75
PHYSICIAN-PATIENT EXPECTATIONS IN PRIMARY CARE* SAMUEL W. BLOOM, PH.D. Professor of Sociology and Community Medicine
PAMELA SUMMEY Department of Community Medicine The Mount Sinai School of Medicine of the City University of NewYork New York, N.Y.
I N the lexicon of sociology, expectations are the building blocks of culture. Culture, in turn, is defined as "the total way of life of a people, the social legacy the individual acquires from his group."1 Culture can be viewed also as a blueprint for all of life's activities, containing relatively standardized prescriptions as to what ought to be done, may be done, and must be done. Illness is universal. No person or society is without it. Illness is also a threatening event, to the individual and to society. Not surprisingly, therefore, every society prescribes acceptable responses to illness, and, through institutions such as the family, teaches its members how to behave in the role of patient.2 In other words, we learn what others expect of us and what to expect from others in the status and roles that we occupy in society. As patients, we expect doctors, and indeed other patients, to behave according to certain standards. Needless to say, these are not simple either-or expectations, any more than we ourselves deliberately conform to these patterns of expectations. Nevertheless, these expectations exist, and at some level of awareness we all respond to them. Our own culture, for example, emphasizes rationality and individualism. Its general orientation includes beliefs that each of us controls his fate, that man through science can dominate nature, and that the postponement of gratification is justified by future rewards. These are a few of the guides for our expectations of ourselves and others, and they apply to illness as well as to health. We have just described the groundwork for early theories of the doctor* Presented in a panel, Source of the Problem, as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Vol. 53, No. 1, January-February 1977
76
76-
P..SME SUMMEY S.W. BLOOM AND LO N
SW
TABLE I. PARSONS' MODEL OF DOCTOR-PATIENT SYSTEM Doctor
Patient Status
Role
as
Professional role
patient
To be motivated to get well To seek technically competent help To trust the doctor or to accept the competence gap (asymmetry of the relation)
Exemption from the performance of normal social obligations Exemption from responsibility for one's own state
Obligations To act for the welfare of the patient (collective versus self orientation) To be guided by the rules of professional behavior (universalism versus particularism) To apply a high degree of achieved skill and knowledge to the problems of illness To be objective and emotionally detached (affective neutrality) To maintain professional self-regulation Privileges Access to physical and personal intimacy Autonomy Professional dominance
Premise
"Modern medicine is organized about the application of scientific knowledge to the problems of illness and health and to the control of disease." (functional specificity) Reprinted by permission from Parsons, T.: The Social System. Glencoe, Ill., Free Press, 1951.
patient relationship. Lawrence J. Henderson in 19733 was among the first to conceptualize the relationship between physician and patient as a social system. In his work as a biochemist Henderson applied the concepts of equilibrium, regulation, and homeostasis to the chemistry of the blood. Willard Gibbs' classic model of the physico-chemical system provided inspiration for much of Henderson's scientific work. Turning to social science, Henderson suggested that we could view the relationship between physician and patient as a system, similar to the Gibbs' model of the physiochemical system.4 In Henderson's model, a movement of one component leads to change throughout the system. In his studies of the blood, Henderson demonstrated the system concept by the method of simultaneous equations. He sought to develop the conception of social systems with the same type of rigor. THE PARSONS MODEL
Talcott Parsons, a student and colleague of Henderson, used the latter's Bull. N.Y. Acad. Med.
