Table Of Contentiv Contents
Communicating with Patients and Caregivers
8. Incomplete Narratives of Aging and Social Problems
in Routine Medical Encounters
HOWARD B. WAITZKIN, THERON BRITT,
AND CONSTANCE WILLIAMS
9. Family-Centered Geriatric Medical Care
REBECCA A. SILLIMAN
10. Parenting a Disabled Child: Problems in Interacting
with Health Professionals
JAN. L. WALLANDER AND DENISE F. HARDY
11. Quality-of-Life and End-Of-Life Decisions for
Older Patients
ROBERT A. PEARLMAN
Future Educational Considerations
12. The Role of Patient Education in Doctor-Patient
Relationships
MARIE R. HAUG
13. Teaching Communication Skills to Medical Students
and House Officers: An Integrated Approach
RICHARD M. FRANKEL AND HOWARD B. BECKMAN
Concluding Commentary
14. Toward a Social Medicine
JAMES E. LEWIS AND J. CLAUDE BENNETT
References
Contributors
Author Index
Subject Index
Sociomedical
Perspectives
on Patient Care
Jeffrey Michael Clair
Richard M. Allman
Editors
THE UNIVERSITY PRESS OF KENTUCKY
Copyright © 1993 by The University Press of Kentucky
Scholarly publisher for the Commonwealth,
serving Bellarmine College, Berea College, Centre
College of Kentucky, Eastern Kentucky University,
The Filson Club, Georgetown College, Kentucky
Historical Society, Kentucky State University,
Morehead State University, Murray State University,
Northern Kentucky University, Transylvania University,
University of Kentucky, University of Louisville,
and Western Kentucky University.
Editorial and Sales Offices: Lexington, Kentucky 40508-4008
Library of Congress Cataloging-in-Publication Data
Sociomedical perspectives on patient care / Jeffrey
Michael Clair and Richard M. Allman, editors,
p. cm.
Includes bibliographical references and indexes.
ISBN 0-8131-1815-8 (cl: alk. paper): ISBN
0-8131-0819-5 (pa : alk. paper):
1. Physician and patient. 2. Medical care—Psychological aspects.
3. Interpersonal communication. 4. Communication in medicine.
I. Clair, Jeffrey M., 1958- II. Allman, Richard M., 1955-
[DNLM: 1. Comprehensive Health Care—trends. 2. Physician-
Patient Relations. W62S6785 1993]
R727.3.S63 1993
610.69'6—dc20
DNLM/DLC
for Library of Congress 92-48516
Contents
List of Figures and Tables v
Foreword vii
EUGKNE B. GALLAGHER AND JOHN R. DURANT
Acknowledgments xiii
Introduction 1
JEFFREY MICHAEL CLAIR AND RICHARD M. ALLMAN
Issues and Perspectives 11
1. The Application of Social Science to Medical Practice 12
JEFFREY MICHAEL CLAIR
2. Reconciling the Agendas of Physicians and Patients 29
RICHARD M. ALLMAN, WILLIAM C. YOELS,
AND JEFFREY MICHAEL CLAIR
3. The Changing Pattern of Physician-Patient Interaction 47
WILLIAM C. COCKERHAM
The Social Context of Medical Practice 59
4. From Bedside to Bench: The Historical
Development of the Doctor-Patient Relationship 60
CHARLOTTE G. BORST
5. High Tech vs "High Touch": The Impact of Medical
Technology on Patient Care 82
H. HUGHES EVANS
6. Contractual Arrangements, Financial Incentives,
and Physician-Patient Relationships 96
ROBERT L. OHSFELDT
7. Fear of Malpractice Litigation, the Risk Management
Industry, and the Clinical Encounter 114
FERRIS J. RITCHEY
iv Contents
Communicating with Patients and Caregivers 139
8. Incomplete Narratives of Aging and Social Problems
in Routine Medical Encounters 140
HOWARD B. WAITZKIN, THERON BRITT,
AND CONSTANCE WILLIAMS
9. Family-Centered Geriatric Medical Care 162
REBECCA A. SILLIMAN
10. Parenting a Disabled Child: Problems in Interacting
with Health Professionals 174
JAN. L. WALLANDER AND DENISE F. HARDY
11. Quality-of-Life and End-Of-Life Decisions for
Older Patients 186
ROBERT A. PEARLMAN
Future Educational Considerations 197
12. The Role of Patient Education in Doctor-Patient
Relationships 198
MARIE R. HAUG
13. Teaching Communication Skills to Medical Students
and House Officers: An Integrated Approach 211
RICHARD M. FRANKEL AND HOWARD B. BECKMAN
Concluding Commentary 223
14. Toward a Social Medicine 224
JAMES E. LEWIS AND J. CLAUDE BENNETT
References 237
Contributors 269
Author Index 274
Subject Index 280
Figures and Tables
Figures
1.1. Psychosocial Resource Model 23
6.1. Primary Methods of Compensation among Non-Solo
Physicians, 1983 100
6.2. Stated Primary Reasons for Self-referral,
by Specialty, 1989 108
6.3. Ratios of Self-referring to Referring Physicians, 1986-88 108
7.1. Medical Injuries, Negligence, and Malpractice Claims 119
7.2. Disposition of Malpractice Claims 121
8.1. Schematic, Structural Elements of Medical Encounter A
(Independent Older Woman) 152
8.2. Schematic, Structural Elements of Medical Encounter B
(Retired Widower) 158
9.1. The Doctor-Patient-Family Caregiver Relationship 164
9.2. Example of a Genogram 167
12.1. Relationship between Educational Level and Challenge of
Physician Authority 203
14.1. Shifting Cultures of Medicine 228
14.2. Relationship of Medical Art, Medical Science,
and Patient Age 235
Tables
7.1. Behavior Modifications Advised by the Risk Management
Industry to Avoid Malpractice Suits 123
7.2. Perceived Reasons for Malpractice Action 132
7.3. Evaluations of Proposals to Reduce
Malpractice Litigation 133
vi Figures and Tables
9.1. Activities of Daily Living and Instrumental Activities of
Daily Living 163
