Bilateral Consensus in Doctor-Patient Transactions
MARGARET BRIEN DiCANIO
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
Thanks are due:
To Dr. Gerald R. Leslie for guidance, and for discovering a
To Dr. Richard Reynolds for the opportunity of using clinic
To Mrs. Evangeline Chandler, principal of The District Ele-
mentary School for sharing her knowledge and her friendship.
To Pat Millet for struggling through revisions of the coding
form, and through a mound of coding.
To the clinic staff for refraining from complaining about
having an intruder underfoot.
To Felice Pralle, to Mrs. Howard Curry, and to Mrs. Edward Gaia
for wading through a messy manuscript.
To the late Dr. Henry Meleney for sharing an interest in The
District and for trying to change some of the living conditions.
To my mother and daughter for accepting without protest a year
of having a living room that looked like a bookstore about to go out of
business, and for doing much more than their share of chores.
To the residents of The District for making a nosy stranger feel
welcome in their midst.
The major objectives of this study were two:
(1) to determine whether a perceived imbalance in the infor-
mational transaction between patients and doctors is real
or only apparent;
(2) to suggest the need for routine follow-up procedures in the
practice of general medicine.
If the ideal doctor had an ideal fairy godmother who would grant
him three wishes toward the attainment of an ideal patient, those three
wishes probably would be:
(1) a patient who would present only relevant symptoms;
(2) a patient who would follow the doctor's advice;
(3) a patient who would call him or return to his office only
If the ideal patient had an ideal fairy godmother who would
grant him three wishes toward the attainment of an ideal doctor, those
three wishes would probably be:
(1) a doctor who would reassure him;
(2) a doctor who would tell him what to do in order to regain
(3) a doctor who would be available when he was uncertain about
the changes that he perceived in the state of his health or
about the methods that he was using to regain his health.
Despite the shortage of fairy godmothers, the doctor is in a far
better position to approach his ideal than is the patient. By skillful
questioning and modern instrumentation, the doctor can pry the relevant
symptoms from the patient. He cannot make the patient follow advice,
but he can protect himself from unnecessary demands upon his time
through use of a whole host of intermediaries which include recep-
tionists, nurses, and answering services. If the imbalance that this
researcher suspects occurs in the exchange of information between
doctors and patients, then some attention to this exchange might move
the doctor closer to attainment of his other wish; for patients who
Aside from the two major objectives of this study, minor
objectives emerged during the process of thinking through the problems
and coping with the data. One of these was the development of a
practical technique for classifying and analyzing the diffuse activities
that occur during a doctor-patient interaction.
Another minor objective that emerged was the intention to pay
some heed to the communication process, an area which sociologists for
the most part ignore. The sociologist's lack of interest overlooks the
role that communication plays as a component in the ongoing process of
socialization, his own as well as that of his subjects. Communication
is easily dismissed as more properly belonging to those hybrid social
scientists, the social psychologist and the linguistic anthropologist,
yet each time a sociologist sets out to write an interview schedule he
is making assumptions about the language norms of his target population.
Peter Berger claims that the sociologist enjoys the discovery of the
extraordinary within the ordinary of everyday life (1963:21). It would
seem that communication is so ordinary that even the sociologist over-
A final minor objective that emerged concerned the presentation
of the data. Powdermaker, echoing an earlier point made by Merton,
commented that the process of research is seldom presented in enough
detail to enable the reader to distinguish between the ideal world of
textbook research and the real world of research done with live people.
Little record exists of mistakes and of learning from them, and of
the role of chance and accident in stumbling upon significant
problems, in reformulating old ones, and in devising new tech-
niques, a process known as "serendipity" (1966:10-12).
In the presentation of the data, an effort was made to include the com-.
promises that had to be made. This method carried with it its own
complement of hazards; a balance had to be struck between chronology,
logic, and the stylistic demands of traditional dissertation formats.
The details of tabulation and analysis attempted to adhere to the
intention to be explicit.
The approach to medical data used resembles content analysis.
In that respect it differs from the only comparable research, studies
done by Ley and Spelman (1967) and studies done by Pratt, Seligmann, and
Reader (1957). Neither of these two sets of researchers concerned them-
selves with the need for making the different areas of discourse com-
parable nor with criteria for making a decision that a patient was
poorly informed. They did, on the other hand, touch on critical prob-
lems which this study had neither the funds nor the time with which to
deal. They dealt with the levels of medical knowledge on the part of
the patient, the presumptions of the physician about the patient's level
of knowledge, and the problems of forgetting. This study, without
discounting the importance of those factors, chose to deal with an area
that seemed to have a chronologically earlier priority; i.e., what in
fact does a patient remember, and how can it be consistently measured.
The content analysis approach itself may have some advantages
in a medical setting that it does not enjoy in its use in areas such
as propaganda analysis. Alexander George comments:
Propaganda analysis is cumulative in character. "New" content
features encountered in the second (larger) body of communication
material may force the investigator to alter his hypothesis or to
employ additional or different content categories. Moreover a
skillful propagandist changes his strategy to preclude his future
plans being easily read from the pattern of his past conduct (Pool,
Presumably the medical setting has more regularities built in.
Approach and procedures are more standardized, and the intention to be
novel or to deceive are not an integral part of the communication
TABLE OF CONTENTS
ACKNOWLEDGMENTS . . . . . . . . . . . . ii
PREFACE . . . . . . . . . . . . . . i
LIST OF TABLES . . . . . . . . . . . . xiii
LIST OF FIGURES . . . . . . . . . . . . xv
ABSTRACT . . . . . . . . . . . . . . xvi
I. SAMPLE, DATA COLLECTION, METHOD DEVELOPED FOR COMPARISON
OF DOCTOR-PATIENT TRANSACTIONS . . . . . . 1
Sample and Data Collection . . . . . . . 1
Circumstances Which Permitted the Research to
Take Place . . . . . . . . . . 1
Idea to be investigated and location of
investigation . . . . . . . . . 2
Reasons for study of the records instead of the
doctors . . . . . . . . . . 4
Reasons for choice of the black community as a
patient source . . . . . . . . 5
Comparison of patients and non-patients . . 5
Semifocused Interview and Tape Recorder as
Instruments . . . . . . . . . . 6
Data Collection . . . . . . . . .. 7
Problems . . . . . . . . . . 7
Forced revision of research plan . . . . 8
Respondents, patients, and households sampled . 9
Explanation of uncommon interviews . . . 9
Explanation for omitted households . . . 10
Method Developed for Comparison of Doctor-Patient
Transactions . . . . . . . . . . . 11
Paucity of Patients' Verbal Behavior . . . . 11
Questions Asked about the Clinic Visit . . . 12
A Method for Making the Different Discourses
Comparable . . . . . . . . . . 13
The Coding of an Actual Patient as an Example of
the Method . . . . . . . . . . 14
Step 1: Transfer patient's version from the
tape to notes . . . . . . . . . 14
Step 2: Extract notes from the medical record 14
Step 3: The two versions sorted and arranged
side by side . . . . . . . . . 15
Step 4: The two versions coded onto the coding
form . . . . . . . . . . . 16
Coding Form . . . . . . . . . . 16
Coding Rationale . . . . . . . . . 21
Reasons for procedure . . . . . . .
Methods for circumventing patient's brevity . .
Obstacles presented by the diagnosis category .
Exclusion of physical examination findings . .
The use of an item of information only once . .
Six Eliminations from the Coding . . . . . 24
Coder Reliability . . . . . . . . . 24
II. COMMUNICATION THEORY . . . . . . . . . 26
Objectives and Communication Overview . . . . 26
Postponement of Hypotheses and Restatement of
Objectives . . . . . . . . . . 26
Brief Overview of Communication . . . . . 26
Action and reaction . . . . . . . 27
Different concerns of the disciplines associated 27
Emphasis on syntactics . . . . . . 27
Relationship between syntactics and semantics . 28
Pragmatics . . . . . . . . . . 28
Coding . . . . . . . . . . . . 29
The Idea of Coding . . . . . . . .. 29
Different Structures Develop Different Codes . . 29
Elaborated code environment . . . . . . 30
Distinctions among restricted code environments 30
Differences in the socialization of elaborated
code users as distinguished from restricted code
users . . . . . . . . . . . 32
The Relevance of Code to the Concept of Social Class 32
An effort to inform patients . . . . . 34
What options does the non-comprehending patient
have? . . . . . . . . . . . 35
The absence of dissatisfied patients . . . 36
III. SOCIOLOGICAL THEORY . . . . . . . . . 38
Communication Links with Sociology . . . . . 38
Reality of Gestures Expressed in Action . . . 38
Sociology Ignores the Role of Communication in
Consensus . . . . . . . . . . . 38
Thomas Linked with Mead and the 1930's Linked with
the Present . . . . . . . . . . 39
New objects from communication; responses give
meaning to gestures . . . . . . . 39
The interplay of the present and the pre-existent 39
Mead's focus differs from Thomas' . . . . 40
Sherif Extends Mead and Thomas . . . . . 40
External and internal factors are complements 40
Ambiguity forces the use of pre-existing
attitudes . . . . . . . . . 41
Ambiguity Encourages Use of Internal Standards as
Anchorage . . . . . . . . . .. . 42
Patients lack a standard to assess symptoms or
advice . . . . . . . . . . 43
Normative Influences . . . . . . . . 43
Another Communication Link with the 1930's . .. 43
Reciprocal recognition . . . . . . 43
Festinger's Specification of Coorientation . .. 44
Trend toward uniformity . . . . . . 45
Group pressure . . . . . . . . 46
Theory of Correspondent Inferences . . . . 46
Additional generators for inferences . .
