INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT, VOL.

zyxwv2, 301-304 (1987)

BOOK REVIEWS

zyxw
zyxwv
zyxwvu
ANSELN STRAUSS, SHIZUKO FAGERHAUGH, BARBARA SUCZEK and
CAROLYN WIENER, Social Organization of Medical Work Chicago: University of
Chicago Press, 1985, 310 pp. plus xii. Price (UK) f21.25.

This innovative volume must be recognized as a major contribution to the sociological

understanding of medical work. Social Organization of Medical Work has direct rel-
evance for health planners and medical care researchers because it offers an innovative
approach to studying caring activities in hospital settings. The book provides an alterna-
tive conceptual framework for examining the management of chronic disease processes
by specialized teams of health workers. Health planners and evaluators have applied
sociological research on clinician/patient interaction and inter-professional relations in
hospitals; most noticeably, perhaps, in analyzing specific processes such as institutionaliz-
ation and professionalization. Strauss and his co-authors describe clinical interaction in
hospitals within a more neutral framework, and thereby avoid limiting the analysis t o
a single outcome measure such as depersonalization or dominance.
Social Organization of Medical Work also offers an innovative approach to the
classification and analysis of work, which contrasts with research emphasizing task
analysis or case studies of the decision-making process. The authors use the concept of
‘illness trajectories’ as a mechanism for documenting the organization of complex tasks
in the treatment of chronic illness. They describe the changing contexts in which health
workers manage evolving chronic conditions.
This approach overcomes the limitations of cross-sectional analyses of hospital activi-
ties. It allows the authors to describe caring activities within a temporal sequence. Their
case studies successfully describe the clusters of work activities undertaken by clinicians
and patients at each stage of the progression of an illness.
Strauss, Fagerhaugh, Suczek and Wiener’s development of concept of ‘illness trajecto-
ries’ is perhaps their most significant contribution. Their approach avoids focusing on
delimited ‘patient careers’, because an analysis of chronic disease requires an analytical
approach which can deal with sequences without defined points of onset or cure. The
authors’ theoretical and empirical framework extends the concept of trajectory beyond
previous applications in research on terminal illness. Trajectory provides a unique
framework for describing the reflexive processes in which care activities are continuously
rearranged in response to progression of chronic illness. Analysis of trajectory also
allows the authors to examine the reciprocal impact of medical work on the social
structure of hospitals.
For health planners and researchers specifically, the concept of trajectory provides a
meaningful alternative to conventional organizational analysis. The authors’ observations
of interaction between illness events and work processes avoid the trap of characterizing
hospitals primarily as ‘containers of medical work’. Their profile of the organizational
structure of the hospital emerges as an aggregation of descriptions of individual work
activities and treatment settings.
Strauss, Fagerhaugh, Suczek and Wiener provide detailed and poignant descriptions of
the changing character of therapeutic work in San Francisco hospitals. Their observations
dramatize the technological complexity and protractedness of medical response to
chronic disease. They clearly demonstrate that documentation of medical work must
not only describe individual clinical encounters, but must also document complex
sequences of interaction involving teams of specialists working in diverse treatment
settings. The introduction to the monograph summarizes their general framework for
observing and classifying medical work. Subsequent chapters provide detailed analysis
of the social organization of ‘machine work’ (i.e. activities related to monitoring,

@ 1987 by John Wiley & Sons, Ltd.

302 BOOK REVIEWS zyxwvu
transporting, storing and calibrating sophisticated medical technology); ‘safety work’
(i.e. activities associated with managing risks to the patient and health worker); and
‘comfort work’ (i.e. caring activities by clinicians and the informal work undertaken by

zyxwvutsr
the patient and family). Analysis of psychosocial support is extended in an analysis of
informal caring activities, self-care activities undertaken by the patient and family.
Ethnographic observations emphasize the role of technology in medical work in coronary
care and neonatal intensive care units. The rich descriptions of events in the daily life
of hospitals add a dimension of familiarity and validity for both practitioners and applied
researchers.
Social Organization of Medical Work also successfully integrates the analysis of macro
and micro levels of hospital organization. Strauss and co-authors provide rich descriptions
of the work of clinicians, ancillary workers, patients and family members and relate
these activities to the temporal and spatial arrangements of hospitals.
There might be considered to be an absence of consideration of the influence of
broader structural factors upon the organization of hospital-based work. However, most
readers will find that a lack of emphasis on the political and economic context of
hospital-based work does not detract from the monographs’s overall contribution. For
social scientists, planners and managers the book provides an innovative conceptual and
methodological standard for the next generation of research examining the organizational
and technological response to chronic illness.

JOSEPHM. KAUFERT,
Faculty of Medicine,
The University of Manitoba,
Canada.

WILLIAM M. KIZER, The Healthy Workplace: a Blueprint for Corporate Action. New
York: John Wiley, 1987, 187 pp. Price (US) $24.25.

‘The bottom line is, we can only be as good as our people. So if we’re to keep our
competitive edge in America, our employees of all ages have to be healthy.’ Roger B.
Smith, Chairman of General Motors, 1983 (cit.p.1).
‘What you are doing in the Wellness Council responds to this Administrations’s belief
that private initiatives rather than government programs can be of great benefit to the
nation in dealing with many social and community needs.’ Ronald Reagan, President
of USA, 1981 (letter to author, cit.p.98).
A past chairman said that what was good for General Motors was good for America.
Kizer endorses a present-day chairman’s view that what’s good for Americans is good
for General Motors. However, his model for health care in the ‘new welfare capitalism’
is radically different from the British National Health Service. In a study of the British
Blood Transfusion Service, another health care model builder, Richard Titmuss (1970)
saw the democratic state as the optimally efficient intermediary between citizens, who
are rationally committed to give to strangers in need, blood or taxes for health-care,
because they expect that they may one day require such a gift themselves. Kizer, on
the other hand, sees the enlightened self-interest of the employer, acting through the
market, as the guarantor of the health of those in need, his employees. Kizer’s model
will be as attractive to the New Right in Britain as it clearly is to President Reagan: in
place of largely curative, state provision for a healthy workforce, it involves a combi-
nation of business and community initiatives, spurred by the high costs of medical
insurance, which aim to educate employees and their families in healthy living.
Kizer himself has a business interest in the model. He is chairman of the largest
supplier of credit card insurance in USA. Insurance companies have been at the forefront
of attempts to reduce the high costs of medical care, for these costs are pushing health
premiums beyond the reach of employers, who (for those fortunate enough .to be