Medical Professionals and the Organization of Knowledge

Eliot Freidson, Judith Lorber

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138527850
• eBook ISBN: 9781351506229
• Topic: Medicine
• Subtopic: Health Care Delivery

"Medical Professionals and Their Work" conveys how medical people shape and organize the knowledge, perception, and experience of illness, as well as the substance of illness behavior, its management, and treatment. It is now well established that the unique symbolic equipment of the human animal is intimately connected with the functioning of the body. Freidson and Lorber believe that the proper understanding of specifically human rather than generally "animal" illness requires careful and systematic study of the social meanings surrounding illness.The content of social meanings varies from culture to culture and from one historical period to another. As important as the content of those social meanings, is the organization of groups who serve as carriers and, sometimes, creators. In the case of illness, a critical difference exists between those considered to be competent to diagnose and treat the sick and those excluded from this special privilege - a separation as old as the shaman or medicine-man. Such differences become solidified when the expert healer becomes a member of an organized, full-time occupation, sustained in monopoly over the work of diagnosis and treatment by the force of the state, and invested with the authority to make official designation of the social meanings to be ascribed to physical states.The medical profession in advanced nations is in a vise between professional needs and political demands. Its organization and its knowledge establish many of the conditions for being recognizably and legitimately ill, and the professional controls many of the circumstances of treatment. It thus plays a central role in shaping the experience of being ill. With this fact of modern life in mind, this collection on the character of experts or professionals in general and of medicine as a profession in particular is uniquely fashioned.

II
Medical Work

Managing Patients

The papers thus far have analyzed the profession of medicine with little reference to a very important aspect of practice—the client. Medicine is a consulting, not a scholarly, profession. The bulk of a consulting practitioner’s work relationships involves clients, not colleagues. Clients, unlike colleagues, are not usually in the same social world as the professional; that is, they are frequently not in the same social class, ethnic group, or on the same educational level. And of course, they have not undergone the same training and socialization as the professional. Clients, therefore, do not “speak the same language” as the professional; the two do not share the same phenomenological meanings, assumptions, or concepts. Illness never means the same thing to the client and to the professional. Everett Hughes put his finger on the most obvious difference between professional and client perspectives when he said that what was routine to the professional was an emergency to the client. The client, however can ignore or handle his emergency himself if he so wishes. The professional, on the other hand, needs clients to carry out his work, to apply his knowledge, to practice his calling. He must persuade clients to accept his ministrations or be able to place them in a position where they have nothing to say about the matter.

Professional practice cannot exist without clients, but the influence of the client over the professional does not end with that simple dependence. As the papers in this section reveal, medical practice owes much of its variety and patterning to the type of client dealt with. This is not to say merely that clients of different classes, cultures, or degrees of cosmopolitanism present the practitioner with a variegated work life. The power of the client goes much deeper than that. First of all, different types of clients make different demands on the practitioner, and the way he meets these demands significantly shapes his routines of work. Secondly, different types of clients force the practitioner to do different kinds of work, not all of which carry the same prestige in his colleague-world. The everyday work life and the social identity of the professional are thus intimately related to his clientele.

The first paper in this section focuses on work routines dictated by the physical helplessness of patients who are social infants—speechless, incontinent, incapable of self-care. Although the intriguing description of the daily life of institutionalized idiots by MacAndrew and Edgerton tells what is done to the inmates, it is clear that the staff, in their intimate contact with these most physically demanding clients, do not have a clean, neat, or intellectually stimulating work life. Their work is, in Everett Hughes’ words, “dirty work” only slightly glorified by a hint of professionalism. In the medical division of labor, caretaking or custodial work is usually done by paraprofessionals who, because they are low in prestige, are delegated such work, and who are low in prestige because they do such work.

There is another sociologically pertinent aspect to the work described in this paper. Although the actual content of the work is dictated by the physical helplessness of the client, the staff has complete control over the timing of eating, sleeping, washing, and dressing; the client is a unit in a production line. In many large custodial and treatment institutions, where the client is only moderately helpless physically and otherwise a fully competent adult, the staff nevertheless, for purposes of convenience and efficiency, imposes the same sort of “batch” routines. In the more common instances, the staff imposes physical incompetence on the client in order to maintain control over the work routine.