Efficiency, anxiety, and levels of inference
Summary . . . . . . . . .
IV. THE PATIENT'S COMMUNITY . . . . . .
Preface . . . . . . . . .
The Community as a Pre-existing Situation .
Problems with Language Norms Again .
Age and Sex Distribution . . . .
Children's role in clinic attendance
Sex ratio differences . . . .
Dependency and aging . . . .
Education . . . . . . . .
Employment and Sources of Income . .
Underemployment . . . . . .
Employment and education . . . . .
Non-employed . . . . . . . .
Interviewer Avoidance of Income Amount Question
When and Why of Migration to Meccaville . .
Male-Female Roles in The District . . . .
Male dominance . . . . .
Family patterns . . . . .
. . . 49
. . . 52
. . . 52
. . . 53
. . 53
. . . . 54
. . . . 68
. . . . 6 9
. . . 69
. . . . 71
One-half of Thomas' Gestalt . . .
The Community as an Objective Situation .
Housing . . . . . . . .
Maternal Care . . . . . . .
Health Care Choices . . . . .
Choice of physician . . . .
Choice of being hospitalized . .
Choice of waiting rooms . . .
Budget choice . . . . . .
Health Care Problems . . . . .
Dental care . . . . . .
Parasites . . . . . . .
Mass-Conservative Migration . . .
Why Meccaville? . . . . . .
. . . . 77
. . . . 77
. . . . 77
. . . . 79
. . . . 80
I I I j I
V. THE STUDENT-PHYSICIAN COMMUNITY . . . . . . .
Student-Physician Socialization . . . . . .
Professional Socialization . . . . . . .
Socialization into the Use of Professional
Language Norms . . . . . . . . . .
VI. FINDINGS FROM THE DOCTOR PATIENT TRANSACTION COMPARISONS
A Compatible Hypothesis and Statistic . . .
Summary of Assumptions . . .
Framing an Hypothesis . . . .
Hypothetical Outcomes . . . .
Search for a Statistic . . .
Promising Statistical Methods . .
Card-matching model . . .
Clarification of agreement .
Robinson's method . . . .
If agreement implies identity .
Significance through failure to
S . 88
A More Suitable Statistical "Fit" . . . .
Similar code or similar level of skill .
Zelditch's method . . . . . ..
Another Way of Looking at the Response Totals .
Optimal Patient Participation . . . . .
Comparison of Matched and Unmatched Responses .
. . 98
. . 98
VII. MEDICAL MELANGE . . . . . . . . .
Defining and Coding . . . . . . .
Preface . . . . . . . . . .
Definition of a Situation . . . . .
Physician Coding . . . . . . .
Patient Coding . . . . . . . .
Coding Criteria . . . . . . . .
. . 105
. . 105
Recognition of a Need for Medical Care . . .
Recognition Related to Socioeconomic Level . .
Purpose of Introducing the Symptoms into the
Interview . . . . . . . . . .
Statistical Treatment . . . . . . .
Some Less Stringent Observations Acquired with
Koos's List . . . . . . . . . .
Less serious symptoms . . . . . .
Home Remedies and Folk Remedies . . . . . .
A Symptom Diagnosed Is a Symptom That Can Be Ignored
Koos's Symptoms as an Interviewing Technique
VIII. CONCLUSIONS, IMPLICATIONS AND LIMITATIONS . .
Conclusions . . . . . . . . .
Doctor-Patient Transactions . . . . .
Unsatisfactory Communication . . . .
Black Community . . . . . . .
Implications . . . . . . . .
Written Instructions . . . . . .
A "Team" Member Responsible for Follow-up .
Nonscientific Assumptions . . . . .
Assumption Monitoring . . . . . .
Inroads into Local-Cosmopolitan Distinctions
Black families . . . . . . .
Limitations . . . . . . . . . .
Need for Follow-up Can Only Be Inferred .
The Lack of a Middle Class Sample . . . .
Recall and Forgetting . . . . . . .
A Parting Postscript . I . . . . .
APPENDICES . . . . . . . . . . . .
. . 118
. . 119
. . 119
. . 119
. . 119
I . 120
. . 122
. . 124
0 . 125
A. Directions for Coders . . . . . . . . . 130
B. Coding Totals . . . . . . . . . . . 145
C. Koos's Symptom List--Original and Reworded . . ... . 157
D. Folk Remedies . . . . . . . . . . . 170
E. Introductory Statement and Questions Asked of District
Residents . . . . . . . . . . . . 174
F. Summary of Studies Dealing with the Effectiveness of
Advice Given to Patients . . . . . . . . 179
LIST OF REFERENCES . . . . . . . . . . . 183
BIOGRAPHICAL SKETCH . . . . . . . . . . . 188
LIST OF TABLES
Patient and Non-Patient Households Interviewed in The
District . . . . . . . . . . . .
Persons Interviewed in Connection with 51 Clinic Patients
Percentage Distribution of District Residents by Age and
Sex Categories . . . . . . . . . . .
4. Fertility Ratios of District Residents . . . . .
5. Percentage Distribution Among Active and Dependent Age
Groups . . . . . . . . . . . .
6. Percentage of Residents of The District by Years of
Completed Schooling . . . . . . . . .
7. Percentage of Total Number of Either Sex of District
Residents Falling into Years of Schooling Categories
8. Percentage of The District Residents Employed in Various
Occupations . . . . . . . . . . .
9. Income from Nonoccupational Sources of Heads of
Households of The District . . . . . . .
10. Percentage of Respondents by Length of Time Lived in
The District . . . . . . . . . . .
11. Consanguineal Ties Among District Households . . .
12. Living Arrangements by Marital Status of District Heads
of Households . . . . . . . . . .
13. Percentage of District Households by Various Levels of
Housing Quality . . . . . . . . . .
14. Age Distribution of Percentages of Mothers by Method of
Delivery for Patients and Non-patients of The District
15. Percentage of District Respondents and Their Children by
the Status of Their Dental Care . . . . . .
16. Cities or Towns of Birth of District Households'
Children . . . . . . . . . . . . 80
17. Percentage Distribution of Matched and Unmatched
Responses for Doctors and Patients . . . . . 92
18. Percentage Distribution of Doctors' and Patients' Response
Within Transaction Categories . . . . . . 93
19. Findings for Coding Categories of Doctor-Patient
Transactions Using the Difference Between Two
Proportions When N Is Large: The Normal Approximation
to Binomial Probabilities . . . . . . . 100
20. Percentage Distribution of Doctor-Patient Comparison
by Response Categories . . . . . . . . 102
21. Percentage Distribution of Each Participant's Matched and
Unmatched Response Activity by Transaction Categories 103
22. Comparison of Unmatched and Matched Responses to
Demonstrate Their Inherent Differences but Apparent
Similarity . . . . . . . . . . . 104
23. Percentage of Regionville's Three Classes and Patients
and Non-patients from The District Who Recognize
Symptoms as Requiring Medical Attention . . . . 113
24. Coding Totals by Categories and Subcategories for Matched,
Unmatched, Ambiguous and Contradictory Responses . . 146
25. Proportion of Doctors' Unmatched, Patients' Unmatched,
and Matched Response Totals Falling into Each Coding
Form Section . . . . . . . . . . . 149
26. Proportion of Each Coding Form Section Total Distributed
into Doctors' Unmatched, Patients' Unmatched, and
Matched Responses . . . . . . . . . 150
27. Coder Agreement Totals for Each Patient . . . . 151
28. Coder Variance Computed for Each Patient . . . . 153
29. Seventeen Symptoms Tabulations for District Patients . 161
30. Seventeen Symptoms Tabulations for District Non-patients 165
31. Seventeen Symptoms Comparison of Patients and Non-patients
Percentage Distribution among Responses . . . . 168
32. The Effectiveness of Advice Given to Patients . . . 180
LIST OF FIGURES
1. Age Distribution for The District: 1969 . . . . 55
Abstract of Dissertation Presented to the
Graduate Council of the University of Florida in Partial Fulfillment
of the Requirements for the Degree of Doctor of Philosophy
BILATERAL CONSENSUS IN DOCTOR-PATIENT
Margaret Brien DiCanio
Chairman: Dr. Gerald R. Leslie
Major Department: Sociology
A comparison was made between black patients' verbal accounts
and medical records' accounts of the same doctor-patient transaction. A
coding form was developed to assist the comparisons. Consensus was
found for slightly more than 50 per cent of the total responses. The
comparison excluded, with a few exceptions, physical and examination
findings and limited itself to information garnered through conversation
and questioning. The transaction appeared to be a unilateral exchange
of information. Only 25 per cent of the patients' information was unre-
corded, while 60 per cent of the doctors' information was not mentioned
in the patients' accounts.
The concept of coding as developed by Bernstein was used to
explain the communication difficulties between doctors and patients.
The doctor has access to two codes, a flexible elaborated code acquired
with middle-class socialization and a restricted occupational code
available only through specialized training. The patient has access to
only one code, an elaborated code if he is a middle-class patient, and
probably a restricted, gemeinschaft-type code if he is a lower-class
patient. Coding norms are stringently circumscribed by group pressure
and by the coder's desire to be understood.
Respondents from seventy-two out of seventy-six households in a
black community were interviewed. Questions were asked of all
respondents about whether they would seek medical care for a list of
seventeen symptoms developed by Koos. All of the symptoms require
medical attention. The findings suggest an overall rise in level of
health knowledge and an intraclass difference not focused upon by Koos.
Information gathered about the black community indicated that
family patterns were relatively stable. Twenty per cent of the house-
hold heads are female heads living with their children, their grand-
children, or boarders. Twenty-one per cent of the household heads live
alone. Forty-nine per cent of the community's households are headed by
marital pairs. A need for dental care and freedom from parasites are
two obvious health problems. Sixty-nine per cent of the childbearing
experiences by the residents had been non-hospitalized deliveries sug-
gesting that maternal and infant care has been a health need.