9.2. The Evolving Doctor-Patient-Family
Caregiver Relationship 170
12.1. Challenges to Physician Authority by Level
of Patient Education 204
12.2. Types of Authority Challenge by Race
and Education (USA) 206
12.3. Types of Authority Challenge by Education,
USA and Japan 207
12.4. Elements of Authority Challenge by Ethnicity and
Education, U.S. Residents with Arthritis 208
12.5. Types of Doctor-Patient Relationship 210
Foreword
A Social Perspective
I spent two weekends steeping myself in the 13 chapter manuscripts
that comprise this intriguing and rich book. In its implications for
medical education and practice, for the social-behavioral sciences, and
for public debate on health care, this book could not come at a better
moment. It reminds us of how much more there is to medical care than
the technical means to carry it out and the economic means to pay for
it—important as those factors obviously are.
In current public debate, thoughts, anxieties, and strategies over-
whelmingly fasten on economic issues. How can we provide medical
services for the underserved segments of the population? If there is to
be true public rationing—not simply market allocation—how can we
frame priorities that reflect a public consensus? How can we contain
aggregate costs and tame the rampant inflation? How should we con-
ceptualize benefits, and how can we get more benefit per dollar
expended?
Aside from the economic issues that capture the headlines, the
public has many long-standing doubts and grievances about its medi-
cal care, centering on problems in communication and relationships.
Patients want less hurried, more communicative, more caring doctors
who will recognize them as individuals. Even when definitive medical
intervention is not possible (e.g., for chronic or terminal illness), or
necessary (e.g., for self-limiting illness), they still want such doctor-
ing. Medical care with these superadded qualities of caring becomes
patient care. The latter embraces and goes beyond the former. Patient
care distinguishes human medicine from veterinary medicine. Relating
to a sentient patient with communicative capacity and self-awareness
directly establishes an accountability for the doctor that goes beyond
the requirement of technical proficiency and conscientiousness.
viii Foreword
This book deals forcefully with patient care issues and only glanc-
ingly with economic issues. It is thus a valuable counterpoise to the
blinding focus on economics; at the same time, patient care has an es-
sential connection with economic issues, as shown in the following
considerations.
With 42% of the health care dollar coming from public funds, and
another large chunk coming from employer funds, there is rising con-
cern about value-for-money and a call for critical cost-benefit analyses.
The first, almost "fun" part of such analysis is to identify the harmful,
downright iatrogenic practices that have no redeeming virtues for the
recipient. Next comes the category of "wasteful" practices—so-called
needless surgery and medication, and needless or needlessly pro-
longed hospitalization. Finally, one moves into the more difficult
terrain of deciding which of the many beneficial medical services—
whether diagnostic, curative, palliative, supportive, or rehabilita-
tive—justify, and which do not justify, the requisite expenditure of
resources.
In the foregoing argument, the benefits to be assessed are tan-
gible, measurable outcomes, such as postponement of death or inca-
pacity, relief of pain and distress, and improved quality of life.
Medicine can in varying degrees yield these vital benefits. From its
perspective, this book deals, however, with those less tangible, mea-
surable, and categorizable benefits that inhere in the processes of
patient care. These benefits contribute to the satisfaction of the pa-
tient's need for information, guidance, care, and recognition.
In its many-sided concern with communication and relationships,
this book deals with the patient care components of the overall benefit
package. One would be rash to reckon too precisely in economic terms
the value of good communication in the doctor-patient relationship,
yet it is worth a great deal. If forced to choose, patients might prefer
the technically superb surgeon who is brusque or inarticulate to a sen-
sitive bumbler. In effect, the present system has—without consulting
anyone—already made exactly that choice for us: it values and incul-
cates technical proficiency and disregards, almost systematically,
communicative skill.
Why can't patients have a doctor who does his or her job well and
who also cares and—better still—who talks and listens? These latter
two qualities of patient care are not "free goods" in the sense of being
part of the genetic endowment ("some docs have it and some don't") or
early training of pre-doctors. Medical care organizations and medical
training programs should emphasize, encourage, reward, and instill a
sense of responsibility as well as skill in patient care. Further, the in-
dividual physician cannot be expected to function as a single-minded
"patient care practitioner" against the tide of a depersonalizing envi-
