The impact and integration of behavioural sciences in the education of health care professionals

Health, defined as physical, mental and social well-being, should be adequately conceptualized in organic as well as non-organic terms, thus implying a criticism of some training programmes which ought to recognize the dire need to integrate the socio-behavioural sciences--geography, social anthropology, sociology, psychology, political science and economics--in the education of health care professionals. The two components of this education, medicine and health care and the socio-behavioural sciences, should prepare the professional adequately to practice the science of medicine and the art of the profession in varying socio-cultural contexts of co-existing health care systems. This paper argues that it is only those institutions which integrate the socio-behavioural sciences in their programme of health care education that are on the path of progress by keeping scientific pace with our understanding of the structural realities of contemporary societies.     

Reflections on the health social sciences--then and now.

After its beginnings in the United States, medical sociology started to take hold in Germany in 1958 with a conference that resulted in the first book on medical sociology published in Germany. From uneasy marginality, the field has grown to include disciplines other than sociology--anthropology, economics, and political economy. Today, the field might best be called the "health social sciences." The main body of work employs the consensual perspective, but work done using a class conflict perspective is increasingly significant.     

Towards a sociology of disease

We argue for a sociology of health, illness, and disease. Under the influence of Talcott Parsons, the social study of health began as medical sociology and then morphed into sociology of health and illness, focusing largely on the social aspects of health-related topics. Social scientists have been reluctant to tackle disease in its physiological and biological manifestations. The result is an impoverishment of sociological analysis on at least three levels: social scientists have rarely made diseases central to their inquiries; they have been reluctant to include clinical endpoints in their analysis; and they have largely bracketed the normative purpose of health interventions. Consequently, social scientists tend to ignore what often matters most to patients and health care providers, and the social processes social scientists describe remain clinically unanchored. A sociology of disease explores the dialectic between social life and disease; aiming to examine whether and how social life matters for morbidity and mortality and vice versa. Drawing from specific advances in science and technology studies and social epidemiology, we point to ways that sociologists can participate as health researchers.     

From sick role to practices of health and illness

Context Health care research generally, and medical education research specifically, make increasingly sophisticated use of social science methods, but these methods are often detached from the theories that are the substantive core of the social sciences. Enhanced understanding of theory is especially valuable for gaining a broader perspective on how issues in medical education reflect the social processes that contextualise them. Methods This article reviews five social science theories, emphasising their relevance to medical education, beginning with the emergence of the sociology of health and illness in the 1950s, with Talcott Parsons’ concept of the ‘sick role’. Four turning points since Parsons are then discussed with reference to the theory developed by, respectively, Harold Garfinkel, Michel Foucault and Pierre Bourdieu, and what is called the ‘narrative or dialogical turn’. In considering these, the author argues for a theory‐grounded research that relates specific problems to what Max Weber called the ‘fate of our times’. Conclusions The conclusion considers how medical education research can critique the reproduction of a discourse of scarcity in health care, rather than participating in this discourse and legitimating the disciplinary techniques that it renders self‐evident.     

Ageing,dementia and the social mind: past,present and future perspectives

Accompanying the ageing of contemporary ageing societies is an increase in age associated morbidity, with dementia having an important impact. Mental frailty in later life is a source of fear for many and a major policy concern to all those concerned with health and welfare services. This introduction to the special issue on ‘Ageing, dementia and the social mind’ situates the selected papers within the context of debates about dementia and its social relations. In particular it draws attention to the importance of the social imaginary of the fourth age and what this means for the issue of personhood, care, social representations of dementia and its social contextualisation. The papers illuminating these themes draw on a variety of disciplines and approaches; from the social sciences to the humanities and from the theoretical to the empirical in order to help orientate future researchers to the complexities of dementia and the social and cultural matrix in which it exists. This paper provides an introduction to the potential for a more extended sociology of dementia; one which could combine the insights from medical sociology with the concerns of social gerontology.     

Mapping the field of medical sociology: a comparative analysis of journals

A comparative keyword analysis of the content of nine leading journals is used to suggest potential new directions for medical sociology. The major British and American journals in sociology and medical sociology tend to publish authors based in their own countries, contrasting with the internationalism of other social science disciplines relevant to health, although Sociology of Health and Illness is an exception to this. Medical sociology journals on both sides of the Atlantic focus on individual experience more than general sociology journals, which focus more on social systems levels of analysis. While journal contents reveal British medical sociology to be relatively atheoretical when compared with British general sociology journals, American medical sociology appears relatively apolitical on the same comparison with American general journals. American journals of sociology publish more quantitative studies than their British equivalents, more studies concerning race and other social divisions in American society, and less work drawing on social constructionist perspectives or that is engaged with social theory. Analysis of health and health care at societal and global levels and a deeper engagement with the political and public issues that concern non-sociologists represents a possible future for a medical sociology that is internationally relevant and outward looking.     