The socialization process of the doctor is briefly discussed as
a balance for the discussion of the patient's community, and as an
aspect of the acquisition of the doctor's occupational code.
SAMPLE, DATA COLLECTION, METHOD DEVELOPED FOR
COMPARISON OF DOCTOR-PATIENT TRANSACTIONS
Sample and Data Collection
Circumstances Which Permitted
the Research to Take Place
A unique set of circumstances offered an opportunity to examine
the exchange of information between doctor and patient. The University
of Florida elected to introduce into the program for their medical
students a period of training devoted to community medicine. The
community chosen for this new program is the seat of a rural county
whose population amounts to slightly under 3,000, about 600 of whom
live in the county seat.
A medical clinic had been built with federal funds within the
community but had remained unopened for lack of personnel. The
University Medical School, with the cooperation of the community, chose
to use this site as a part of the rotation of fourth year medical
students through the various services of the medical specialties. The
students spend three weeks living and working at the clinic site where
they are supervised by a resident physician. They gain experience
performing in the role of a general practitioner, in the same way that
they gain experience by working on the other teaching hospital services,
such as pediatrics, obstetrics, or surgery.
The community, referred to in this study by the pseudonym
Meccaville, had been without a practicing physician for several years.
The nearest medical care had been twenty-five miles away in one
direction or twenty-seven miles away in another direction.
The clinic directors, who were innovative in developing this
original training program, were equally flexible in encouraging this
research. Equally fortunate was the existence of a small enclave of
black residents, known locally as "The District" (also a pseudonym),
which had been untapped in earlier research done in the white community
of Meccaville. The fortuitous coincidence of a clinic willing to permit
research and a black community that might be willing to talk with a
researcher provided a setting in which an idea might be investigated.
Idea to be investigated and location of investigation.--The idea
to be investigated had been gained by the researcher in eight years of
paramedical working experience within general and psychiatric medicine.
The idea was that patients often emergedfrom interviews with a doctor,
exhibiting signs of uneasiness. The uneasiness seemed to center upon
whether they had told the doctor all the important symptoms and, if they
had not, whether the omission would critically affect the treatment they
were to follow.
Substantial literature supports the fact that patients often do
not follow treatment. Ley and Spelman provide a bibliography of the
literature dealing with this topic. (The bibliography is included in
Appendix F of this study 1967:41-43.) Other literature deals with what
Roth calls the "management bias" of medicine and social scientists which
assumes the patient will be motivated to conform to the medical model of
a "good" or "cooperative" patient who follows advice. (See Roth, 1962;
Roth and Eddy, 1967; Goffman, 1961; Braginsky, 1969.) This bias assumes
that it is possible for the patient to follow the advice given, and it
assumes that the patient has no conflicting needs.
Still another related area, the retention of information, has
been explored by Ley and Spelman (1967:Chapter 6), and Pratt, Seligmann,
and Reader (1957:1277-83). Both sets of researchers found that patients'
retention of information was relatively low.
With the intention of investigating the cumulative impression
mentioned above and the leads provided by the literature, it was pro-
posed to interview each patient from the black community in his home,
shortly after his clinic appointment with the student-physiciarn to see:
(1) whether the patient felt that he had been given sufficient
time to tell the doctor everything he had wanted to tell
(2) whether the patient felt that the doctor had understood him;
(3) whether the patient had understood the doctor;
and to have
(4) the patient repeat what had transpired during the trans-
Then the patient's version was to be compared with the medical
record's version to see:
(1) if the patient's version of what had transpired would reveal
that the patient who felt rushed had omitted symptoms that
he considered important;
(2) and, if the "rushed" patient would be inaccurate in his
remembrance of the treatment he was to follow.
As it happened, study of the problems of the "rushed" patient
was effectively thwarted by the halo the black community has erected
around clinic personnel. The halo was made manifest by the obvious dis-
pleasure interviewees displayed toward the interviewer in response to
questions that might be considered critical of the clinic's doctors.
The comparison of the two versions of the medical transaction also
proved to be sufficiently taxing that the problem of the "rushed"
patient was postponed until another time without regret. The study con-
centrated upon asymmetry in communication between patients and doctors.
Reasons for study of the records instead of the doctors.--The
choice of the medical record rather than the student-physician as the
other half of the doctor-patient transaction was based on three factors.
1. The same physician might have to be interviewed several
2. The student-physician might have been rotated off the com-
munity service before he could be interviewed, particularly
if the patient of interest was seen toward the end of the
physician's three-week service.
3. Awareness of the possibility that being interviewed might
change the behavior of the student-physician.
Beyond these three reasons, the medical record prepared by a student-
physician was deemed a particularly good comparison source because the
student-physician works under the constraint of preparing a record to be
reviewed by his instructors.
There is a risk that the medical student will include procedures
in the record that he did not do and items that he did not tell the
patient. (See Becker, Reader, Kendall, 1961). The contraindication to
this possibility in this setting is the more leisurely pace of this
rural practice and the close supervision given by the resident in
Reasons for choice of the black community as a patient
source.--The black community was chosen as the source of the patient
population for two reasons:
(1) to provide as homogeneousa patient population as possible.
The black community is predominantly lower class by reason
of income, occupation, and housing. This social class homo-
geneity contrasts with the social class homogeneity of the
student-physicians who can be construed as middle class by
origin or aspiration;
(2) because the black community, which had not been studied
before, was intrinsically interesting to the researcher.
Comparison of patients and non-patients.--The possibility
existed that residents of The District who sought medical care were dif-
ferent in some respect from residents who did not seek care. Reasoning
that this difference might include their attitudes toward medical care,
the researcher proposed to administer a symptom list, developed by Koos
(1954), which contains seventeen symptoms usually considered to require
medical attention, to all patients and to a random sample of non-
patients. The list involves asking each respondent whether he would or
would not seek medical care for each of the seventeen symptoms. Koos
found that the perceived seriousness of the symptoms varied by social
class, with the lower class viewing the symptoms as less serious. The
wording of the list was revised to make it more suitable for the com-
munity. Koos does not specify any specific wording for the symptoms.
He merely says that the respondents were asked to indicate "whether
each of a selected list of readily recognizable symptoms was significant
and should be called to the attention of a doctor" (1954:32). See
Appendix C for the original list and the revised list.
Semifocused Interview and Tape
Recorder as Instruments
The tools chosen for data collection were simple. A semi-
focused interview was preferred to a structured questionnaire in order
to permit the flexibility in language choice that was warranted by the
local vocabulary and dialect. The questions to be asked were written on
a small pack of three by five cards which were flipped unobtrusively as
questions were covered. The order of questions sometimes varied
slightly to keep the interview conversational. The order of the seven-
teen symptoms was not varied, although comments sometimes intruded
between them. Other data were gathered at the same time. Questions were
included about where people had been born, and lived; who lived in their
household; and what their previous health care had involved. The entire
list of questions and the introductory statement are included in
Interviews lasted twenty to forty minutes, occasionally
stretching to an hour, but for the most part they were brief. Residents
were not voluble. On the other hand, they were not aloof. They seemed
to enjoy the interview.
To allow additional flexibility, each interview was tape-
recorded. Expecting some reluctance to be provoked by the tape
recorder, each interview was prefaced with comments that said, in
effect, that the respondent was to refuse any question which he did not
want to answer and that if he became unhappy with the interview, the
tape would be erased in his presence. Only one respondent out of
seventy-two refused to permit taping. Once the recorder was set up, the
researcher ignored it and the respondents seemed to forget its presence.
Ignoring the recorder sometimes caused later grief because of the wide
variability in the quality of the tapes. The flexibility, however, was
well worth these minor problems.
Surprisingly, the small pack of cards provoked more problems..
Respondents would look at the pack and say, "That's a lot of questions
you got to ask." Subsequently, this was circumvented by splitting the
questions into smaller packs of different colored cards and tucking them
into various pockets. The color helped the researcher to keep the
questions in an orderly sequence and the smallness of the packs seemed
to reduce their threat.
Problems.--Several problems were encountered in the actual col-
lection of data. Trying to find the patients provided the first of a
number of "rural-urban cultural shocks." A box at the post office is
just not the same as living on a street that has a name and in a house
that has a number. Obtaining directions was a second shock. Directions
came replete with assumptions that everyone knew where the "MacStein's
place" was. It was just down the road, the road being a choice of
several. "Down" meaning one, two, five or ten miles. It seemed reason-
able, after being lost a few times, to postpone seeing patients who
lived outside The District proper until the area became more familiar.
In The District expectations were even higher that everyone
knew where the Johnsons lived. In time-, we learned that there might be
five or six Johnson households. Whatever house was settled on as being
the correct house was frequently one where no one was home. There was
no way of verifying that it was the correct household until someone was
found at home who could be asked if a household member had recently been
to the clinic. The search for that specific patient had to be halted
until verification was made.
During the period of planning this research, the researcher had
been introduced to the elementary school principal. She had worked in
The District for eighteen years and knew almost everyone. When the
search bogged down, an appeal was made to her for help. Time out was
taken to make a map. Then the principal helped to label as many house-
holds as possible. Later more labels were added, as additional house-
holds were discovered, tucked away out of sight behind trees. In time,
it became clear that only ten black households in the entire county
lived outside of The District proper.
