. our job is to debate: why is this happening now? going to statistical science feels “familiar,” like “the right thing to do.” why EBM? why now? what accounts for it? John: market shelter. one more thing to teach in med school, to legitimize that physicians have the authority to do something. another thing the public doesn’t know or will have trouble learning. it’s a self-perpetuating thing. Tania: not all physicians subscribe to EBM John: I don’t think epidemiologists need the market shelter physicians do. Tania is saying: we say it’s this overwhelming trend, but there’s a good number of physicians who don’t actually believe in EBM. I talk about these things being socially constructed and historically specific; not long ago, physicians were saying their knowledge was too esoteric to be standardized. now the whole attraction.. where is this push for EBM coming from and why, and whose interests does it serve? there’s still a good chunk of MDs who don’t subscribe to that model of practicing medicine. did clinical practice guidelines arise b/c we need them? is that a functional way of looking at it? self-fulfilling, tautological? Erica: thinking back to role of foundations. what foundations have decided to put their money toward been funded by federal government, federal research funding agency. some have been supported by professional organizations. Krista: evidence-based standards can be fused with corporate interests. medical device companies saying their reusable devices can’t be reused Jonathan: AHA published ACLS guidelines that said to use a new drug, and no longer use an old drug that was under patent protection. the study funded by the maker of the new drug Beth: going back to point re: tautology. structural form in which we work affects how we work. any institution that gets bigger and bigger develops mechanisms for data transfer. it would seem odd for medicine not to develop some way of easily accessing the information it needs to make decisions, particularly when the rest of the world is doing that. Martine: but that’s not the “functional” we’re talking about. we’re talking about rationalization, more rational way for doctor to provide care.. that’s a particular movement that might seem valid b/c that’s the way society works, but there are underlying social/historical factors. there was always way more knowledge than any one practitioner could wrap his/her brain around. so why is EBM coming up now? EBM presumes certain functions, ideas of the social problems it’s meant to fix. raises lots of empirical and theoretical questions. Beth: what was your point re: cyclical? one of the critiques of functionalism is that it necessarily leads to its own conclusion. it’s a logical cycle that you can’t step out of. it becomes self-evident and self-fulfilling. John: can’t you say Marxism does the same thing?

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that’s why I was saying in a previous week that there’s a way in which Marxist theory is very packed. John: I’m suspicious of Alain Enthoven. cross-pollination of different academic disciplines. maybe EBM was the result of that why this answer, and why now? we see this business model of efficiency. to have efficiency be equated with good is a very particular way to look at something. it’s a recent phenomenon for medicine, for the quality of health care to be equated to efficiency. Cindy: very insidious. get ‘em through the ER. flow was the big word. the contemporary experience of dying now – 80% in a hospital, which is structured to move things along. institutional and clinical, now seemingly human imperative to keep things moving, as opposed to keeping someone on a ventilator for months. and that’s how death happens, when we decide time’s up. Krista: medicine becoming very businesslike. whole idea of “it could have been otherwise” is useful in thinking about it. we’re so naturalized to the idea of EBM that we can’t get anything done unless it’s evidence-based. the obvious intuition that people make more mistakes when they’re sleep-deprived is not enough to make changes to residency hours; you need hard data. rise of academic medicine probably a large part of the story. John: sociologists legitimizing their field in the 1950s. ongoing trend that’s been remaking our definitions of what constitutes disciplinary knowledge, and what constitutes legitimate/authoritative knowledge (and authority) at all. epidemiological fallacy. a lot of this data is collected from populations, so whatever unit of analysis you get your data from is the only unit to which you can then generalize. so if you’re getting population-level data (in US history, tonsillectomies ineffective), you can only say that in this other population, on average, tonsillectomies will also be ineffective. the fallacy is when you jump to another level of analysis (e.g., the individual or the small group). so in actual fact, EBM is based on an epidemiological and mathematical fallacy. Craig: what about social epidemiology? social epi people use epi techniques, but the questions they’re interested in are very different. Beth: but not all EBM is based on population-level data. some are based on clinical trials. epidemiologists don’t look at therapy. we talk about epidemiology, but really what they’re using is probability and statistics. epidemiologists are concerned about disease causes, disease determinants, disease risks. and they use probability/statistics to get at the answers. Beth: but that’s different from a clinical guideline. but guidelines being produced from epidemiological data. that’s my sense of what the bulk of EBM is referring to.. the practice of medicine based on explicit clinical practice guidelines developed by different groups, that are in turn based on a database that tells you what works and what doesn’t. Beth: my understanding was that EBM is more looking at the good studies that have been done. so the correlational fallacy is looking at clinical trial data and apply it to an individual. John: we’re funding this study b/c it reproduces the existing social order. the people making the decisions are the ones who have the vested interests to keep things the way they are.

