Health and Illness: Chapters 11-15

Question 1

Proportion of medical workforce

Answer 1

physicians constitute less than 10 percent of the total medical workforce, yet the entire US healthcare industry is subordinate to their professional authority in clinical matters

Question 2

Medicine as a profession (Goode)

Answer 2

two basic characteristics are sociologically relevant in explaining professionalism: 1) prolonged training in a body of specialized and abstract knowledge and 2) an orientation toward providing a service
once a professional group is established, it begins to further consolidate its power by formalizing social relationships that govern the interaction of the professionals with their clients, colleagues, official agencies

Question 3

Additional features of a profession

Answer 3

determines its own standards of education and training; student goes through more stringent socialization experience; professional practice is legally recognized by some form of license; licensing and admissions are staffed by members of the profession; most legislation concerned with the profession is shaped by that profession; the occupation demands high-caliber students as it gains income, power, and prestige; practitioner is free of lay evaluation and control; members are strongly identified by their profession

Question 4

History of medical profession in US

Answer 4

quality of medical education in US remained low and physicians had little prestige until late 1850s; european-trained physicians returned to develop labs and science in the US; by 1895, americans were ready to forge ahead thanks to sums of money poured into medical research by private American foundations

Question 5

American Medical Association

Answer 5

weak and ineffectual in the beginning, but then gradually extended its authority to become single greatest influence on organization and practice of medicine; reputation of AMA as a lobby in Washington may now be spurious - role of maintaining best financial and policy outcomes for doctors, regardless of public’s interest, has eroded credibility

Question 6

Flexner report and changes in medical education

Answer 6

beginning of 19th century, many proprietary medical schools emerging - generally had low standards of instruction and poor facilities and admitted any student who could pay; AMA established Council on Medical Education;
Flexner report - Flexner visited every medical school in the country and indicated the lack of quality of medical education in the US; he encouraged schools to integrate teaching and research along with classroom instruction and clinicals;
many lesser med schools closed –> quality of education increased, but women med schools and AA med schools closed so diversity decreased

Question 7

Socialization of the physician

Answer 7

decision to study medicine is largely social in character; originates in a social group that can generate and nuture the medical ambition; family influence is big; most are from upper or upper-middle classes;
med students experience 3 types of uncertainty- uncertainty resulting from awareness of not being able to learn everything about medicine, realization that limitations existed in current medical knowledge and techniques, problems distinguishing between personal ignorance and the limits of available knowledge; as the student gained knowledge and sense of adequacy, it’s easier to deal with the uncertainty

Question 8

Changing perspectives American medicine

Answer 8

females and racial minority students are increasingly attending med schools; American medicine changed from 1) a system run by doctors to one shaped by purchasers of care and competition of profits 2) a decline in public’s trust in doctors to greater questioning 3) change in emphasis on specialization and sub specialization to primary care and prevention 4) less hospital care to more outpatient care in homes and doctor’s offices 5) less payment of costs

Question 9

changing power structures of American medicine

Answer 9

medicine has its own power structure; 3 factors important in establishing prestige within the medical profession:

1) hospital affiliation - if affiliated with a prestigious hospital, more financially rewarding medical practices
2) Clientele - physician required to interact with patients to secure their approval of the services provided
3) inner fraternity - operated to recruit new members, allocate these new members to positions in the various medical institutions, help them secure patients through referrals; urban power structure consisted of the inner core (specialists who have control of major positions), then then new recruits at various stages of their careers, then the general practitioners who are linked to inner core by referrals, and then the marginal physicians (practices were less successful and on the fringes of the system)

Question 10

Social control of medical practice

Answer 10

social control forms of bureaucratic supervision and judgment are lacking in medicine; problems of controlling medicine is solved by the strong self-control of the physician and ethical stance - this argument has defects;

laypersons do judge technical performance, regardless of whether they are competent to do so; the choices of clients acts as a form of social control over professionals and can mitigate against the survival of a group as a profession or the career success; norms governing colleague relations, rule of etiquette, restricted the evaluation of work and discourage expression of criticism; autonomy granted to the physician is conditional, assuming doctors will resolve issues in favor of the public interest - doctors don’t do this, it seems as if they only consider their own financial interest rather than have concerns of public welfare

Question 11

Countervailing power

Answer 11

shifted from the idea of inner circle to countervailing powers and have many diff influences; greatest impact on the autonomy of the medical profession is external and largely due to the countervailing power of 4 sources:

1) Government regulation - government wanted to control costs of care despite AMA opposition
2) Managed care - manage or control the cost of healthcare by monitoring how doctors treat specific illnesses, limit referrals to specialists, require authorization before hospitalization
3) Corporations - doctors can’t control basic issues such as time of requirement and there will be more regulation of pace and routines of work

Question 12

Changing physician-patient relationship

Answer 12

shift in medicine from treatment of acute diseases toward preventive health services intended to offset the effects of chronic disorders; growing sophistications of the general public with bureaucracy; the development of consumerism

Question 13

Deprofessionalization

Answer 13

increased consumerism and greater government control has resulted in decline of professional status; lessened authority; a decline in power which results in a decline in the degree to which professions posses, or are perceived to possess, a constellation of characteristics denoting a profession; medical work is subject to scrutiny

Question 14

Subordinance

Answer 14

nurse, pharmacist, lab tech, and pt reflect characteristics that account for their subordinate position - the technical knowledge must be approved by physicians, the workers usually asset physicians in their work, their work occurs largely at the request of a physician, physicians have more prestige

Question 15

History of professionalization of nursing

Answer 15

nursing was influenced by the presence of large numbers of nuns who performed nursing services; nursing was originally described as an activity for women who lacked specialized training in medical care, a supportive work role that was not officially incorporated in to the formal structure of medical services, not held in high regard by the general public

Question 16

Florence Nightingale

Answer 16

decided to be a nurse as her religious vocation/calling; git training from a nurse in Germany and came back and established a hospital for “Sick Gentlewomen in Distressed Circumstances” and staffed it with trained nurses from good families; during crimean war - first time nursing services offered to British troops; gained publicity and got enough money through fundraising to start a nursing school; created the “Nightingale System” for training nurses - had a strict protocol to get rid of sexual stigma associated with nurses

Question 17

Nursing education

Answer 17

Nightingale formed the basis for nursing education; nursing has been characterized by different educational experiences - 3 types of programs available for RNs: 2 year associate degree programs usually at a community college, hospital-based diploma schools requiring 2.5-3 years of study, 4 year university baccalaureate programs
Baccalaureate program is most prestigious, but most US nurses were trained in hospital-based diploma school; used to be poorly paid, but improving on that and also gaining more prestige

Question 18

Socialization of nursing students

Answer 18

6 distinct stages: initial innocence - nursing students wanting to do things for patients within a secularized humanitarian ethic of care and kindness, consistent with the lay (mother-surrogate) image of nursing while schools tended to depersonalize care;
labeled recognition of incongruity (disillusionment) - students began to collectively articulate their disappointment and openly question their choice of become a nurse
psyching out - students attempt to anticipate what their instructors wanted them to know and try to satisfy these requirements
role simulation - students performing to elicit favorable responses from the instructors, performing accepted mode of behavior such as being objective and professional - felt like they’re playing a role
provisional internalization and stable internalization (5th and 6th stages) - nursing students took on a temporary self-identity as a “professional” nurse, as defined by the faculty, and settled into the identification by the time of graduation

Question 19

Gender and nursing

Answer 19

gender inequality is declining in nurse-doctor relationships dues to 3 things: greater assertiveness by nurses, increased numbers of male nurses, and the growing number of female doctors

Question 20

Doctor-nurse game

Answer 20

most nurses have been able to develop an effective, informal interactional style with physicians; nurses should be bold, show initiative, make recommendations to the doctor in a manner that appears passive and totally supportive of the “super-physician” - avoid open disagreement between the players; physician can use nurse and a consultant and nurse gains self-esteem and professional satisfaction

Question 21

Future trends

Answer 21

lower-echolon workers such as nurses’ aides provide majority of bedside care; RNs expanded their range of services to include hospital administration, primary-care healing, nurse anesthetists, cardiovascular nurse specialists - they have enhanced status and greater autonomy in patient care

Question 22

Advanced practice nursing

Answer 22

nurse practitioner - about 2-3 more years of training after getting the RN; they play a bigger role in patient care now because of the shortage of primary care doctors, work position is similar to PA role and provide some of the same care as physicians

Question 23

Physician assistants

Answer 23

typically have bachelor’s degree, experience in health care as a nurse of paramedic, and become qualified after completing a PA training program of about 26 months; licensed to practice medicine under the supervision of a physician and trained to handle routine medical problems;

Question 24

Pharmacists

Answer 24

prepare and dispense medication and also provide advice, information, and instructions about drug use using laypersons terms; pharmD degree for 6 years of study beyond high school; assumes greater patient counseling now, but they supplement rather than challenge the patient care tasks of physicians

Question 25

Midwives

Answer 25

women who assist a mother during childbirth; nurse-midwives assist to deliver babies under the supervision of a physician and lay midwives assist births on their own in the home; midwifery has made a comeback for women who wish to have a natural birth