Forced revision of research plan.--Even with the map and the
security of having the right house, the "not-at-homes" made the lengthy
trip from the university impractical without a revision of the original
research plan. The revision called for inclusion of the whole community
by house-to-house interviewing as people were found at home. Household
members were asked whether anyone in the house had been to the clinic or
not. Patient households were considered to be those households where
someone had been to the clinic by the time they were interviewed. The
"not-at-homes" were revisited until they were found at home, and all but
one of them were ultimately contacted.
Respondents, patients, and households sampled.--The distribution
of interviews that was obtained is included in Tables 1 and 2.
PATIENT AND NON-PATIENT HOUSEHOLDS
INTERVIEWED IN THE DISTRICT
Interviews in patient households 47
Interviews in non-patient households 25
Households not interviewed 4
Total households in The District 76
Whoever was willing to talk with the researcher was interviewed.
Luckily, if anyone at all had been to the clinic, generally the spokes-
man had-been too and, therefore, told us about his own visit. Among
the ten spokesmen who gave information about another's visit, seven were
parents talking about one or more of their children, one was an older
sister talking about her younger sister, one was a husband talking about
his wife, and one was an infirm, elderly lady talking about her more
infirm elderly boarder.
Only one visit per household was recorded, with three
exceptions. The exceptions were relaxed conversational interviews where
the additional visits were covered as a natural part of the conver-
sation. The exceptions amounted to four additional records. Con-
sideration was given to eliminating these extras but it seemed to
introduce as much bias to eliminate them as it did to keep them. They
were somewhat balanced by six visits which had to be eliminated.
Explanation of uncommon interviews.--One of the non-patient
household interviews was incomplete. The respondent was the oldest man
in the community, aged ninety-nine. He considered himself the merry-
maker of the senior set. For every question he was asked, he asked one
in return. Sometimes he answered the question, and sometimes he did
not. His frolic was sufficiently reassuring to neighbor onlookers that
four of them sat on his porch to be interviewed that same afternoon.
A joint interview involved two brothers, one of whom lived in a patient
household while the other lived alone in a non-patient household. They
alternated answering questions.
PERSONS INTERVIEWED IN CONNECTION
WITH 51 CLINIC PATIENTS
The patient himself 35
The patient's parent 7
The patient's older sister 1
The patient's husband 1
The patient's landlady 1
The patient's aunt 2
Total spokesmen 47
Total patients for whom data were available 51
Explanation for omitted households.--From the seventy-six house-
holds that comprise the community, someone from seventy-two households
was seen. Only one of the four not seen was a refusal. She owns the
only store within the confines of The District. During a visit to her
store she asked for help to fill out a mailed health questionnaire. It
was given, but when a later attempt was made to interview her it was met
with the response'that she had already answered enough questions. The
second household not seen was mentioned above as just never having
anyone at home. The third household, if it could be considered a house-
hold, consisted of two teenage orphans who were living and working on
the farm of a local white landowner under, what was reported to be, com-
fortable circumstances. It did not seem reasonable to jeopardize their
stable arrangement by asking permission of their employer to talk with
them, lest fears might be aroused in his mind about authorities coming
to question the legality of his arrangement with the boys. The last
household not seen was missed. Its existence was not discovered until
long after data collection was completed. Three attempts to find the
resident were the most that could be spared him since he lived an
additional fifteen miles out of Meccaville,
Method Developed for Comparison of
Paucity of Patients' Verbal Behavior
A possibility that had been anticipated was that The District
residents' limited skill with language would cause communication prob-
lems in the doctor-patient transaction. A possibility only dimly
anticipated was the problems this would cause the researcher in
obtaining sufficient information about the transaction. At the same
time, it produced the awkward position of achieving the objective of
demonstrating an imbalance in the doctor-patient transaction simply by
refraining from asking the dozens of questions that came to mind.
This problem resembled that of Schatzman and Strauss (1966) who
talk about the difficulties they experienced in their analysis of 340
interviews taken following a tornado disaster. They found that lower-
class interviewees often confronted the interviewer with fragments of a
narrative which the interviewer had to piece together with a barrage of
"who?" "when?" and "where?"
This dilemma had still another facet. Having sometimes read the
medical record before talking with the patient, the researcher often
knew that more had transpired in the doctor-patient transaction than the
patient was recalling. The temptation to probe was often strong. The
obligation to refrain from any questions that might suggest a corrobora-
tive source of information was strong enough, however, to resist the
Questions Asked about the Clinic Visit
Essentially the patient's version of the transaction was
obtained by asking seven questions. The questions were:
1. What was wrong? What made you go to the doctor?
2. What did you tell him?
3. Did he seem to understand you?
4. Did you understand him?
5. What did he say? What was wrong?
6. What did he tell you to do?
7. Do you remember how often you had to take it (the medicine)?
Questions three and four were usually interpreted as criticism
of the doctor and elicited a prompt defense. The patient, fist on hip
and head nodding in punctuation with the words, would say, "He examined
me real good! He was real nice." This was the "halo" that prevented
examination of patients who might have felt that they had been rushed in
their interviews. No doubt, the halo was well earned. Sometimes two or
three additional questions were asked if the picture of what had
happened still was not clear. The additional questions most often
1. What did the doctor say was wrong?
2. Did he give you any medicine at the clinic, or did you have
to go to the drugstore for medicine?
A Method for Making the Different
Before any statements could be made about the comparability of
the two versions of the doctor-patient transaction, the versions had to
be first cast into a form in which they could be compared. To this end,
a coding form was developed. The form permitted an item to be coded
into five different categories.
1. Items were considered matched if the medical record item and
the patient's item referred to the same topic and agreed upon
2. Items were considered contradictions if they pertained to the
same topic but were opposed on details that would have led to
behavior contrary to the intended behavior.
3. Items were considered ambiguities if they pertained to the
same topic but details were such that they could be construed
to either match or contradict depending upon the whim of a
4. and 5. Items were considered unmatched if either participant
offered an item that had no corresponding item in the dis-
course of the other. These were coded patient's unmatched
(PUM) and doctor's unmatched (DUM). The researcher realizes
that the abbreviations sound like a vaudeville dance team,
but alternatives that were considered were equally bad or
caused semantic problems.
The Coding of an Actual Patient as
an Example of the Method
Presentation of the data from an actual patient's tape and
medical record may make the procedure clearer.
Step 1: Transfer patient's version from the tape to notes.--
Patient's Version--Patient #4. "I had the virus last week. I felt
terrible. My stomach was upset. I didn't have no energy." (Note:
Patient was obviously six or seven months pregnant. She also mentioned
the pregnancy elsewhere in the interview.) "He said it was a virus,
just like I thought it was. There wasn't nothing to do except drink a
lot of fluids and not eat till I felt better."
Step 2: Extract notes from the medical record.--Medical Record
Version--Patient #4. 6/7/69. Seven months gestation, being followed
at Obstetric Clinic. Presents today with a history of
malaise for one day with one episode of vomiting and one episode of
diarrhea. No one else in the family or neighborhood has similar symp-
Impression: 1) Viral Gastritis.
Disposition: 1) No food by mouth for 12 hours. Clear liquids for
12 hours, then normal diet.
2) Aspirin 6.5 milligrams by mouth every four hours as
needed for discomfort or pain.
3) Return to clinic as necessary if nausea and vomiting or
The notes taken from the medical record included: (1) only those items
that could be gained through conversation with, or questions to the
patient; (2) the diagnosis; (3) treatment recommended, including
requests to return or referrals elsewhere.
Step 3: The two versions sorted and arranged side by side.--
Medical Record Version
7 months gestation
Malaise for 1 day
Vomiting, one episode
1) No food by mouth for
12 hours. Clear liquids
for 12 hours, then normal
2) Aspirin 6.5 milligrams by
mouth every four hours as
needed for pain or
Is pregnant, approximately six
or seven months
Stomach was upset
1) Not eat till I felt better.
2) Drink a lot of fluids.
Return to clinic as necessary
if nausea or vomiting or
Step 4: The two versions coded onto the coding form.--The
reader may find the coding form easier to follow if he glances at the
general and specific directions for coders which were too lengthy for
inclusion here but are included in Appendix A.
Dr. DUM Match PUM Pt.
Al Family history of this
or relevant illnesses)
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXX
Preg. x M x A2 Factors in patient's own
history relevant to his
present illness, for example
is pregnant or diabetic
A3 Treatment by doctors)
previously for the present
illness or condition
A4 Previous occurrence(s)
of this illness that were
Coping Behavior Pertaining
to the Present Illness
Dr. DUM Match PUM Pt.
Bl Remained at home and/or
Dr. DUM Match PUM Pt.
B2 Went to a physician
(other than the one he is
dealing with in this record)
or home remedies
Contrary Behavior Pertaining to This
Illness or to Conditions Diagnosed
Prior to the Present Episode
Dr. DUM Match PUM Pt.
Cl Did not return for
_treatment, x-rays, lab
tests, appointment with
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXX
___________ C2 Did not take medication
________ previously prescribed for
C3 Did not follow diet,
that is, weight reduction,
Dr. DUM Match PUM Pt.
Malaise* x M x DI Presenting symptoms (do
Malaise* x M x not record again if already
Vomit x M x recorded under history)
Diarrhea x x
*Malaise is coded twice because it is a medical term that covers
a variety of vague symptoms which the patient might take three or four
descriptive terms to convey. (See Appendix A, specific coding
instructions section D.)
Dr. DUM Match PUM Pt.
D2 Absence of symptoms,
that is, patient does not
have chills, or G.I. upset,
or patient says, "My nose
isn't running like it
X XXXXXXXXXXXXXXXXXXXX XXxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXX
D3 Symptom elaboration:
details about duration, for
example, has had for 3 days,
10 years. . .
D4 Progress of symptoms
this episode, for example,
gradual increase . .
apparent disappearance and
reoccurrence on and
off . etc.