PHYSICIAN-PATIENT EXPECTATIONS
77
idea of the physician-patient relationship as a social system and elaborated the expectations of both physician and patient (Table I).2 Patients, according to Parsons, are expected to be motivated to get well, to seek help in order to get well, and to trust the physician. In exchange for these obligations, patients are exempted both from the responsibility for being sick and from the performance of the normal duties of their role. Physicians are expected to apply their skill in managing illness by acting for the welfare of the patient, by following the rules of professional behavior, and by being objective and emotionally detached. THE SZASz-HOLLENDER MODEL
The types of behavior expected of physicians and patients were further delineated by Thomas S. Szasz and Marc H. Hollender,5 who describe three models of the physician-patient relationship based on the degree of control of each participant (Table II). With the Szasz- Hollender model, the choice of which type will be actually employed is mediated by the type and severity of the illness, as well as by the personality and preferences of physicians and patients. A patient in coma can be nothing but passive; he requires an active and authoritative physician. When that patient comes out of a coma a different model becomes appropriate in the relationship. The personalities of both individuals must be taken into account, as certain persons show stronger needs for control than others. The models discussed above delineate the general expectations which govern the behavior of physicians and patients. In these early theories of the doctor-patient relationship, the major assumption was that pathways to this relationship were essentially voluntaristic, that is, the decision by the patient to seek care and the selection of whom he would consult were made by individual choice. This was seen as a direct consequence of our culture, reflecting several of its major value orientations: individualism, orientation toward the future (i.e., willingness to postpone gratification for future rewards), and belief in man's dominance over nature. To be sure, it was recognized that individual choice could be influenced and modified by outside forces. Among such influences on illness behavior were socioeconomic status6 and culture;7 8 nevertheless, the individual patient was assumed to be the decision-maker. This individualistic assumption was further reinforced by the findings of studies such as those of Balint.9 In the framework of a national health service, Balint found that his patients continued to shop for a doctor who was somehow compatible as a human being. He reported that from 8% to Vol. 53, No. 1, January-February 1977
78
S.W. BLOOM AND P. SUM MEY
Cz.
z~~~~~~~~~~~~~~~
0~~~~~~~
4-7 00~~~~~~ -
0
=~~~~~~~o ~~~~0 ~
~
L
cl0
7,~~~~~. H~~~~~~~~~~~~~~~~7
Bull. N.Y. Acad. Med.
PHYSICIAN-PATIENT EXPECTATIONS
79
10% of the patients on a London doctor's list changed their doctors in any one year. This was supported by KoOS6 from his sample of rural Americans, 13% of whom were found to have dropped a doctor. Let us assume that in the United States and Western Europe in 1930, when these hypotheses emerged most strongly, this assumption of underlying freedom of choice by the patient was essentially correct. The question is: Is the same assumption true today? My answer is at the heart of today's presentation. It is not a simple answer. It must be considered still hypothetical, even though strongly supported by data. If the analysis is now restricted to the United States, the answer, in outline, is as follows: 1) Freedom of choice for medical care does exist, but for a portion of the population of patients it is severely limited. 2) The portion of patients who are able to exert this right effectively is determined by a number of factors, including ability to pay and availability of the medical care of choice. 3) Because of the constraints involved, the portion of the population that exerts this right is decreasing. 4) The choice of doctor is mediated increasingly by the influence of third parties, including insurance plans, unions, and employers. 5) The effect is to reduce individual choice and the influence of client networks which are the natural source of referral in conditions which provide for individual choice.10 6) In place of these, the bureaucratization of medical relationships is expanding rapidly. 7) The result, from the viewpoint of the patient, is a series of effects: a) A system of medical care in which quality varies, especially in primary care, according to social status b) The loss of personal connection between doctor and patient c) The proliferation of providers of care for each patient-client, both the financially able and the poor 8) The results, from the viewpoint of the society, are: a) Costly, inefficient delivery of health care b) A dissatisfied, restless group of consumers which falls back on militant hostility toward the health-care establishment and projects anger on its own providers of care c) Increased legalistic challenge to the doctor's autonomy d) Increased defensive medicine practiced by providers and general Vol. 53, No. 1, January-February 1977
80
80
S.W. BLOOM AND P..SME SUMMEY S..BOMAN