Changing Political Economy of Medical Care what kinds of effects/consequences do you think it has for people’s relationship w/ doctors?  John: rationalization/managed care has cut off people’s access to doctors  Cindy: there were more uninsured people before (as a percentage of population)  Jonathan: how many services could you even buy in the 1930s?  Beth: Carnegie bought his own doctor.  Jonathan: but as far as technology..  Cindy: people have a longer life expectancy.  Martine: on average.  John: that’s a myth. most life expectancy gains came w/ sanitation, immunization against infectious disease what are the consequences for medical sociology? what new dilemmas do we need to be cognizant of?  John: new institutions evolved in a new and different way. that’s when medical sociologists need to reexamine that new environment  Krista: Canadians consider health care to be part of their national identity  John: political economy of medical care further legitimizes the role of the state. the relationship between the state and the citizens and the medical professions is that it can only do so much. there are people that have more control over what those decisions are than others. it goes back to maintaining the existence social order. there would be a crisis of state if something really radical happened, even if it was best for the people (e.g., universal health care, or confiscation of private property, or nationalizing private hospitals) Reflections on the Quarter John: internal and external forces. certain medical professions (nurses) want to get more power and autonomy. specialists and generalists arguing with each other over who performs which service. environmental shocks that have brought the rise of managed care. Jonathan: for some of the theorists (Parsons), they just see it as a closed system. Beth: each one of the individual authors, I can place them, I get what they’re saying. but in terms of trying to lay them out and sort them by theory/categories, I get lost there. for my paper, do I compare this author with this author? Alford’s three perspectives is one nice way to think about these authors, but it seems like there are other aspects to the key issues. I’m struggling with the framework there’s no one framework. Alford’s typology = role of the state, how the state organizes itself, to whom it is beholden. Beth: what would be helpful for me is to get a sense for some of the other ways of categorizing. even though that typology is specific to ways of thinking about the role of the state, it is also more broadly applicable.. early on we did readings about conflict theory vs. consensus theory. that’s another dimension. there are broad themes that lots of people touch on. it’s our collective task to see what other people would say along those lines. you could pose a

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question: what did < > have to say about professional autonomy? most every one of them had some kind of answer. it’s those big questions or big themes that I’m asking you, looking back, to pull out. what are the prevailing themes we’ve read about where people have differing opinions? The List the role of the state would be one of those things. the role of the state in medicine. the rise of modern medicine.  how is that explanation rooted in particular assumptions about how the world works? rationalization. corporatization.  in some cases, corporatization equals rationalization. in other cases, some say rationalization is done in the service of corporatization  what is the relationship between the increasing influence of private interests and private capital.. what’s the relationship of that trend to different forms of rationalization? explicate what that relationship is.  John: you can have rationalization without corporatization. sources of conflict within health care. tensions within health care that are forcing a change. sources of tensions  dynamics without change?  how do different groups get divided up? what’s the dimension along which groups differentiate themselves? for Marxists, it’d be capitalists vs. labor – that’s the big division they see. others would have different kinds of answers to that. the role of physicians. autonomy as dependent upon the consensus of other social groups. physicians have been treated in different ways. sometimes they’re central, sometimes they’re more peripheral  question about professional autonomy. how autonomous are they? what is/are the basis/bases for autonomy? legitimacy. legitimate knowledge. legitimacy as a condition for control over a variety of things. control over your work, control over a set of knowledge  creation and sustaining of legitimacy in relation to the creation and sustaining of professional authority and professionalism  to all of the authors, knowledge is an important component. is the role of knowledge different for different people, or are they all in agreement that it’s an integral component? where does knowledge come from?  who is in charge of the knowledge, in addition to the money and the resources?  at least a couple of the theorists have talked about the necessity for physicians to persuade the public of certain things, in terms of the social process of making something seem real and legitimate. just to think about legitimacy as a socially accomplished phenomenon. what are the ways in which legitimacy is socially achieved, in this person’s view of this, that, or the other outcome?  what function does legitimacy have? the question of what is the social role of medicine? this is something Parsons was critically involved in trying to answer. Freidson and Navarro talk about it.  what is meant by social role? the way you answer that generates different assumptions.  think not only about the answer, but what’s assumed in answering it that way vs. another way

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how health and illness are dealt with in our society? how things have become increasingly medicalized.. deviance. we might talk about this more next quarter. see what happens in other countries. Krista’s example of Canada.  Light and Navarro talk about the global perspective, but it’s not really a key theme for most of these sociologists.  that’s American medical sociology. for better or for worse, that’s what we study in this program. in part it’s based on the canon, so that if you’re asked to go elsewhere in the U.S. and teach medical sociology, there’s a lot that would be perfectly recognizable.  we talked a bit in the health policy class about our values/system being exported to other countries  this course was never meant to be a study of different health care systems. it’s meant to be an introductory course to a particularly American brand of medical sociology. American medical sociology shaped to a great extent how medical sociology looks in other countries.  the impetus to conduct comparative studies is a fairly recent phenomenon.  Beth: Light does talk about the need to contextualize your analysis, and that’s why doing cross-cultural studies would be enlightening.  to help raise the question of in what ways have things been otherwise. there’s definitely value there.  Krista: it’s good to keep in mind that we’re learning about the U.S. system  there’s certain aspects/assumptions in this value that do end up getting exported to lots of other places.  Beth: we don’t import a lot, we export a lot. in terms of what’s functional in other countries, we don’t want it.  Navarro’s critique of Starr: we want what we want, and what we get is what we get another artifactual thing about our canon: historically, physicians were the epitome of professions. whole sociology of professions was constructed around looking at physicians, and how they did it. a final theme:  there is a crisis.  Alford said it dated to 1940  some of the theorists (last week’s Alford) say the concept of a crisis is a fallacy and that in fact it’s obscuring the real problems  how does crisis get framed? what’s the definition of crisis for different people?  insurance crisis? social justice crisis?  whose crisis? who’s in crisis?  who’s mobilizing or who’s deploying this language of crisis, and what ends is it serving?  some would say it keeps people going to the doctor. for papers? these themes aren’t the different boxes you draw people in. when I talk about comparing theoretical perspectives, for all intents and purposes you can use the Alford and Friedland. you don’t want to use people in the same box.

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your paper can but does not need to take up these themes. these themes are more for preparing for quals. what did <author> say about <theme>, and how does that differ from what <another author> said? medicalization the medicalization literature assigned for this class is more in the vein of political economy. the typology we have now is kind of historically bounded and limited, in that a lot of the people we’ll read in medicalization and beyond have somewhat different ideas about the state and about the nature of power. it doesn’t reside in institutions; it’s more fluid and situational. the issue isn’t really how to place medicalization within the typology we have now

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