D5 Symptom circumstance,
that is, ". . appears
XXXXXXXXX XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxxxxxxx XXXX
D6 Symptom location, that
is, patient makes an effort
to pin-point, for example,
pain over the left eye,
laceration mid-thigh, hurts
on inside of elbow, etc.
D7 Type of pain--radiating,
dull, throbbing, sharp.
D8 Amount of exudate,
excretion or drainage, for
example, "must have bled a
quart' Drained so long
. had to change the band-
age three times," etc.
Dr. DUM Match PUM Pt.
D9 Conditions apparent or
known to the patient, for
example, swelling, itching,
a rash, flushing, restless-
ness, hunger, etc.
XXXXXXXXXXXXXXXXXXXXXXXXXx XXXXXXXXXXXXX XXXXXxXXX XXXXXXXXX XxXXXxxX
D10 Patient makes an
unmatchable statement, for
example, "got to feeling'
bad, got to hurtin' so."
Dr. DUM Match PUM Pt.
El Record mentions one
XXXXXXXX XXXXXXXX XXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXX
E2 Record mentions at least
one diagnosis with compli-
cations, or it mentions
E3 Patient says, "He didn't
XXXX,XXXXXXX XXXXX XXXX XXXXXXXXX X XXX XXX say."_ Record
Treatment--Medicine and Tn-Clinic
Dr. DUM Match PUM Pt.
Fl A shot; a bandage;
stitches (sutures); an
enema; wound cleaning;
foreign body removal, etc.
Note: Each of categories F2, F3, F4 becomes more specific than
the previous category. Check only one of categories F2, F3, or F4
depending upon the level at which the patient is specific.
F2 A prescription or medi-
cation was Riven.
Dr. DUM Match PUM Pt.
F3 The patient can specify
that the medicine was
liquid, pills, ointment,
F4 The patient can specify
the specific dosage.
F5 Patient says, "He didn't
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxx give me anything."
Record mentions no medi-
Dr. DUM Match PUM Pt.
No food x M x G1 Bedrest; over the
12 hours x A a lot" x counter medicine such as
Fluids x M x aspirin, or liniment; plenty
Aspirin x x of fluids; stop solid foods
or stop baby's formula, etc.
*The patient said "a lot of water." The coding choices are:
(1) to ignore the comment and score a DUM;
(2) to equate 12 hours of liquids with "a lot" and score a
(3) to decide that it is not possible to determine whether
the two phrases do or do not have the same meaning and
therefore score an ambiguity.
Dr. DUM Match PUM Pt.
HI Patient told to return
PRN (as need be)
xxxxxxxxxxxxxxxxxxxxxxxxxxxxx- xxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXX XXXXXXXXXXXXXXXXXXXXXXXX
H2 Patient told to return
for lab tests, further
H3 Patient told to return
on a specific date for check
in -- days
Dr. DUM Match PUM Pt.
H4 Patient told to phone in
a progress report.
H5 Patient comments that he
doesn't intend to return.
TOTALS 10 7M IA 8
History 1 IM 1
Symptoms 4 1 3M 3
Diagnosis 1 iM 1
Clinic 4 1 2M 1A 3
Follow-Up 0 0 0
Reasons for procedure.--The general directions for coders were
intended to explain the general procedure and its sequence. The
specific instructions to coders were intended to explain each category
on the coding form and the kinds of items to be coded into that cate-
gory. The possibility that items might be construed as fitting into
more than one category was anticipated and an attempt was made to
develop rational reasons for fitting the item into one or another cate-
gory. The history section of the coding form is presented first even
though the symptoms section is used to a far greater extent because the
reverse position led coders into coding history under symptoms or
forced them to flip ahead to the history section since it is generally
presented first in the narrative sequence of the patient, if it is going
to be presented at all.
The precision of the doctor's approach to language created some
difficulties. For example, if the doctor said that the patient had a
periumbilical pain it was simply recorded under presenting symptoms;
however, if the patient commented that he had a pain "around his navel"
it was recorded as an attempt to specify the pain's location. (See
specific coding instructions section D6.) A similar problem was touched
on earlier in this chapter. If the doctor used an abstract term such as
malaise, which covers a variety of symptoms, the patient needed several
concrete terms to convey the same information. Neither of these kinds
of incidents happened more than once or twice but the possibility of
their happening forced the development of a rationale for coding. The
rationale was to weight every effort of the patient to be exact. It was
hoped this would offset to some extent the weighting built into the
Methods for circumventing
To cope with the dilemma of the patient's brevity, any infor-
mation he might have given elsewhere in the interview with the
researcher was included in coding his version of the interview. The
reasoning was that the interest was not in whether he could neatly
answer the researcher's questions but in whether he came away from the
doctor-patient transaction informed. Patients often presented infor-
mation while they were responding to the seventeen-symptom list. Having
taped the interview proved invaluable in this respect. The coding form
was deliberately designed to give greater weight to the areas about
which the patient was likely to know the most, that is, his history and
his symptoms. These are the areas in which the information flow is pre-
sumably from the patient to the doctor, if one can assume that infor-
mation is unidirectional at given moments in the transaction. Con-
versely the information flow presumably would be from doctor to patient
during diagnosis, treatment, and follow-up.
Obstacles presented by
the diagnosis category
The diagnosis section of the coding form was kept small for two
reasons, first because the patient was least likely to remember details
in this area and, second, it presents difficult coding problems. The
coding problems stemmed from the obstacles to the development of
mutually exclusive categories. For example, a record might list
separately a patient's heart condition and his swollen ankles while
another record might list the heart condition and add "with swelling of
the ankles." This makes it appear as if they vary in importance, one
being considered a separate diagnosis and the other a contributing symp-
tom when in reality they probably represent different stages in the
writer's thinking. At one point he is likely to think of the swollen
ankles as a contributing symptom that helps him to make a diagnosis, and
at another a separate condition that will need medication. The range of
possibilities was too great to permit simple coding rules to be written.
The present diagnosis section was developed by trial and error methods
using a sample of diagnoses taken from other records at the clinic.
Exclusion of physical
The presentation of the medical record version for Patient #4
indicated that notes from records included only information that could
have been gained through conversation or questions. This was intended
to exclude findings from physical examinations. The only exception to
this was if the patient had said, "I had an earache," the record was not
likely to repeat "The patient said he had an earache." It was more
likely to have said something like "scarred tympanic membranes," a fact
that could only have been discovered through examination. In this type
of instance, an arbitrary assumption had to be made that the patient's
ears were examined in response to the patient's complaint rather than as
a part of a routine examination.
The use of an item of
information only once
An item of information was not counted or recorded more than
once on the coding form except where it would mean leaving an item
unmatched when it had in fact been acknowledged by the other partici-
pant. Successive revisions eliminated this possibility as much as
Six Eliminations from the Coding
Ultimately six transactions had to be eliminated from the coding
because they could not be coded. Either information was lacking, or was
so contradictory that reconciliation was impossible.
Because the coded material to be treated statistically was so
dependent upon the accuracy of the coders, a search of the literature
was made to find a reliable method of computing reliability. The yield
was sparse, but a method by Guetzkow was uncovered (1950:47-58). His
method provides a measure of the relationship between the obtained
agreement and theoretical agreement; and between theoretical agreement
of coders and theoretical correctness of classification. See Appendix B
for formula and computation.
Two coders coded all of the material. A third coder coded small
segments of material to test the intelligibility of the coding rules,
but her assistance was not used to compute reliability. The sta-
tistical comparisons on the doctor-patient transaction were made only on
those items upon which both coders agreed. All other items were elimi-
Small samples of the material were computed for reliability
while the form was being revised. The increases in reliability were not
dramatic from the revisions; therefore they were recomputed as a part of
the overall reliability for the whole sample. The form revisions,
instead of increasing reliability, appreciably decreased the time
necessary to code a transaction.
Objectives and Communication Overview
Postponement of Hypotheses and
Restatement of Objectives
Formal hypotheses will not be stated until the theoretical
assumptions underlying this research have been presented. This chapter
will attempt to bring together relevant positions from communication
literature. The chapter that follows will attempt to muster views from
sociological theory. Until that task is completed, the researcher will
simply present, as a reminder, the overall objectives of this research,
which were: (1) to determine whether a perceived imbalance in the infor-
mational transaction between patients and doctors was real or apparent;
and (2) to explore a need for follow-up procedures in the routine
practice of general medicine.
Brief Overview of Communication
Communication encompasses, intrudes upon, or complicates most
disciplines. For this reason, perhaps, its literature is widely dis-
persed. Communication and Culture, edited by Alfred Smith (1966) under-
takes to bring together some of the scatter. He believes that there are
three major theoretical approaches, any or all of which can be used to
look at the three major dimensions of communication. The three theo-
retical approaches are: the mathematical, within which Smith includes
cybernetics and information theory; the linguistic- anthropological; and
the social psychological. The dimensions of the field include syn-
tactics, semantics, and pragmatics. To provide a brief glimpse of the
scope of communication before trying to fit the interests of this dis-
sertation within the field, the researcher will skim over some of the
points which Smith covers in the succinct introduction to his book.
Action and reaction.--Language is behavior. Speaking is action
and understanding is reaction. Interaction takes place not only through
words but also through spatial relations, as when a couple who are
attracted to each other can make their way furtively through the maze of
a cocktail party toward one another. Interaction also takes place
through temporal relations, as when an unwelcome salesman is kept
waiting in an outer office. Communication involves a variety of methods
of reciprocating and mediating meaning to sustain a communal dialogue.