Another kind of control over work is attempted by higher-level professionals. The demands their clients make on them are not the physical kind made on paraprofessionals; the clients of physicians and nurses are more apt to make intellectual and psychological demands. When clients can choose, they may demand reasons for cooperating with treatment. Then, when they have accepted treatment, they may demand solicitousness and sympathy. The image of the professional is one who is concerned but detached, omniscient, and effective in his treatment. There are many situations, however, in which the intellectual and emotional demands of clients threaten the detachment and omniscience of the physician. Such situations are often encountered when treatment has not been effective and the prognosis is bad. If the physician tells the patient the truth—that he will not be cured—his professional image as a healer is tarnished. What is more, he is likely to be faced with an outpouring of emotion directed at him.

The two papers by Quint and by Davis are concerned with what professionals do when faced with this problem of psychological “dirty work.” Quint, a nurse herself, details the way doctors and nurses try to avoid long conversations with patients dying of cancer and tend to limit their work to the technical side of treatment, the area over which they feel they have the most control. Davis describes another technique used by physicians to avoid the “onerous and time-consuming” task of dealing with the distraught—in this case, parents of children who will be crippled for life. Instead of telling parents the true prognosis, physicians pretend it is still uncertain and thus avoid an emotional scene they would have to take care of. In Davis’s cases, the physicians sacrificed the prestige they might have gained from total omniscience in order to avoid a challenge to their detachment—or concern.

Such avoidance techniques on the part of medical personnel result in a deep-seated resentment by patients in hospitals. They frequently resent either not receiving any sympathy or understanding for their plight or not receiving any concrete information at all. Shiloh, in his study of hospitalized patients in Israel, discovered that what patients resented most about the hospital was the lack of information about their condition, treatment, and prognosis. Being kept in a state of ignorance was particularly annoying to those patients whose social status outside the hospital led them to expect, as Shiloh puts it, “to be equal partners with the hospital in the mutual goals of successful treatment and prompt discharge, and they expected the hospital to provide them with the information necessary for the consummation of these mutual goals.” Such information would also have enabled them to argue with their physicians, so they were kept in ignorance —passive recipients of care, not “equal partners,” as they wished. In sum, control over patients who are not intellectually helpless is managed by careful control over their access to information in order to protect the authority and aura of the professional.

As we have seen, the prestige level of an occupation is closely related to the type of work done, so it is not surprising that members of upwardly mobile occupations try to avoid doing work they consider demeaning. Not surprisingly, avoiding “dirty” clients is one way of avoiding “dirty work.” In the last paper of this section, a study of professional social climbing, Walsh and Elling argue that the negative attitudes of public-health nurses toward lower-class clients is indicative of their desire to raise the prestige level of their profession by shaking off low-prestige clients. They considered lower-class clients most often “difficult” and “unpleasant” and preferred middle-class clients. Ironically, in Shiloh’s study, lower-class patients were least irritated about the lack of information, while high-status patients were most likely to make a fuss, which demonstrates that all professionals are likely to have trouble managing some clients.

Earlier papers showed that the professional’s autonomy over his work was hard won, as was his social prestige. These analyses of the effects of clients on professional work indicate that autonomy and prestige must be carefully nurtured every working day. As a result, many professional activities are probably best viewed as stemming from a conflict over control of the situation. The particular form this conflict takes depends on the relative social status of professional and client, and on the extent of institutionalized control the professional wields, but in a symbolic sense, all patients are idiots to professionals.

BIBLIOGRAPHIC SUGGESTIONS

The standard analysis of the doctor-patient relationship is Talcott Parsons, The Social System (Glencoe, 111.: The Free Press, 1951), Chapter 10. Parsons focuses on the complementary obligations of patient and physician in the pursuit of their mutual goal of moving the patient out of the sick role and back to his usual social roles. An extensive treatment of the doctor-patient relationship which discusses the problems of autonomy, prestige, and conflict over control of the situation is Eliot Freidson, Patients’ Views of Medical Practice (New York: Russell Sage Foundation, 1961), Part 3. Freidson discusses the consulting professional’s problem of persuading lay clients that he is indeed an expert authority in “The Impurity of Professional Authority,” Institutions and the Person, Howard S. Becker et al., eds. (Chicago: Aldine, 1968), pp. 25-34. The insights in Erving Goffman, The Presentation of Self in Everyday Life (Garden City, N.Y.: Doubleday Anchor, 1959), the well-known account of impression management in work and other settings, can usefully be applied to the social aspects of medical work.