rejection by doctors of the client-patient as unreasonable, spoiled, and ungrateful Nowhere are these effects more intense than in primary care. The reasons are obvious; the trend toward bureaucratization is part of the trend toward specialization. Secondary and tertiary care are, by definition, rationalized; they are based in the houses of technological medicine, the hospitals. Primary care, also by definition, is personal care; thus, by experience, it is at risk under the conditions of the rational institutionalization (bureaucratization) of medical technology. In sum, we are describing a situation in which the doctor-patient relationship is being replaced for a large segment of the general population by a relationship in which the patient does not engage the services of a professional person, but rather of a professional institution. If we reflect upon this situation, it appears that either our cultural expectations about the doctor-patient relationship were only myths or revolutionary changes have occurred in the fundamental structure of society. Literature on the doctor-patient relationship is abundant, but most of it deals with doctors' expectations of patients. More than any other aspect of the problem, patient compliance receives the bulk of attention. Utilization runs a close second. Compliance seems to be a biased conception from the start. In studies of compliance the emphasis is necessarily upon predictability. The questions are framed about which patients do as they are told rather than upon what patients actually do. Indeed, research in this field has been mainly documentation of what kinds of patients are more likely to follow medical regimens and what kinds are not. It tells us, for example, that lower socioeconomic classes are less compliant than higher.1-13 In other words, a specific set of stereotypes is reinforced. More recently, the more important question of why some patients comply and why some do not is receiving intensified attention from research workers. 1415 Utilization has a similar research record. The overriding concern appears to be overutilization or underutilization. The central issue is usually cost. Again, one must suspect that the design of such research contains an implicit self-fulfilling prophecy. Underlying the real issue is mistrust of the same categories of patients whom we stereotype in the formulation of compliance. It would be more fruitful to study variations in utilization according to the kinds of facilities offered, patients' life-cycle stages of growth and development, and patients' life activities such as occupations. One of the most Bull. N.Y. Acad. Med.
PHYSICIAN-PATIENT EXPECTATIONS
81
interesting studies bearing on this problem was done by Breslau and Reeb. 16 Families of patients were studied under two conditions of delivery of care, but with the same doctors. The first condition was a private office practice: the second condition involved the same doctors operating a pediatric practice in the pediatric unit of a university hospital. Under the second condition the number of visits by well children declined; the number of visits for illness increased. Continuity of care was lower. The number of telephone consultations decreased. Thus, although the patients were held constant, there was a great difference in patterns of utilization according to the structure of the practice situation. In our judgement, the problems of compliance and utilization are more matters of structural organization of health-care delivery than variables dependent on demographic characteristics. Continuity of care is the variable that will prove to be the significant determinant, rather than the traits of patients. Patients, no less than doctors, are influenced by the dramatic changes that have occurred in the technology of medicine in recent years. They want expert treatment. As Freidson showed in his study of the Montefiore Hospital group, patients value competence as highly as the medical profession does.'0 However, they equally value the personal interest which they expect a doctor to have for his patient. Attempts have been made to separate types of patients according to these two expectations.17 Presumably, some patients have greater affective needs than others. Our reading of the evidence is that all patients seek both competent and concerned personal care. What has happened is that they no longer expect both from the same doctor. Friedson's Montefiore patients went to the hospital group when they felt they were in clear illness-distress, but frequently used safety-valve visits to neighborhood physicians when symptoms were vague and less threatening. We believe that more and more of today's patients are dividing the labor of illness, as it were, and in a similar manner using different doctors for different self-diagnosed problems. The trend toward more organized, institutionalized medicine, however, is inexorable. Within the dramatic social change that has occurred, the expectations of doctor and patient for each other also must change. The present situation seems to be one of the persistence of obsolete expectations in circumstances of radical change. Beliefs and the social expectations which follow from them must adjust to changes in social structure, but the process is seldom smooth.
Vol. 53, No. 1, January-February 1977
82
S.W. BLOOM AND P. SUMMEY
REFERENCES I
2. 3. 4.
5.
6. 7. 8.
9. 10.
