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Feldstein, P. J. (1966). Research on the Demand for Health Services. New York: Milbank Memorial Fund. Freidson, E. (1972). Profession of Medicine. New York: Dodd, Mead and Co. Marinker, M. (1974). Medical education and human values. Journal of the Royal College of General Practitioners, 24, 445-462. Ministry of Health (1959). Final Report of the Committee on the Cost ofPrescribing. (Hinchliffe Report) London: HMSO. Office of Health Economics (1970). The Cost of the National Health Service. Information Sheet No. 15. London: OHE. Office of Health Economics (1974). The Work of Primary Medical Care. London: OHE. Parsons, T. (1951). The Social System. Chicago: Free Press. Royal College of General Practitioners (1973). Present State and Future Needs of General Practice. 3rd ed. Report from General Practice No. 16. London: Journal of The Royal College of General Parctitioners. Stimson, G. V. (1974). Obeying doctor's orders: a view from the other side. Social Science and Medicine, 8, 97-104. Stimson, G. V. & Webb, B. (1975). Going to See the Doctor. London: Routledge and Kegan Paul. Teeling-Smith, G. (1969). Economics and Innovation in the Pharmaceutical Industry. London: Office of Health Economics. Teeling-Smith, G. (1972). ThePharmaceutical Industry and Society. London: Office of Health Economics. Wilson, C. W. M., Banks, J., Mapes, R. & Korte, S. M. T. (1964). The assessment of prescribing: a study in operational research. Problems and Progress in Medical Care. Series No. 1, 173-210. London: Oxford University Press. Wilson, G. M. (1972). Prescribing for patients leaving hospital. Prescribers' Journal, 12, No. 3, 63-68. Zola, I. K. (1972). Medicine as an institution of social control. Sociological Review, 20, 487-504. 0

18. A SOCIOLOGICAL VIEW OF MEDICINE AS A PROFESSION

DAVID HALL

Sociologists have devoted much attention to medicine because in many ways it presents a fairly pure type of that pattern of work which is known as a 'profession'. In the emphasis on the autonomy of the profession, on the special knowledge and skill, with barriers against unqualified entry, and on responsibility to its peers, medicine is a clear case of the professionalism to which other workers aspire. But though such characteristics may serve to define a profession in itself, they cannot show how professionalism is articulated in the relationships between the profession and the rest of society. For professions cannot exist in a vacuum, and one must turn to see how they treat and respond to their clients, and the organisational context of modern society in which they operate. The very grounds on which professionals claim special standing, their knowledge and skill, may become their greatest threat if professionals fail to meet the high standards they proclaim. Other papers in this supplement argue that general practitioners are uncertain about aspects of drug treatment, and are looking at present without success for guidance from within the profession; also that the diagnosis and treatment of patients is being influenced from outside the profession by the drug industry. Here 1 wish to set these arguments in a wider context of the relationship between professionals and the organisations in and through which they work. In ordinary speech ' professional ' has not yet acquired that degree of pejorative connotation which attaches to 'bureaucracy '* with its implications of rigidity and red tape. But there are signs of a mood which sees professionals-or more strictly ' the experts '-as the new sophists, making the bad argument the good. 'Lies, damned lies and statistics 'is the intuitive reaction of those who feel the wool is being pulled over their *Weber has defined bureaucracy more strictly as a form of administration grounded on a basis of rationality rather than traditional or personal considerations (Gerth and Mills, 1948).

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eyes by recourse to technical criteria for decision-making that by-passes the ultimate issues involved. For example, the measurement of atmospheric pollution may take the place of action to remove it (Hall, 1976), because this is something that can be done, and is scientific and therefore on the face of things less controversial. In a similar way, doubts have been raised about whether the reorganisation of general practice results in any higher quality of care for the patient. It is modern, it is claimed to be more efficient with doctor's time, but it may be diverting intending patients away from consultation and failing to meet the existing needs. The result of such discontent with professional performance is that deprofessionalisation has been seen as an " alternate hypothesis for the future " (Haug, 1975). As yet, however, the trend is towards more attempts to become professional, and this has been of considerable concern to students of organisations. It had been thought that professional and bureaucratic criteria of work were different and incompatible, with the professional emphasising expert knowledge and colleague control against the rules and hierarchy of bureaucracy (Gouldner, 1957). But other studies have shown how professional rewards and commitment may be used by managers to ' cool out ' those who fail to make the grade into management (Goldner and Ritti, 1967). Thus the relationship of professionals to organisations is contingent upon the operating conditions allowed to or claimed by the professionals. The question of control and autonomy is central in any classification of what constitutes a profession; it implies both a claim over a specialised field of operation and a restriction on others entering that field. Wilensky (1964) has detailed the typical stages in the emergence of a profession and has asked why professional status has eluded some of the many claimants. He identifies the service ideal as an important part of the professional ethic, which in some contexts is threatened by the commercialism of the organisations involved. So estate agents fail to qualify on this definition; and undertakers, despite their arcane knowledge and specialised performance, do not seem to have the social esteem required, although they may change their title to funeral director and otherwise emphasise the responsibilities of the job (Habenstein,