Different concerns of the disciplines associated.--The mathe-
matician is concerned with electronic signals with scant regard for
meaning. The linguistic anthropologist concerns himself with human sig-
nals encompassing a world-wide range of data. The social psychologist
is generally concerned with human communication in his own culture and
in his own time.
Emphasis on syntactics.--Most empirical studies of human com-
munication have involved syntactics which studies the relationship of
signs to other signs. The arrangement of the sentence "Nancy kisses the
boys," differs from the same words in the sentence "The boys kiss
Nancy." In the latter, the position of the words and the form of the
verb have been altered; that is, the relationship of signs to signs has
Mathematicians and linguistic anthropologists are concerned with
syntactics. Mathematicians may find that signs are redundant in being
too predictable in their relationships with one another, or entropic in
being too unpredictable in their relationships with each other. A lin-
guistic anthropologist may find redundancy built into a language in
which adjectives must agree with nouns.
Relationship between syntactics and semantics.--Meaning is
largely dependent upon structure. Hence, there is a logical development
between syntactics and semantics. Beyond structural meaning, there is
assigned meaning, the relationship between a sign and its object. There
is a relationship between the name, Nancy, and the object, the girl who
is called Nancy.
Mathematicians generally are not concerned with the meanings of
messages, only with their transmission. Meaning for them is simply a
part of the process of encoding and decoding. Coding is a form of
behavior that is learned and shared by the members of a communicating
group. Meaning is a product of coding.
The reactions people have to signsare pragmatics. This follows
from the way they decode signs. How do policemen react to being called
"Pigs," or "Fuzz"? Do people feel more positive if they are told they
are "suffering from parasites," than if they are told they have "got
worms"? (Smith, 1966:1-10)?
The Idea of Coding
From the above overview of the field of communication, the
researcher believes that the most useful concept for her purposes is the
idea of coding. In the introduction to a section of Smith's book that
he calls "Codes and Culture," the general meaning of coding is sum-
marized briefly as follows:
Coding is the process of translating between meanings and signals,
and Bateson shows that it involves a psychological perception of
configuration, the gestalt of the situation-behavior. Coding is
meaning making and the meanings are configurational. Coding is
also decision making, choosing between a figure and ground in a
gestalt, and these choices involve evaluations and values (Smith,
Develop Different Codes
More specific to the researcher's particular purpose is a paper
by Basil Bernstein called "Elaborated and Restricted Codes: Their
Social Origins and Some Consequences" (Smith, 1966:427-41). Bernstein's
practical interest is the differential response of children from dif-
ferent social classes to educational opportunities. He suggests that
the linguistic codes of different speech systems may be generated by
different social structures through the specific principles of choice
regulating the selections a child makes from the total number of options
offered by a given language. Those choices, made from the total pos-
sible choices, strengthen progressively. In time those choices estab-
lish the "planning procedures" an individual uses in readying his own
speech and in orienting him to the speech of others. As a child learns
specific codes regulating his verbal acts, he learns the requirements of
his social structure. Every time the child speaks or listens, the
social structure of which he is a part receives reinforcement, and con-
strains his identity. The critical choices, the preferred alternatives,
become fixed through time and, in turn, regulate orientation.
Elaborated code environment
The environment within which an elaborated code user learns the
code is one which permits, perhaps even requires, a flexibility in the
speech system that allows it to deal with novelty. The structure of
speech is such that an almost infinite set of theoretical arrangements
can be made to transmit unique experiences. For example, if an adver-
tiser wanted to coin a new word for femininity he could call it "she-
ness." He could feel relatively safe that his audience knowing the
separate meanings of "she" and "-ness" could comprehend the two meanings
joined as one. The elaborated code allows the user to confront and par-
ticipate in situations unanticipated by, perhaps even unknown to, his
earliest socialization environment.
Distinctions among restricted code environments.--Bernstein sub-
divides restricted codes into "restricted codes (lexicon prediction)"
and "restricted codes (high structural prediction)." He makes further
distinction between verbal and extraverbal components of messages. The
verbal component refers only to the transmission of words. The extra-
verbal component refers to what other authors call paralinguistics; that
is, qualities of the voice, facial set, and physical movements.
Bernstein indicates that three kinds of cases fall under the
heading of restricted code with lexicon prediction. The first variant
involves messages in both verbal and nonverbal channels which are
maximally redundant. This variant is most likely to be found where
social relations are rigidly prescribed, as in the military, in
religions, and in legal transactions. Departures from maximal redun-
dancy are likely to be regarded as profane. For the purposes of this
research, this variation will be referred to as an "occupational code."
The second variant involves maximal redundancy in the verbal
channel with less redundancy in the extraverbal channel. An example of
this is a mother telling her child a story they both know by heart--"And
little Red Riding Hood knocked on her grandmother's door," ceremonial
pause, "and then what happened?" ceremonial question. The verbal
options are limited. The only uniqueness the mother can add is through
the extraverbal channels.
The third variant involves social relationships where partici-
pants have low predictability about each other's discrete intent. The
verbal components come "prepackaged." Extraverbal channels carry the
interpersonal aspects solely. The development of the relationship
depends upon the decoding of the extraverbal messages. The example the
author uses is a boy at a dance who has just asked a girl, whom he has
never met before, to dance. The language exchanged is highly predict-
able as the two grope for cues to one another's intent.
Bernstein's second category of "restricted code with high struc-
tural prediction is likely to arise in a context of assumptions the
speakers hold in common. The structure of speech can be simplified and
the vocabulary range narrowed to a degree that permits taking the intent
of the others for granted. This diminished verbal elaboration and
reduced lexicon range is likely to come into being in closed groups such
as prisons, combat units, peer groups, and couples married for a length
of time. For the purposes of this research, this category will be
referred to as a "gemeinschaft restricted code."
Differences in the socialization of elaborated code users as
distinguished from restricted code users.--The flexibility of the
elaborated code permits the user to achieve role distance and manipulate
himself, as well as others and the situation, verbally. In Parson's
terms ego can become alter, or in Mead's terms ego can become gener-
alized other through elaborated code manipulation.
In contrast the individual socialized in an environment using a
restricted code learns to use language as a more finite set of possi-
bilities limited by the needs and activities of the group in which he is
imbedded. Having a more or less stable status within the group there is
less need for the expression of unique experience, or the achievement of
role distance, or verbal versatility. Maximal redundancy is built into
the code by the assumptions shared by the code users. Those assumptions
may have been internalized by living all one's life within the group or
by having been trained intensively within the group. To the uninitiated
who do not share the assumptions of the group, the code may have no
redundancy at all.
The Relevance of Code to
the Concept of Social Class
The usual explanation that is evoked to explain the communi-
cation difficulties between middle-class professionals and lower-class
laymen is a difference in class. This hardly explains what aspect of
the class difference causes the problem; and it avoids the question of
why a middle-class layman does not always come away well informed from
his dealings with a middle-class professional.
A brief look at some medical research may help to delineate the
aspect of class which creates the communication failure. In a study
done by Pratt, Seligmann, and Reader (1957), 214 patients were given a
multiple choice test about some routine facts concerning common
diseases. The patients were able to answer correctly about 55 per cent
of the questions. Eighty-nine doctors were given the same test and
asked how much of the information they thought patients ought to know.
Almost three quarters of the doctors thought patients ought to know at
least 82 per cent of the information.
A breakdown by educational level revealed that those with less
than an eighth grade education were able to correctly answer only one-
third of the questions while those with a high school education could
answer two-thirds of the questions correctly. Even two-thirds was below
the level the doctors felt the patient ought to know.
The authors found through observation of the doctor-patient
transactions that the patients in their sample interacted with the
physicians at a very low level. Some did not ask a single question.
However, with physicians who did offer information, the patients were
slightly more likely to ask questions.
The physicians were asked to estimate the proportion of the
clinic patient population who might know the thirty-six facts covered in
the questionnaire. The estimates consistently underestimated the know-
ledge level of the patients, low as it was. Those physicians who did
underestimate patient knowledge were less likely to discuss the
patient's illness with him than were the physicians who did not under-
estimate or who overestimated patient knowledge.
The apparent paradox uncovered by Pratt, Seligmann, and Reader
was that the patients who were deemed most in need of explanations were
least likely to get them. This observation was lent support through
intensive observation by the authors of fifty physician-patient
relationships. The dynamics were somewhat as follows:
when a doctor perceives a patient as poorly informed, he con-
siders the tremendous difficulties of translating his knowledge into
language the patient can understand, along with the dangers of
frightening the patient; and therefore avoids involving himself in
an elaborate discussion with the patient; the patient, in turn,
reacts dully to this limited information, either asking uninspired
questions or refraining from questioning the doctor at all, thus
reinforcing the doctor's view that the patient is ill equipped to
comprehend his problem, and further reinforcing the doctor's tend-
ency to skirt the problem. Lacking the guidance of the doctor, the
patient performs at a low level; hence the doctor rates his
capacities as even lower than they are (1958:226).
Returning to the relevance of code, one might suggest that the
physician may have an option of translating for a middle-class patient
from the restricted medical code to the elaborated code which he and the
layman probably share in common. The middle-class layman is likely to
have at least been socialized into elaborated code use during the edu-
cational process, if not at home. The physician may not have the option
to translate for a lower-class patient socialized in a "gemeinschaft-
type" restricted code. No matter how redundant the physician may sound
to his own ears, he may not be at all redundant to the lower-class
An effort to inform patients
In a study by Hugh-Jones et al. (see Ley and Spelman, 1967:31),
doctors made a special point to inform patients. Despite their efforts,
39 per cent remained dissatisfied with the information given them, and
20 per cent had an incorrect idea about their diagnosis. One man with a
heart condition thought he had tuberculosis. Studies by Spelman, Ley,
and Jones found no relationship between patient satisfaction, the knowl-
edge patients had, and the information that they had been given (Ley
and Spelman, 1967:32-35).