Objectification,standardization, and commodification in health care: A conceptual readjustment

Historically, medical sociologists have used the interrelated concepts of objectification, commodification, and standardization to point to the pathologies of modern medicine, such as the depersonalization of care and the effects of bureaucratic control. More recent work in science studies, economic sociology, and sociology of health and illness, however, has begun to explore how the social processes of objectification, commodification, and standardization produce a wide variety of biomedical achievements. We provide a theoretical synthesis of this emerging body of scholarship centered upon the intended and unintended consequences of objectification, commodification, and standardization to improve health. We then outline a research agenda that would result from a more comprehensive assessment of how these processes manifest themselves in clinical care.     

From diagnosis to social diagnosis

In the past two decades, research on the sociology of diagnosis has attained considerable influence within medical sociology. Analyzing the process and factors that contribute to making a diagnosis amidst uncertainty and contestation, as well as the diagnostic encounter itself, are topics rich for sociological investigation. This paper provides a reformulation of the sociology of diagnosis by proposing the concept of 'social diagnosis' which helps us recognize the interplay between larger social structures and individual or community illness manifestations. By outlining a conceptual frame, exploring how social scientists, medical professionals and laypeople contribute to social diagnosis, and providing a case study of how the North American Mohawk Akwesasne reservation dealt with rising obesity prevalence to further illustrate the social diagnosis idea, we embark on developing a cohesive and updated framework for a sociology of diagnosis. This approach is useful not just for sociological research, but has direct implications for the fields of medicine and public health. Approaching diagnosis from this integrated perspective potentially provides a broader context for practitioners and researchers to understand extra-medical factors, which in turn has consequences for patient care and health outcomes.     

Teaching sociology to medical students

A recent change in many medical curricula has been the introduction of courses in the behavioural sciences. These courses, while introduced with the intention of emphasizing interpersonal and behavioural skills, have not been shown to lead to any of the changes towards which they are directed. Rather, there is evidence that students find these courses 'waffly' and boring. If the sociology component of these courses is to lead to change, then there is the need for a continuing process of evaluation and modification. In this paper we report upon one medical sociology course, its evaluation, subsequent modification and re-evaluation. Our evidence would suggest that sociology courses can lead to changed attitudes and values, but that such changes are contingent upon the overt application of relevant sociological concepts to the health care field.     

Margot Jefferys: the British voice of medical sociology

Margot Jefferys (1916-1999) was not only the person who introduced medical sociology into Great Britain, but also the researcher and professor who, during thirty years, exerted the most deep influence on the teaching of health social sciences either in undergraduate or especially graduate studies, since the beginning of her career, in 1953, at the London School of Hygiene and Tropical Medicine. In addition to create a global panorama concerning the Jefferys' works, this study highlights two texts, which are situated into the field we are researching: the history of health sociology. The first one, published in 1991, discusses the relationships between epidemiology and sociology; and the second, published in 1996, discusses the field of medical sociology. Both texts are a series of considerations regarding the Jefferys' thought and the more recent questions of the field in Great Britain.     

The role of epidemiology in the committee on the costs of medical care

Among the most important 20th century documents of American public health is the 1932 report of the Committee on the Costs of Medical Care (CCMC). In May 1927, leaders of medicine, public health, and the social sciences, met at the annual meeting of the AMA, to consider that, despite advances in medical sciences, a vast amount of preventable disease and unnecessary death existed. A committee of 50 men and women, the CCMC, was formed to investigate. Of the six public health members, three were epidemiologists. A spectrum of governmental and private organizations supported the CCMC and eight foundations provided funding. A staff of 51 conducted 26 studies, many epidemiological, to support its five categorical recommendations. Briefly these were: 1) Medical services, preventive and therapeutic, should be provided by interdisciplinary groups; 2) Basic public health services should be available to all without cost; 3) The costs of medical care should be placed on a group basis (insurance, taxation, or a combination thereof); 4) Study, evaluation, and coordination of medical and public health services should be important functions for local and state governments; and 5) Professional education for a wide variety of medical and public health personnel should be greatly expanded with emphasis on prevention and social considerations.Perhaps the most interesting of the CCMC's epidemiological studies was, "The Incidence of Illness and the Receipt and Costs of Medical Care Among Representative Families: Experiences in Twelve Consecutive Months During 1928-1931." This study included 8,639 families comprising 38,668 persons and described the then current status of medical care and public health practice in the U.S.A.The final report of the CCMC contained minority reports ranging from claims that the recommendations were too radical to assertions that they didn't go far enough! Nevertheless, they have been the focus for medical and public health concern and controversy for almost three-quarters of a century. Their roots in epidemiology should not be forgotten!     