1962). If the possession of a specialised body of knowledge is one of the requirements of a profession, so the alteration of names and titles forms part of a conscious process of seeking a professional identity. The service ideal justifies social approval, but has to be promoted first. Weber (Gerth and Mills, 1948) argues that the development of status rests upon usurpation and then persists in privilege. The title is a political weapon in the claim for status. At the present time, one can wonder at the increasing use of the term ' community' in the medical and social work spheres, to say nothing of politics, when sociologists have for the most part abandoned it as a misleading and at best imprecise term (Stacey, 1969). Thus, for example, mental hospitals are urged to release patients to the community without it being clear to what the community refers. Often it appears in practice to mean no more than the relatives-but perhaps this is a more palatable way of saying so? The creation of a professional vocabulary is one thing, its use is another. Many studies have investigated failures of communication between the professional and layman, especially in the field of doctor-patient interactions (Stimson and Webb, 1975), but less concern has been shown with the equally important sphere of professional-professional interactions where the professions concerned are not the same. Here, each is effectively a layman to the other, with the added refinement that each maintains his own professional standpoint and does not necessarily agree in the other's conceptualisation of himself as a layman with its implied inferiority of status. The co-ordination of doctors with other health care professionals is a case in point, while Roth (1963) states in respect of long-stay patients that they were less inclined to accept the doctor's authority the more they considered they knew about their own illness, and the argument about the relative

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exclusiveness of professional knowledge holds here. Someone else's specialised body of knowledge may be dismissed as 'just common sense'. The situation is likely to lead to more confusion and misunderstanding than the 'simple' doctor-patient relationships, and lest it be thought that the argument is being directed totally against doctors, one can point to the failures and misgivings about inter-disciplinary research in universities as further evidence of the clash of disciplines and professions. Failures of communication may occur about specialised knowledge and professional status in the cases where a doctor's conception of a social worker's role is that of providing mechanical aids for the disabled, while the social worker considers this job can be adequately performed by her clerical assistant and is wanting to do 'casework'. Or a social worker may insist on direct contact with the consultant, who for his part defines his appropriate contact as being with the director of social services. At other times the misconceptions do not surface but run as undercurrents in an outwardly placid relationship. If professionals restrict themselves to their own sphere of knowledge, co-ordination ofjoint concerns may fail. So where a doctor does not interfere in the work of, say, teachers in a children's ward on the supposition 'if they had any problems, they would tell me', neither does he actively enquire if there are in fact any problems. The teachers for their part defer to their expectations of the doctor's response and conceal their problem while remaining anxious and hoping against hope the doctor will give them an opportunity of raising it. Parish (1973) has noted in another context that doctors often judge the success of a treatment by the failure of the problem to be

presented again. In addition to the vocabularies, then, there is the creation of an image as a specialist in a field in which one may remain unchallenged. Perhaps the greatest difficulties face those occupations seeking to become professions which are closely related to established professions. In general practice the role of the pharmacist is currently under debate, as a gap is increasingly being identified in the service to patients due to the proliferation of drug treatments and the problems of doctors coping with this expanding field of know-

ledge. In hospitals, nursing has been described as a profession in crisis because on the one hand it is fighting a rearguard action against those specialisms which have split off from it, while at the same time it has not yet succeeded in winning its battle for independence against the doctors. Autonomy for nurses is what seems to be desired, and sometimes in terms that equate professionalism with personality development (Marram et al., 1974); luckily, it is also claimed that nurse autonomy leads to better services for patients. The establishment of nurse-clinicians shows that the battle is advancing, but it may yet be overtaken by a wider movement to deprofessionalisation, in which the needs of the clients are seen as paramount against the career development of professionals. With the establishment of multi-disciplinary teams come the problems of managing teamwork. Essentially the argument of professionals for colleague control makes professionalism the ideology of the individual, accountable only to his peers. The failures to which this doctrine may sometimes lead have been criticised, most notably in the Report of the Committee of Inquiry into South Ockendon Hospital (1974). Multi-disciplinary teamwork is difficult to arrange, and one may question the extent to which the development of health centres, for example, is more a manifestation of centralisation rather than co-operation in providing services for the public. The response to innovation is often retrenchment rather than adoption, particularly on the part of those with something to lose by the change, even if this is only the relative certainty of the present compared with the uncertainty of the future. It has been remarked that hospitals seem particularly resistant to change and share many of the features of Goffman's (1961) " total institution ". A symptom of this is the