Ley and Spelman suggest that patient dissatisfaction may be due
to the fact that the patient did not understand the information given to
him. They point out that knowledge does not always include compre-
hension. The' cite as an example a study done by Roth et al. (1962) in
which only three out of thirty ulcer patients knew that acid was
secreted by the stomach. Over half believed that it was ingested with
food that was eaten (1967:35).
What options does the non-
comprehending patient have?
Studies done by Roth and Eddy (1967), Goffman (1961), and
Braginsky (1969) indicate that chronic patients learn to "live in the
cracks," as Roth and Eddy describe it (see Roth and Eddy,
1967:Chapter 8). They find ways to compensate for their lack of power
and lack of information by intervening in their own treatment and by
The unilateral nature of the doctor-patient relationship being
described in this research pertains more to the occasional patient who
becomes ill and does not have the opportunity to learn the rituals and
some of the jargon that the chronic patient through repeated exposure
has learned to utilize. This is not to imply that the occasional
patient has no options.
He has the option to do nothing or to resort to other sources of
information such as television and his primary group's folk traditions.
Lyle Saunders cites a New Mexico woman who was a regular cardiac patient
at an Anglo clinic. In addition to the professional care that she
received, she treated herself, her family, and her neighbors from a
pharmacopoeia consisting of Anglo preparations, household remedies drawn
from both Anglo and Spanish folk traditions, and herbal preparations she
had learned from her Indian uncle (Jaco, 1958:189).
A study by Roth, although not focusing on patient options, fits
in with the reasoning above; i.e., where new information is lacking
old substitutes for information will prevail. He found that protective
devices for the control of contagion were most consistently used by
lower status employees in a tuberculosis hospital. He reasoned that
they were less likely to know that good evidence to support the efficacy
of many contagious controls is lacking (1958:229-34).
The absence of dissatisfied patients.--The implication that
middle-class patients are more likely to leave a doctor-patient trans-
action informed, comprehending and possibly satisfied, raises the
question of why the patients in this sample, on the whole, were satis-
fied despite their lower-class status.
There are several possible explanations. Possibly the 50 per
cent redundancy built into the structure of English, coupled with
-increasing exposure to television (see Silberman, 1970:31-41) may have
been enough to overcome coding difficulties. Another possibility is
suggested by Ley and Spelman (1967:35) who point out that patients have
to remember what they are told in order to remain satisfied. Among the
studies mentioned by Ley, Spelman, and Jones, the authors did a study in
which people were asked during their first week in the hospital if they
had been told what was wrong with them. They were asked the same
question a week later. Out of forty-three who had claimed that they
had been told, 28 per cent denied it a week later.
The authors imply that comprehension and information are
related. Comprehension and information in turn are related to satis-
faction. If this is so, then the patients in this sample, given their
class level and their satisfaction, are likely to have been informed
A third possible explanation as to why the patients in this
sample were satisfied is one this researcher and probably most
researchers would prefer not to entertain. It is made explicit in a
comment by Warren Weaver in which he said:
If Mr. Y says, "Do you understand me?" and Mr. X says, "Certainly
I do," this is not necessarily a certification that understanding
has been achieved. It may just be that Mr. X didn't understand
the question (Smith, 1966:16).
Any or all of these possibilities may have been operative,
thereby contributing to the patient's apparent satisfaction. None of
these possibilities rules out the value of the concept of coding dif-
ferences as an aspect of class that contributes to communication diffi-
culties between classes.
Communication Links with Sociology
Reality of Gestures
Expressed in Action
Just as in fencing the parry is an interpretation of the thrust
so, in the social act, the adjustive response of one organism to the
gesture of another is the interpretation of that gesture by that
organism--it is the meaning of the gesture.
At the level of self-consciousness such a gesture becomes a
symbol, a significant symbol. The interpretation of gestures is not
basically a process going on in a mind as such or one necessarily
involving a mind; it is external, overt, physical or physiological
process going on in the actual field of social experience
(G. H. Mead, 1962:78-79).
Sociology Ignores the Role of
Communication in Consensus
In an article which he called "The Search for a Social Theory of
Communication," Hugh Dalziel Duncan criticized American sociology for
its lack of interest in the process of communication among human beings.
He reminded his readers that the specific social end of communication is
consensus which is expressed in role performance that guarantees the
social order. That end is reached by establishing and maintaining knowl-
edge, beliefs, and attitudes. "To have" or "to have not" applies
equally as well to the acquisition and use of symbols as it does to
industry, or land, or money (1967:236-40).
Thomas Linked with NMed and the
1930's Linked with the Present
If one looks for literature under the label of communication,
Duncan is apparently justified in his caustic complaint about the lack
of concern on the part of American sociologists since the early thirties
when work was being done by Mead, Burke, and Sapir. (The latter is
variously categorized as a linguist, an anthropologist, and a sociolo-
gist.) Yet the time since the thirties has not been barren; communi-
cation links with the thirties are simply hidden under unexpected
labels. A line of thought that can b. traced to the more recent past
requires a shift in consideration from the work of Mead to that of
W. I. Thomas. A brief comparison of Mead and Thomas may make this seem
New objects from communication; responses give meaning to
gestures.--Mead has said:
(1) that the social process, through the communication which
it makes possible among the individuals implicated in it, is
responsible for the appearance of a whole set of new objects in
nature, which exist in relation to it (objects namely of "common
sense"); and (2) that the gestures of one organism and the adjustive
response of another organism to that gesture that exists between the
gesture as the beginning of the given act and the completion or
resultant of a given act, to which the gesture refers (1962:79).
Mead seems to be saying that two things happen from communi-
cation: a set of new objects arises as a result of the process; and the
gesture of the first organism is given meaning by the response of the
The interplay of the present and the pre-existent.--W. I. Thomas
Every concrete activity is the solution of a situation. The
situation involves three kinds of data: (1) the objective
conditions under which the individual or society has to act, that is
the totality of values--economic, social, religious, intellectual,
etc.--which at the given moment affect directly or indirectly the
conscious status of the individual of the group. (2) The pre-
existing attitudes of the individual or the group which at the given
moment have an actual influence upon his behaviour. (3) The defi-
nition of the situation, that is, the more or less clear conception
of the conditions and consciousness of the attitudes. And the defi-
nition of the situation is a necessary preliminary to any act of the
will, for in given conditions and with a given set of attitudes an
indefinite plurality of action is possible, and one definite action
can appear only if these conditions are selected, interpreted, and
combined in a determined way and if a certain systematization of
these attitudes is reached, so that one of them becomes predominant
and subordinates the others (Volkart, 1951:57).
Maad's focus differs from Thomas'.--Both Mead and Thomas seem to
suggest that a new condition arises as a result of the interaction and
that each participant influences the other. Their emphasis, however,
seems to be different. Mead focuses on the transaction itself while
Thomas focuses on the preconditions the participants bring with them
into the transaction and the resolution by the participants of the
interplay of existing objective conditions and their own pre-existing
Sherif Extends Mead and Thomas
The general approach presented by Sherif in 1935 and 1936 seems
to be an extension of Thomas' emphasis on preconditions as well as
Mead's and Thomas' concern with the resolution of the actual trans-
action. Sherif, with others, has continued over the years to develop
the line of thought which Shaw and Costanzo in Theories of Social
Psychology (1970:294-301) classify under the title "Social Judgment
External and internal factors are complements.--Sherif claims
that man structures situations that are important to him. This
structure includes: (1) internal factors of attitudes, emotions,
motives, past experience; and (2) external factors of objects, persons,
and events existing in his physical surroundings. Both external and
internal factors operate in a given situation at any given time. Any
given behavior can be understood only within the frame of reference
which is the interaction of the internal and external factors. Internal
and external factors are not additive in the sense of having cumulative
intensity. In general, the more intense the motive state, and the
greater the ambiguity of the stimulus structure, the greater will be the
influence of internal factors. Conversely, the less intense the motive
and the more structured the stimulus, the greater the influence of
The absence of an explicit standard or anchor leads to a less
stable scale of judgments. Some anchors within a total frame of
reference may be more influential than others. To discriminate or to
categorize involves making comparisons between alternatives. A
situation may force an individual, through lack of an external standard,
to use or create an internal standard to use as one of the alternatives
or to use as an anchor to assist in his comparisons. Evidence
supporting the development of internal standards has come from a number
of studies of autokinetic movement in which judgment of apparent move-
ment becomes stabilized (Shaw and Costanzo, 1970:297).
Ambiguity forces the use of pre-existing attitudes.--Sherif
seems to be making more specific the factors called for in W. I. Thomas'
definition of the situation, which involves a combination of the pre-
existing conditions the participants bring with them and the conditions
of the objective situation in which they participate. For this
research, it is suggested that the participants, the doctor and the
patient, bring into the medical interaction restricted language codes
which have been structured by the differing circumstances of their lives
prior to their interaction with one another. With these, they structure
the objective situation at hand. The more ambiguous the situation, the
more internal standards play a part in the outcomes and the more
dependence the participants place on pre-existing norms and attitudes.
Ambiguity Encourages Use of
Internal Standards as Anchorage
Over the years, Sherif's work has moved from Thomas' definition
of the situation toward Mead's meaning--making of the actual inter-
change. This later work seems to the researcher to provide additional
explanation of the differential participation of patients and doctors
in their communication exchanges. Sherif's work builds upon recog-
nition of individual differences in acceptance or tolerance of positions
other than one's own, and individual differences in the importance of
issues to specific individuals. Observation of these differences has
led to the development of the concepts of latitudes of acceptance,
rejection, and noncommitment. When an individual is forced by the lack
of an objective standard to use his own position as an anchor, he
becomes involved and hence selective about the items he is willing to
accept. Only items close to his position are absorbed into his latitude
of acceptance. The threshold of acceptance which items must pass
becomes high. The range of items that will be assimilated becomes
inversely proportional to the degree of involvement. Conversely, the
rejection threshold is lowered and the range of items that are
unacceptable increases in proportion to the degree of involvement.