Kluckhohn, C.: Mirror ftr Man. Greenwich, Conn., Fawcett, 1957 (originally published by McGraw- Hill, 1949), p. 20. Parsons, T.: The Social System. Glencoe, Ill., Free Press, 1951. Henderson, L. J.: Physician and patient as a social system. N. Engl. J. Med. 212:819-23, 1935. Henderson, L. J.: Pareto's General Sociology: A Physiologist's InterpretatiOn. Cambridge, Mass., Harvard University Press, 1937. Szasz, T. S. and Hollender, M. H.: A contribution to the philosophy of medicine: The basic models of the doctorpatient relationship A.M.A. Arch. Intern. Med. 97:585-92, 1956. Koos, E. L.: The Health of Regiont'ille. New York, Columbia University Press, 1954. Zborowski, M.: Cultural components in response to pain. J. Soc. Issues 8: 16-30, 1952. Mechanic, D.: Response factors in illness: The study of illness behavior. Soc. Psych. 1:11-20, 1966. Balint, M.: The Doctor, His Patient and the Illness. New York, Int. Universities Press, 1957. Friedson, E.: Patients' Views of Medical Practice. New York, Russell Sage
Foundation, 196 1. 11. Bergman, A. B. and Werner, R. J.: Failure of children to receive penicillin by mouth. N. Engl. J. Med. 268:133438, 1963. 12. Deasy, L. C.: Socioeconomic status and participation in the poliomyelitis vaccine trial. Am. Sociol. Rev. 21: 185-91, 1956. 13. Gordis, L., Markowitz, M., and Lilienfeld, A. M.: Why patients don't follow medical advice: A study of children on long-term antistreptococcal prophylaxis. J. Ped. 75:957-68, 1969. 14. Becker, M. H., Drachman, R. H., and Kirscht, J. P.: A new approach to explaining sick-role behavior in lowincome populations. Am. J. Public Health 64:205-16, 1974. 15. Becker, M. H. and Maiman, L. A.: Sociobehavioral determinants of compliance with health and medical care recommendations. Med. Care 13:10-24, 1975. 16. Breslau, N. and Reeb, K. G.: Continuity of care in a university-based practice. J. Med. Educ. 50:965-69, 1975. 17. Coser, R. L.: A Home Away From Home. In: Sociological Studies of Health and Sickness, Apple, D., editor. New York, McGraw-Hill, 1959, pp. 154-72.
Bull. N.Y. Acad. Med.
PHYSICIAN-PATIENT EXPECTATIONS IN PRIMARY CARE* SAMUEL W. BLOOM, PH.D. Professor of Sociology and Community Medicine
PAMELA SUMMEY Department of Community Medicine The Mount Sinai School of Medicine of the City University of NewYork New York, N.Y.
I N the lexicon of sociology, expectations are the building blocks of culture. Culture, in turn, is defined as "the total way of life of a people, the social legacy the individual acquires from his group."1 Culture can be viewed also as a blueprint for all of life's activities, containing relatively standardized prescriptions as to what ought to be done, may be done, and must be done. Illness is universal. No person or society is without it. Illness is also a threatening event, to the individual and to society. Not surprisingly, therefore, every society prescribes acceptable responses to illness, and, through institutions such as the family, teaches its members how to behave in the role of patient.2 In other words, we learn what others expect of us and what to expect from others in the status and roles that we occupy in society. As patients, we expect doctors, and indeed other patients, to behave according to certain standards. Needless to say, these are not simple either-or expectations, any more than we ourselves deliberately conform to these patterns of expectations. Nevertheless, these expectations exist, and at some level of awareness we all respond to them. Our own culture, for example, emphasizes rationality and individualism. Its general orientation includes beliefs that each of us controls his fate, that man through science can dominate nature, and that the postponement of gratification is justified by future rewards. These are a few of the guides for our expectations of ourselves and others, and they apply to illness as well as to health. We have just described the groundwork for early theories of the doctor* Presented in a panel, Source of the Problem, as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Vol. 53, No. 1, January-February 1977
76
76-
P..SME SUMMEY S.W. BLOOM AND LO N
SW
TABLE I. PARSONS' MODEL OF DOCTOR-PATIENT SYSTEM Doctor
Patient Status
Role
as
Professional role
patient
To be motivated to get well To seek technically competent help To trust the doctor or to accept the competence gap (asymmetry of the relation)
Exemption from the performance of normal social obligations Exemption from responsibility for one's own state
Obligations To act for the welfare of the patient (collective versus self orientation) To be guided by the rules of professional behavior (universalism versus particularism) To apply a high degree of achieved skill and knowledge to the problems of illness To be objective and emotionally detached (affective neutrality) To maintain professional self-regulation Privileges Access to physical and personal intimacy Autonomy Professional dominance
Premise
"Modern medicine is organized about the application of scientific knowledge to the problems of illness and health and to the control of disease." (functional specificity) Reprinted by permission from Parsons, T.: The Social System. Glencoe, Ill., Free Press, 1951.