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attitude to patient complaints, which in many cases are actively discouraged (Stacey, 1974); a parallel observation is the special meaning given to the word ' mistake' by members of the medical profession. Stelling and Bucher (1973) argue that' mistake' is a lay conception that does not find a place in the professional vocabulary. The consequence is a greater emphasis by the medical profession on the uncertainties involved and on technical performance, which makes it more difficult for outcomes to be controlled. The argument returns to the compatibility of professionalism with organisations; the issues are control and the possession of status. Professions are involved in a game of power, in which there are winners and losers. Professions do not become such by possessing the right sociological indicators, these are symbols of the game successfully played. But though our definitions of occupational status are relatively stable, the game is continuously being played; as more people realise the advantages of self-determination and seek to acquire professional status, they maximise the possibilities for inter-disciplinary confusion as the ignorant layman disappears. The conditions for successful cooperation have yet to be conclusively defined, and though better communication is obvious, it is by no means an absolute solution as it ignores the possible conflict of attitudes and values among workers in the organisation. The very concept of teamwork, Fox (1966) argues, is premised upon a unitary view of organisations where all pull together, but the reality of life is that there are a plurality of groups in any organisation, so that conflict so far from being abnormal or destructive is endemic, and may well be, if institutionalised, a sign of higher morale. Teamwork is an ideology which may work in practice, but indications are that it too may be part of the serious game of professionalisation and not its solution. A profession, then, advances special claims to competence against challenges from others. We may, with Bucher and Strauss (1960) look inside the profession at the processes which differentiate higher or lower status segments of medical practice; or equally important, at the way in which counter-claims from outside are dealt with. Granted that doctors are faced in the surgery with practical problems that demand practical remedies, yet the pursuit of technical solutions which ignore the longer term questions of human values may not only alienate the public support on which professional status rests, but eventually diminish the influence of the profession over the ethical debate in which all may legitimately claim a voice. Perhaps it is the job of outsiders to remind the profession-any profession-that its authority rests on a contract of trust which can be jeopardised on two counts, if the profession claims a wider field of competence in practice, and if it short-circuits questions of ends by emphasis on the means alone. For these reasons the increasing domination of everyday life by medicine is of particular concern, and the defence of it being a' medical decision' may become increasingly questioned. REFERENCES

Bucher, R. & Strauss, A. (1960). Professions in process. American Journal of Sociology, 66, 325-334. Fox, A. (1966). Industrial Sociology and Industrial Relations. Royal Commission on Trade Unions and Employers' Associations: Research Paper 3. London: HMSO. Gerth, H. H. & Mills, C. W. (1948). From Max Weber. London: Routledge and Kegan Paul. Goffman, E. (1961). Asylums. Harmondsworth: Penguin. Goldner, F. H. & Ritti, R. R. (1967). Professionalisation as career immobility. American Journal of Sociology, 72, 489-502. Gouldner, A. W. (1957). Cosmopolitans and locals: towards an analysis of latent social roles. Administrative Science Quarterly, December, 281-292. Habenstein, R. W. (1962). Sociology of occupations: the case of the American funeral director. In Rose, A. M. (edit.). Human Behaviour and Social Processes. London: Routledge & Kegan Paul. Hall, I. M. (1976). Community Action versus Pollution. Board of Celtic Studies, University of Wales. Haug, M. (1975). Deprofessionalisation-an alternate hypothesis for the future. Sociological Review Monograph, 20, 195-211.

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Marram, G. D., Schlegel, M. W. & Bevis, E. 0. (1974). Primary Nursing. St. Louis: Mosby. Parish, P. (1973). Drug prescribing-the concern of all. Royal Society of Health Journal, 93, No. 4, 213-217. Report of the Committee of Inquiry into South Ockenden Hospital (1974). London: HMSO. Roth, J. (1963). Timetables. Indianapolis: Bobbs Merrill. Stacey, M. (1969). The myth of community studies. British Journal of Sociology, 20, June, 134-147. Stacey, M. (1974). Consumer complaints procedures in the National Health Service. Social Science and Medicine, 8, 429-435. Stelling, J. & Bucher, R. (1973). Vocabularies of realism in professional socialisation. Social Science and Medicine, 7, 661-675. Stimson, G. V. & Webb, B. (1975). Going to See the Doctor. London: Routledge and Kegan Paul. Wilensky, H. L. (1964). The professionalisation of everyone? American Journal ofSociology, 70,137-158.

A sociological view of medicine as a profession.

102 PRSCRMING IN GENERAL PRACI1CE Feldstein, P. J. (1966). Research on the Demand for Health Services. New York: Milbank Memorial Fund. Freidson, E...
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