There is an enormous literature on patients in mental hospitals which graphically details staff-imposed control, but the best place to begin reading in the area of custodial institutions is Erving Goffman, Asylums (Garden City, N.Y.: Doubleday Anchor, 1961). This widely cited book provides an analytic framework into which other, more descriptive studies can be placed. Some standard references on patients in mental hospitals are Alfred H. Stanton and Morris S. Schwartz, The Mental Hospital (New York: Basic Books, 1954); William Caudill, The Psychiatric Hospital as a Small Society (Cambridge: Harvard University Press, 1958); and H. Warren Dunham and S. Kirson Weinberg, The Culture of the State Mental Hospital (Detroit: Wayne State University Press, 1960). A study of patients in a different kind of custodial institution is Julius A. Roth and Elizabeth M. Eddy, Rehabilitation for the Unwanted (New York: Atherton Press, 1967), which uses many of Goffman’s concepts to describe the life of patients in a long-term rehabilitation program. René C. Fox, Experiment Perilous (Glencoe, 111.: The Free Press, 1959), offers an interesting contrast to the above books, in that it presents an account of the institutional life of the highly praised subjects of a prestigious medical team. Both patients and professionals were at the very top of the medical stratification system, and their prestige was demonstrated by every aspect of hospital life.

Most of the studies of short-term patients in general hospitals are straightforward description, with little attempt at sociological analysis. Ann Cartwright, Human Relations and Hospital Care (London: Routledge and Kegan Paul, 1964), reports on patients in British hospitals, and Elizabeth Barnes, People in Hospital (London: Macmillan, 1961) reports on patients in hospitals of various countries. Raymond S. Duff and August B. Hollingshead, Sickness and Society (New York: Harper & Row, 1968), is an extensive study of a large New England medical center which provides an excellent picture of the different types of care given patients of different social classes. Rose Laub Coser, Life on the Ward (East Lansing: Michigan State University Press, 1962), is one of the few studies of life in a general hospital from the patient’s point of view.

Information control in hospitals has been treated at length in several perceptive books. Barney G. Glaser and Anselm L. Strauss, Awareness of Dying (Chicago: Aldine, 1965), thoroughly discusses who tells what to terminal patients, and the effect of information or lack of it on patients, families, and medical personnel. Jeanne C. Quint, The Nurse and the Dying Patient (New York: MacMillan, 1967), covers the same subject with particular reference to nurse-patient relationships. Fred Davis, Passage Through Crisis (Indianapolis: Bobbs-Merrill, 1963) takes up the problem of information control in incurable illness, and Julius A. Roth, Timetables (Indianapolis: Bobbs-Merrill, 1963), deals with the problem in the case of a partially chronic, but curable illness. In all these studies, the question of who controls the situation, the professional or the patient, is a pertinent part of the discussion. A collection of articles which deal mostly with nurse-patient interaction and which contains useful additional data on communication and the patient’s point of view is James K. Skipper, Jr., and Robert C. Leonard, Social Interaction and Patient Care (Philadelphia: J. B. Lippincott, 1965).

14
The Everyday Life of Institutionalized “Idiots”

CRAIG EDGERTON AND ROBERT MACANDREW

It has been variously estimated that there are 100,000 idiots in the United States today. Because approximately half of these, including almost all of the adults, are in public institutions, common sense knowledge of idiots is typically both sketchy and ridden with clichés. Unfortunately, our scientific knowledge concerning idiots is not a great deal better. While there is a substantial, but spotty, body of medical information at hand, detailed understanding of the psychological functioning of idiots is notably de...

Table of contents

• Cover Page
• Half title
• Title Page
• Copyright Page
• Dedication
• Foreword
• Contents
• I. MEDICAL MEN
• II. MEDICAL WORK
• Index