patient relationship. Lawrence J. Henderson in 19733 was among the first to conceptualize the relationship between physician and patient as a social system. In his work as a biochemist Henderson applied the concepts of equilibrium, regulation, and homeostasis to the chemistry of the blood. Willard Gibbs' classic model of the physico-chemical system provided inspiration for much of Henderson's scientific work. Turning to social science, Henderson suggested that we could view the relationship between physician and patient as a system, similar to the Gibbs' model of the physiochemical system.4 In Henderson's model, a movement of one component leads to change throughout the system. In his studies of the blood, Henderson demonstrated the system concept by the method of simultaneous equations. He sought to develop the conception of social systems with the same type of rigor. THE PARSONS MODEL
Talcott Parsons, a student and colleague of Henderson, used the latter's Bull. N.Y. Acad. Med.
PHYSICIAN-PATIENT EXPECTATIONS
77
idea of the physician-patient relationship as a social system and elaborated the expectations of both physician and patient (Table I).2 Patients, according to Parsons, are expected to be motivated to get well, to seek help in order to get well, and to trust the physician. In exchange for these obligations, patients are exempted both from the responsibility for being sick and from the performance of the normal duties of their role. Physicians are expected to apply their skill in managing illness by acting for the welfare of the patient, by following the rules of professional behavior, and by being objective and emotionally detached. THE SZASz-HOLLENDER MODEL
The types of behavior expected of physicians and patients were further delineated by Thomas S. Szasz and Marc H. Hollender,5 who describe three models of the physician-patient relationship based on the degree of control of each participant (Table II). With the Szasz- Hollender model, the choice of which type will be actually employed is mediated by the type and severity of the illness, as well as by the personality and preferences of physicians and patients. A patient in coma can be nothing but passive; he requires an active and authoritative physician. When that patient comes out of a coma a different model becomes appropriate in the relationship. The personalities of both individuals must be taken into account, as certain persons show stronger needs for control than others. The models discussed above delineate the general expectations which govern the behavior of physicians and patients. In these early theories of the doctor-patient relationship, the major assumption was that pathways to this relationship were essentially voluntaristic, that is, the decision by the patient to seek care and the selection of whom he would consult were made by individual choice. This was seen as a direct consequence of our culture, reflecting several of its major value orientations: individualism, orientation toward the future (i.e., willingness to postpone gratification for future rewards), and belief in man's dominance over nature. To be sure, it was recognized that individual choice could be influenced and modified by outside forces. Among such influences on illness behavior were socioeconomic status6 and culture;7 8 nevertheless, the individual patient was assumed to be the decision-maker. This individualistic assumption was further reinforced by the findings of studies such as those of Balint.9 In the framework of a national health service, Balint found that his patients continued to shop for a doctor who was somehow compatible as a human being. He reported that from 8% to Vol. 53, No. 1, January-February 1977
78
S.W. BLOOM AND P. SUM MEY
Cz.
z~~~~~~~~~~~~~~~
0~~~~~~~
4-7 00~~~~~~ -
0
=~~~~~~~o ~~~~0 ~
~
L
cl0
7,~~~~~. H~~~~~~~~~~~~~~~~7
Bull. N.Y. Acad. Med.