Methodological controversies between social and medical sciences

If doctors find sociological methods unreliable, the results unsound, and the approach irrelevant, this is due to the essential differences between the procedures and interests of the exact and the social sciences. When sociologists raise doubts concerning the one-sidedness of the medical approach, its exaggerated professionalism, lack of concern for the social context of cure, those are latent requirements which do not match the current paradigm of medical knowledge. It is assumed here that the difference between experimental method and the interpretive procedures of sociology has a basic character and cannot be overcome by the methodological refinement of the latter. Understanding sociological knowledge must be based only against a background of a special interest in practical social affairs. Doubst are raised whether such an interest can develop within the prevailing paradigm of medical practice. Nevertheless, some improvements in the presentation of sociological research and in its method, especially as related to conclusiveness and applicability, can enhance the chances of its effective use in medical practice. Possible postulates addressed to medical research do not have methodological consequences requiring a change in the organization of medical services or in the relations with associated industry for the needs of the health care system.     

Animals,veterinarians and the sociology of diagnosis

While sociologists of medicine have focused their efforts on understanding human health, illness, and medicine, veterinary medical practice has not yet caught their attention in any sustained way. In this critical review article, we use insights from the sociology of diagnosis literature to explore veterinary practice, and aim to demonstrate the importance of animals to sociological understandings of health, illness and disease. As in human medicine, our analysis shows the importance of diagnosis in creating and maintaining the power and authority of the veterinary professional. However, we then explore how diagnosis operates as a kind of dance, where professional authority can be challenged, particularly in light of the complex ethical responsibilities and clinical interactions that result from the triad of professional/owner/animal patient. Finally, we consider diagnosis via the precept of entanglement, and raise the intriguing possibility of interspecies health relations, whereby decision-making in human health care may be influenced by experiences in animal health care and vice-versa. In our conclusion, we argue that this analysis provides opportunities to scholars researching diagnosis in human health care, particularly around the impact of commercial drivers; has implications for veterinary and public health practitioners; and should help animate the emerging sociology of veterinary medicine.     

The role of behavioral sciences in the Hungarian and international medical education: overview and possibilities

The unilateral bio-medical approach cannot be effective in the prevention and effective treatment of chronic disorders of great epidemiological significance, because the behavioural risk factors are strongly influenced by psychosocial factors too. After the change of the political system in Hungary the most important step in curriculum development was establishing the institutes of behavioural sciences. However, the share of behavioural sciences nowhere exceeds 3% of the curriculum. Yet it has an important role in bridging the gap between the natural and social sciences. Built on the firm basis of natural sciences, the behavioural sciences complement this foundation with aspects of social sciences which emphasize the psychological needs of the patients as well as the psychosocial determinants of health and diseases. The most significant field of behavioural sciences is medical psychology but according to the latest reports on medical education development communication, medical sociology, medical anthropology and bioethics have become increasingly important disciplines in developing medical competence. These fields are organized into an integrated process, arching over the six years of medical training. The present paper gives an overview of the situation and perspectives of teaching behavioural sciences at medical universities.     

Constructing Empirical Bioethics: Foucauldian Reflections on the Empirical Turn in Bioethics Research

The empirical turn in bioethics has been widely discussed by philosophical medical ethicists and social scientists. The focus of this discussion has been almost exclusively on methodological issues in research, on the admissibility of empirical evidence in rational argument, and on the possible superiority of empirical methods for permitting democratic lay involvement in decision-making. In this paper I consider how the collection of qualitative and quantitative social research evidence plays its part in the construction of social order, and how this creates certain paradoxes for the normative ideal of a public bioethics. The analysis in this paper is based on Foucauldian ideas, and on recent work in the history of the human sciences. The paper closes with some open questions for theoretical work in the sociology and philosophy of bioethics.     