Question 26

The hospital

Answer 26

the major social institution for the delivery of health care, offers considerable advantages to both patient and society; sick or injured can access medical knowledge and technology, while people access care in the hospital instead of home which prevents societal disruptions

Question 27

hospitals as centers of religious practice

Answer 27

hospital has usually been associated with the rise of christianity, many hospitals were established along the routes to the Holy Land followed by christian armies; medieval hospital was a community center for the care of the lower-class sick, care was performed by nuns and clergy; provided a wide spectrum of social tasks for the benefit of the lower class, esp the provision of food, shelter, sanctuary, and prayer as well as nursing;
During Renaissance and reformation, religious character of the hospital began to disappear, but concepts of service orientation, universalistic approach, and custodial nature of care has been derived from the church's influence

Question 28

Hospitals as poorhouses

Answer 28

removal of centralized authority of church left hospitals under many separate administrations; encouraged abuse and neglect of facilities, misappropriation of funds, and the lowering of prevailing standards of patient care; economic and social conditions worsened so many vagrants claimed to be sick or crippled and crowded into whatever hospital facility was available

Question 29

Hospitals as deathhouses

Answer 29

after renaissance and reformation, changes made hospitals contain large numbers of sick and injured people; by early 19th century, hospitals attained the image of an institution for medical care, research, and education; but so few patients survived treatment, so hospitals got the image of a place where the poor went to die

Question 30

Hospitals as centers of medical technology

Answer 30

institutions where patients of all social classes could generally expect to find the highest quality medical care and could reasonably expect to be cured of their disorders; 3 major changed: medicine had become a science in terms of using the scientific method to seek out knowledge and new techniques, discovery and use of antiseptic measure in the hospital to help curtail infection, and the significant improvement in the quality of hospital personnel (esp the entry of the trained nurse and lab tech)

Question 31

Changing patterns of hospital ownership

Answer 31

3 major types of ownership of hospitals: nonprofit, for profit, and government (local, state, or federal)
most common type of hospital in the US is the nonfederal and nonprofit community hospital; america's hospital system is a two class system of medical care - one primarily for the relatively affluent and the other for the less affluent in government hospitals

Question 32

Nonprofit community hospital

Answer 32

exempt from federal income taxes and many other forms of state and local taxes; multipurpose institutions in that they provide a variety of services such as treating patients, research, education, providing facilities, etc;

Question 33

for profit hospitals

Answer 33

usual source of income for profit-making hospitals is internal and generated from patient care, esp payments from private insurance companies;

Question 34

governmental hospitals

Answer 34

tend to lack prestige in comparison to other hospitals, they are the major source of health care for people with low incomes, particularly in urban areas

Question 35

Dual authority structures

Answer 35

most nonfederal hospitals have governing body or a board of trustees; multiple leadership is actually a system of dual authority, one administrative and the other medical; reconcile the physician-professional with the administrator-bureaucrat by establishing a system of dual authority - but the board of trustees still remains the nominal center of authority

Question 36

Hospital-patient role

Answer 36

the sick and injured are organized into various patient categories that reflect the medical staff’s definition of their problem and are then usually subject to standardized, staff-approved medical treatment and administrative procedures; many people feel depersonalized - this is not the goal of hospital personnel, but the organization of hospital’s work favors rules and regulations that reduce patient autonomy and encourage patient receptivity of the hospital routines

Question 37

Stripping

Answer 37

patients are alienated from their usual lives and reduced to a largely impersonal status through 3 mechanisms, stripping, control of resources, and restriction of mobility
stripping - when the hospital systematically divests the person of past representations of self, takes away the social identity

Question 38

Control of resources

Answer 38

controlling physical items but also the control of information about the patient’s medical condition - patients are normally not aware of a prognosis or results or tests unless the physician decides to inform them

Question 39

Restriction of mobility

Answer 39

patients can’t leave the ward without permission of the head nurse; when patients do leave, they are generally accompanied by a nurse or other staff; the ability of patients to move is supervised and controlled

Question 40

Conforming attitudes

Answer 40

some patients may only desire to get well, so they’re willing to conform to the situation; seriousness of a patient’s illness was NOT a good predictor of whether a patient would conform to hospital routine; the younger and better educated the patient, the less likely the patient to express highly conforming attitudes; older and more poorly educated were least likely to express deviant attitudes

Question 41

Sick role for hospital patients

Answer 41

includes an obligation to accept hospital routine without protest; acquiescence is the most common form of patient adjustment to hospital routine and the most successful for short-stay patients