PHYSICIAN-PATIENT EXPECTATIONS
79
10% of the patients on a London doctor's list changed their doctors in any one year. This was supported by KoOS6 from his sample of rural Americans, 13% of whom were found to have dropped a doctor. Let us assume that in the United States and Western Europe in 1930, when these hypotheses emerged most strongly, this assumption of underlying freedom of choice by the patient was essentially correct. The question is: Is the same assumption true today? My answer is at the heart of today's presentation. It is not a simple answer. It must be considered still hypothetical, even though strongly supported by data. If the analysis is now restricted to the United States, the answer, in outline, is as follows: 1) Freedom of choice for medical care does exist, but for a portion of the population of patients it is severely limited. 2) The portion of patients who are able to exert this right effectively is determined by a number of factors, including ability to pay and availability of the medical care of choice. 3) Because of the constraints involved, the portion of the population that exerts this right is decreasing. 4) The choice of doctor is mediated increasingly by the influence of third parties, including insurance plans, unions, and employers. 5) The effect is to reduce individual choice and the influence of client networks which are the natural source of referral in conditions which provide for individual choice.10 6) In place of these, the bureaucratization of medical relationships is expanding rapidly. 7) The result, from the viewpoint of the patient, is a series of effects: a) A system of medical care in which quality varies, especially in primary care, according to social status b) The loss of personal connection between doctor and patient c) The proliferation of providers of care for each patient-client, both the financially able and the poor 8) The results, from the viewpoint of the society, are: a) Costly, inefficient delivery of health care b) A dissatisfied, restless group of consumers which falls back on militant hostility toward the health-care establishment and projects anger on its own providers of care c) Increased legalistic challenge to the doctor's autonomy d) Increased defensive medicine practiced by providers and general Vol. 53, No. 1, January-February 1977
80
80
S.W. BLOOM AND P..SME SUMMEY S..BOMAN
rejection by doctors of the client-patient as unreasonable, spoiled, and ungrateful Nowhere are these effects more intense than in primary care. The reasons are obvious; the trend toward bureaucratization is part of the trend toward specialization. Secondary and tertiary care are, by definition, rationalized; they are based in the houses of technological medicine, the hospitals. Primary care, also by definition, is personal care; thus, by experience, it is at risk under the conditions of the rational institutionalization (bureaucratization) of medical technology. In sum, we are describing a situation in which the doctor-patient relationship is being replaced for a large segment of the general population by a relationship in which the patient does not engage the services of a professional person, but rather of a professional institution. If we reflect upon this situation, it appears that either our cultural expectations about the doctor-patient relationship were only myths or revolutionary changes have occurred in the fundamental structure of society. Literature on the doctor-patient relationship is abundant, but most of it deals with doctors' expectations of patients. More than any other aspect of the problem, patient compliance receives the bulk of attention. Utilization runs a close second. Compliance seems to be a biased conception from the start. In studies of compliance the emphasis is necessarily upon predictability. The questions are framed about which patients do as they are told rather than upon what patients actually do. Indeed, research in this field has been mainly documentation of what kinds of patients are more likely to follow medical regimens and what kinds are not. It tells us, for example, that lower socioeconomic classes are less compliant than higher.1-13 In other words, a specific set of stereotypes is reinforced. More recently, the more important question of why some patients comply and why some do not is receiving intensified attention from research workers. 1415 Utilization has a similar research record. The overriding concern appears to be overutilization or underutilization. The central issue is usually cost. Again, one must suspect that the design of such research contains an implicit self-fulfilling prophecy. Underlying the real issue is mistrust of the same categories of patients whom we stereotype in the formulation of compliance. It would be more fruitful to study variations in utilization according to the kinds of facilities offered, patients' life-cycle stages of growth and development, and patients' life activities such as occupations. One of the most Bull. N.Y. Acad. Med.