Expanding research on the racial disparity in medical treatment with ideas from sociology

While hundreds of studies document racial differences in the use of medical procedures in the United States, by comparison little is known about the causes of these differences. This gap in knowledge should serve as a call to sociologists who, drawing on their disciplinary tradition of studying inequality, could improve understanding of the disparity. This article offers suggestions about how medical sociologists in the USA might bring sociology to the study of racial disparities in medical treatment. The article begins by reviewing the existing approaches to understanding the racial disparity in medical treatment. After considering the extant research and its limits, the article goes on to describe how a few specific concepts from sociology - cultural capital, social networks, self-presentation and social distance, all framed in a race critical framework - and more diverse methodological approaches can advance studies of the racial disparity in medical treatment.     

Why are people dissatisfied with medical care services in Lithuania? A qualitative study using responses to open-ended questions.

OBJECTIVES: To identify and describe the main sources of dissatisfaction with medical services among the population in Lithuania. DESIGN: Analysis of written responses to an open-ended question as a part of a questionnaire survey. PARTICIPANTS: A randomly selected group of 25--64-year-old men and women from the Utena and the Kaisiadorys regions of Lithuania. Of the 1395 survey respondents, 357 persons (25.6%) answered the question regarding the dissatisfaction with health care services. MAIN OUTCOME MEASURES: Identification of the sources of dissatisfaction with medical care services among study participants. RESULTS: Twelve categories of dissatisfaction were identified that were related to three levels: shortcomings in the health care system (systemic level), deficiencies in provision and quality of services (institutional level) and deficiencies in physicians' attitudes, skills and work (individual level). CONCLUSION: Consumers' perceptions of medical care quality can be analysed by using information obtained from simple survey material and can be used to improve the quality of service. The causes of dissatisfaction with medical service can be traced to the development of the health care delivery system and patients' rights in a country.     

Ivan Illich and the pursuit of health

Fifty years ago, when medicine had relatively few effective treatments to offer, its value was unquestioned. Twenty-five years ago clinicians had become concerned that treatment could sometimes do harm and McKeown published epidemiological evidence claiming that medicine did little good. This state of affairs was used by Illich to bolster his crusade against technology in general. Today it is clear that medicine now makes a large contribution to health. But doubts still exist and alternative pathways to health are continually exhorted. Large-scale efforts at behavioural modification, encouraging the adoption of healthier lifestyles, have been largely unsuccessful. Social activists now argue that funds should be diverted from medical care to social programmes that, they claim, might contribute more to health. While it is true that health is strongly associated with socio-economic status (income, education and occupation), there is little sense of how best to reallocate scarce resources so as to improve the health impact of social and economic programmes. Social reform is not a substitute for medical care. Rather, our social environment is a second, important but quite separate, determinant of health and well-being.     

破解社会办医难题的政府责任研究*

鼓励和发展社会办医是新医改的重要内容,目的是满足人们多层次、多样化的医疗服务需求,本文通过分析制约社会办医发展的社会认可、规划准入、审批、人才、税收和补贴等方面的问题,进一步指出政府在破解社会办医难题中要承担起宏观规划和指导、营造公平政策环境和严格监管的责任,以更好的促进社会办医的发展。     

Sociological refigurations of patient safety; ontologies of improvement and ‘acting with’ quality collaboratives in healthcare

The increasing focus on patient safety in the field of health policy is accompanied by research programs that articulate the role of the social sciences as one of contributing to enhancing safety in healthcare. Through these programs, new approaches to studying safety are facing a narrow definition of ‘usefulness’ in which researchers are to discover the factors that support or hamper the implementation of existing policy agendas. This is unfortunate since such claims for useful involvement in predefined policy agendas may undo one of the strongest assets of good social science research: the capacity to complexify the taken-for-granted conceptualizations of the object of study. As an alternative to this definition of ‘usefulness’, this article proposes a focus on multiple ontologies in the making when studying patient safety. Through such a focus, the role of social scientists becomes the involvement in refiguring the problem space of patient safety, the relations between research subjects and objects, and the existing policy agendas. This role gives medical sociologists the opportunity to focus on the question of which practices of ‘effective care’ are being enacted through different approaches for dealing with patient safety and what their consequences are for the care practices under study.In order to explore these questions, this article draws on empirical material from an ongoing evaluation of a large quality improvement collaborative for the care sectors in the Netherlands. It addresses how issues like ‘effectiveness’ and ‘client participation’ are at present articulated in this collaborative and shows that alternative figurations of these notions dissolve many ‘implementation problems’ presently experienced. Further it analyzes how such a focus of medical sociology on multiple ontologies engenders new potential for exploring particular spaces for ‘acting with’ quality improvement agents.