Question 42

Trends in hospital costs

Answer 42

costs of hospitalization has risen sharply in recent years than any other aspect of medical care; manner of payment has also changed as about 90% of all expenses for hospital services are now paid by third-party sources; costs rise because of increased costs for labor, medical equipment, supplies, and new construction; cost of paperwork is significant, technological innovations are expensive
A federal legislation to reduce costs established a fixed rate for each procedure according to what DRG the procedure falls under for medicare patients

Question 43

Emergency Medical treatment and labor act (EMTALA)

Answer 43

if you have an emergency medical condition, hospitals must admit you until you’re stable - regardless of background, state of insurance, etc

Question 44

Key goals of healthcare policy

Answer 44

improve quality, expand access, control cost of care; a lack of insurance over time can have a strong negative cumulative effect on a person’s health

Question 45

Rising costs

Answer 45

the US pays more per person for healthcare than in other countries; partly because of the culture (medicine decision rule), partly because of taste for technology, maybe b/c of aging population; higher administrative costs b/c many insurers all have diff paperwork

Question 46

DRGs (diagnostic-related groups)

Answer 46

based on diagnosis of patient, the insurance pays a flat fine and nothing more - instituted cost controls for services to medicare patients by establishing set fees for DRGs

Question 47

Managed care

Answer 47

limits physician autonomy, don’t get to use treatments or prescribe without managed care or insurance approval; refers to organizations such as HMOs and PPOs; they monitor the work of doctors and hospitals, limiting visits to specialists within a particular managed care network and to all physicians outside it; introduces the case manager to the decision-making process

Question 48

Health maintenance organizations (HMOs)

Answer 48

a form of prepaid group practice emphasizing preventive care, in which a person pays a monthly premium for comprehensive health care services; part of managed care

Question 49

Preferred provider organizations (PPOs)

Answer 49

employers who purchase group health insurance agree to send their employees to particular hospitals or doctors in return for discounts;

Question 50

Medicare

Answer 50

a federally administered program providing hospital insurance and medical insurance for people aged 65 years or older, regardless of financial resources; also includes disabled people under the age of 65 who receive cash benefits from social security or railroad retirement programs and victims or chronic kidney disease; prescription drug coverage available to everyone with medicare

Question 51

Medicaid

Answer 51

a welfare program, provides for the federal government’s sharing in the payments made by state welfare agencies to health care providers for services rendered to the poor; extended medicaid coverage to children under 5 years of age and pregnant women with incomes below the poverty level

Question 52

Affordable care act/Obamacare

Answer 52

provisions state that persons with preexisting medical conditions can no longer be denied coverage b/c of these conditions; minimum level of benefits to be set by the federal govt must be provided in all health insurance plans; state insurance exchanges will be established that will offer a range of competitive health care plans at affordable prices, persons not covered by their employer will be able to purchase coverage through the state exchange, persons under the age of 65 who already have health insurance may also purchase plans from the exchanges and those who earn up to 4 times the federal poverty line will receive govt subsidies to help pay the cost, low-income persons under the age of 65 earning below 133 percent of the federal poverty line will be covered by an expanded Medicaid program, small businesses can buy insurance for their employees through the exchanges and get tax credits, children may remain on their parent’s health insurance plan until age 26, most Americans would be required by law to purchase health insurance or pay a fine while employers with more than 50 workers who do not provide coverage will also pay fines

Question 53

Bismarck model

Answer 53

found in Germany, Japan, Belgium, Switzerland; both health care providers and payers are private entities; private health insurance plans, usually financed jointly by employers and employees through payroll deduction; basically charities: they cover everybody and don’t make a profit; doctor’s office is private business and hospitals are privately owned; multilayer model but still has tight regulation of medical services and fees
similar to employer-based insurance (for middle and working class) in the U.S. system

Question 54

Beveridge Model

Answer 54

health care is provided and financed by the government, through tax payments; no medical bills but rather medical treatment is a public service; many but not all hospitals and clinics are government owned; some doctors are govt employees but also have private doctors who collect fees from govt; Great Britain, Italy, Spain
similar to US Dept of Veteran Affairs, Indian health services, health care for active military members

Question 55

National Health Insurance Model

Answer 55

providers of healthcare are private, but the payer is a govt run insurance program that everyone pays into; national or provincial insurance plan collects monthly premiums and pays medical bills; Canada, Australia, Taiwan, South Korea
similar to medicare

Question 56

Out-of-Pocket Model

Answer 56

the rich get medical care while the poor stay sick and die; Cambodia, rural India
similar to uninsured americans