PHYSICIAN-PATIENT EXPECTATIONS
81
interesting studies bearing on this problem was done by Breslau and Reeb. 16 Families of patients were studied under two conditions of delivery of care, but with the same doctors. The first condition was a private office practice: the second condition involved the same doctors operating a pediatric practice in the pediatric unit of a university hospital. Under the second condition the number of visits by well children declined; the number of visits for illness increased. Continuity of care was lower. The number of telephone consultations decreased. Thus, although the patients were held constant, there was a great difference in patterns of utilization according to the structure of the practice situation. In our judgement, the problems of compliance and utilization are more matters of structural organization of health-care delivery than variables dependent on demographic characteristics. Continuity of care is the variable that will prove to be the significant determinant, rather than the traits of patients. Patients, no less than doctors, are influenced by the dramatic changes that have occurred in the technology of medicine in recent years. They want expert treatment. As Freidson showed in his study of the Montefiore Hospital group, patients value competence as highly as the medical profession does.'0 However, they equally value the personal interest which they expect a doctor to have for his patient. Attempts have been made to separate types of patients according to these two expectations.17 Presumably, some patients have greater affective needs than others. Our reading of the evidence is that all patients seek both competent and concerned personal care. What has happened is that they no longer expect both from the same doctor. Friedson's Montefiore patients went to the hospital group when they felt they were in clear illness-distress, but frequently used safety-valve visits to neighborhood physicians when symptoms were vague and less threatening. We believe that more and more of today's patients are dividing the labor of illness, as it were, and in a similar manner using different doctors for different self-diagnosed problems. The trend toward more organized, institutionalized medicine, however, is inexorable. Within the dramatic social change that has occurred, the expectations of doctor and patient for each other also must change. The present situation seems to be one of the persistence of obsolete expectations in circumstances of radical change. Beliefs and the social expectations which follow from them must adjust to changes in social structure, but the process is seldom smooth.
Vol. 53, No. 1, January-February 1977
82
S.W. BLOOM AND P. SUMMEY
REFERENCES I
2. 3. 4.
5.
6. 7. 8.
9. 10.
Kluckhohn, C.: Mirror ftr Man. Greenwich, Conn., Fawcett, 1957 (originally published by McGraw- Hill, 1949), p. 20. Parsons, T.: The Social System. Glencoe, Ill., Free Press, 1951. Henderson, L. J.: Physician and patient as a social system. N. Engl. J. Med. 212:819-23, 1935. Henderson, L. J.: Pareto's General Sociology: A Physiologist's InterpretatiOn. Cambridge, Mass., Harvard University Press, 1937. Szasz, T. S. and Hollender, M. H.: A contribution to the philosophy of medicine: The basic models of the doctorpatient relationship A.M.A. Arch. Intern. Med. 97:585-92, 1956. Koos, E. L.: The Health of Regiont'ille. New York, Columbia University Press, 1954. Zborowski, M.: Cultural components in response to pain. J. Soc. Issues 8: 16-30, 1952. Mechanic, D.: Response factors in illness: The study of illness behavior. Soc. Psych. 1:11-20, 1966. Balint, M.: The Doctor, His Patient and the Illness. New York, Int. Universities Press, 1957. Friedson, E.: Patients' Views of Medical Practice. New York, Russell Sage
Foundation, 196 1. 11. Bergman, A. B. and Werner, R. J.: Failure of children to receive penicillin by mouth. N. Engl. J. Med. 268:133438, 1963. 12. Deasy, L. C.: Socioeconomic status and participation in the poliomyelitis vaccine trial. Am. Sociol. Rev. 21: 185-91, 1956. 13. Gordis, L., Markowitz, M., and Lilienfeld, A. M.: Why patients don't follow medical advice: A study of children on long-term antistreptococcal prophylaxis. J. Ped. 75:957-68, 1969. 14. Becker, M. H., Drachman, R. H., and Kirscht, J. P.: A new approach to explaining sick-role behavior in lowincome populations. Am. J. Public Health 64:205-16, 1974. 15. Becker, M. H. and Maiman, L. A.: Sociobehavioral determinants of compliance with health and medical care recommendations. Med. Care 13:10-24, 1975. 16. Breslau, N. and Reeb, K. G.: Continuity of care in a university-based practice. J. Med. Educ. 50:965-69, 1975. 17. Coser, R. L.: A Home Away From Home. In: Sociological Studies of Health and Sickness, Apple, D., editor. New York, McGraw-Hill, 1959, pp. 154-72.
Bull. N.Y. Acad. Med.