Patients lack a standard to assess symptoms or advice.--Relating
this to a doctor-patient exchange, it can be posited that a patient
comes into an exchange without an objective standard of health-related
items other than that which his previous experience, the experience of
his significant others, and his socialization through schooling and the
mass media may have provided. Therefore, the likelihood exists that the
number of symptoms offered in evidence will be limited by his past
experience, as will the amount of advice he will accept from the
physician. The more narrow his previous experience and socialization,
the more narrow the range of offered symptoms and accepted advice he is
likely to accept. The breadth or narrowness of the range is likely to
be class-related,with the lower classes being more likely to have a
narrower range. Conversely, the physician enters an exchange with an
objective standard of health-related items by reason of his professional
training. Therefore he has a low degree of involvement and a larger
range of acceptable items.
Link with the 1930's
Another link in the line of thought traceable to the 1930's can
be found in an article by Scheff, which he calls "Toward a Sociological
Theory of Consensus" (1967:32-45). Scheff posits the existence of two
traditional views of consensus. The first views consensus as common-
sense agreement. The second can be found in Dewey and Mead who stressed
the coorientation of individuals in a group, rather than the orientation
of individual members of a group.
Reciprocal recognition.--Scheff relates his own work to
Schelling's concept of tacit coordination (1967:35). He quotes an
example from Schelling which demonstrates the possibility of coordi-
nation, or coorientation, without direct communication. The example
involves the Yalu River as a boundary in the Korean War. Each side of
the conflict was aware of the other side's recognition of the boundary,
and each side realized that their own awareness was understood by the
other side. The first level of coorientation is "we recognize that they
recognize it." The second level of coorientation is "we recognize that
they recognize that we recognize," and so on.
. The potentially endless mirror reflections of each other's
recognition is felt as something utterly final. From this formu-
lation it follows that each actor feels the presence of the col-
lective representation with a sense of exteriority and constraint,
even if he as an individual is wholeheartedly dedicated or opposed
to the representation.
A process similar to the mirroring above is suggested by
Schutz's concept of "the reciprocity of perspectives." The simi-
larity is clearly seen in Garfinkel's explication of the concept of
"background of understanding" (1967:35-36).
The comparison made in this study, of the patient's description
of his encounter with the doctor and the record's version of the same
encounter, could be described using the above terminology as zero-order
coorientation. The questions asked of the patient, "Did he (the doctor)
understand you?" and "Did you understand him?" could be described as
first-order and zero-order orientation, respectively. The design did
not permit asking the other half of the dyad, the doctor, for his
Similar to the notion of coorientation, Shaw and Costanzo, in
the same chapter in which they discuss Sherif's work, consider
Festinger's "Social Comparison Theory" (1967:279-85). Festinger's early
work considered the effects of social communication on opinion change in
social groups. Later, he extended the theory to include the appraisal
of abilities and the evaluation of opinions. The theory holds that
social-influence processes and certain kinds of competitive behavior
derive directly from: (1) a need for self-evaluation; and (2) the
necessity for this evaluation to be based on comparisons with other per-
sons. The theory is so well coordinated that Shaw and Costanzo are able
to lay it out in numbered hypotheses, derivations, and corollaries.
Below are only a few of the hypotheses and derivations relevant for the
. the tendency to compare oneself with another decreases as
the discrepancy between one's own ability and that of the other
person increases. . .
Given a choice, a person will choose someone close to his
own opinion or ability for comparison. . .
. a discrepancy in a group will lead to action designed to
reduce the discrepancy.
. pressure toward uniformity will increase with an increase
in the importance of an opinion or ability, or with an increase
in the relevance of an opinion or ability to immediate behavior
Trend toward uniformity.--The import of the above seems to the
researcher to be that the tendency to compare oneself with those who are
similar, combined with the pressure of the group to reduce dis-
crepancies, creates a trend toward uniformity or homogeneity. If one
agrees that the patient's and the doctor's groups are important frames
of reference for their respective members, then it becomes reasonable
to assume that the patient's geographic isolation and the doctor's occu-
pational isolation will permit each group's coding usage to become
more uniform. There seems to be support for Sherif's position on the
range of acceptable items that can be expected. Sherif suggested that
the range of acceptable items becomes narrowed as situations become more
ambiguous. The standards of other groups are less well known and there-
fore more ambiguous than one's own group standards.
Group pressure.--Pursuing the idea of the existence of pressure
toward conformity, Volkart, in his book about the contributions of
W. I. Thomas (1951:8-9), comments about the influence of the group upon
the individual. He says:
Of course, only the individual can ever define his own situations
and behave in them accordingly, but the effort of the group is to
have him define situations in its own terms so the behavior will
conform to social norms. . In most cases the group succeeds.
The individual does define most situations, most of the time, in a
way which coincides with group norms. . In this connection it
should be noted that even the most extreme radical in any society
is radical in only a relatively few situations; in the rest he is
If one thinks about language in the above light, then possi-
bilities for rebellion are still narrower. The most radical rebel can
only violate a limited number of the norms of his group's language.
Beyond that limit he becomes unintelligible. If he chooses to use words
the group considers unacceptable under certain conditions, he has to use
words that are already part of the group's language, for if he invents
new words the group is not likely to recognize his insult.
Theory of Correspondent Inferences
The theoretical position that most closely relates to the
interest which prompted this study also appears in the same chapter in
which Shaw and Costanzo discuss Sherif and Festinger. They label this
position the "Theory of Correspondent Inferences." The theory was
developed by Jones and Davis as an outgrowth of earlier work done by
It assumes that a perceiver observes the overt action of
another person, following which he makes certain decisions about the
person's knowledge and ability. These decisions, in turn, permit him to
make inferences about the person's intentions. If the observed person
has no knowledge of the consequences of his own behavior, or lacks the
requisite skill to perform adequately, in the opinion of the observer,
intention cannot be inferred. The intentional significance of an action
derives from a consideration of the alternatives open to the actor. If
knowledge of consequences and ability to produce them are evident,
intentions are inferred which can in turn be used to infer the stable
attributes that Jones and Davis call "dispositions."
An example given by Shaw and Costanzo is that of A and B working
together. If A is observed ordering and criticizing B's work, the
inference can be made that A is domineering. But the inference can be
made only in situations where A is free to regulate his behavior. If he
had been ordered to play a directive leadership role then his behavior
could not have been viewed as evidence of personal qualities or, in
Jones and Davis' terminology, inferences about dominance would have been
Additional generators for inferences.--Other variables affect
the perceiver's inferences about the actor. One of these, Jones and
Davis label hedonic relevance. It has two levels of involvement. An
action is relevant if it either promotes or interferes with the per-
ceiver's goal. An action is personalistic if the perceiver believes
himself to be the intended target of the action. Correspondence and
relevance generally increase together.
A striking conclusion to emerge from several studies is that
only negative behavior provides unambiguous information about the true
nature of the individual's intentions, since presumably everyone is
expected to perform his appropriate role.
Efficiency, anxiety, and levels of inference.--In order to pur-
sue the "correspondence" between this theory and the interest which
prompted this study, an impression gathered from earlier working
experience with patients will be repeated here. The impression was that
patients often emerged from interviews with a doctor with a sense of
unease 'about whether they had told the doctor all of their critical
symptoms and, if they had not, whether the omission would affect the
treatment they had been told to follow. Further, they were unsure if
they remembered the details of the treatment they were to follow. It
was suspected that this post-interview anxiety might be related to a
facet of the current medical scene, that is, its efficiency orientation
(1) uses an assembly line of cubicle examining rooms which
make the patient very much aware that he is one of many
who are impinging upon the doctor's time;
(2) uses an intermediary by having a nurse or clerk collect
information prior to the doctor's involvement with the
(3) does not allot a segment of time for translation from
medical discourse to patient discourse.
Relating this to Jones and Davis' terms, it was the
researcher's impression that the behavior of the doctor and his team
led the patient to make an inference about the intention of the doctor
to rush the patient out of his office, without sufficient time being
allotted to assessment of his problem. This thinking had not led up to
the next level implied by Jones and Davis' theory; that is, that the
patient having made a decision about the doctor's intention would then
go on and make inference about the doctor's personal dispositions. The
inference about the doctor's intention would be that he was un-
interested in the patient's welfare. This, in turn, would permit an
inference about the doctor's personal attributes; that is, he was not
nice. The halo effect apparently short-circuited this sequence of
patients' inferences and forced abandonment of the intention to examine
the problem of the "rushed" patient. In answer to the questions
(1) "Did the doctor give you enough time to tell him everything you
wanted to tell him?" (2) "Did he seem to understand?" and (3) "Did you
understand him?" the patients replied, "He examined me real good." The
doctor's thorough examination was the behavior about which the patients
had made inferences. From those inferences, they went on to the next
level of inference; that is, the stable personality attributes of the
doctor by saying, "He was real nice."
W. I. Thomas' "situation" and "definition of the situation" are
closely related to Sherif's work, which involves the structuring of
important situations. Structuring varies with the intensity of moti-
vation, ambiguity, closeness to the person's own position, and the
degree of involvement. The assumptions derived from W. I. Thomas'
theoretical position and Sherif's theory and research lend support to
the contention of this study that doctors and patients bring into the
situation differing frames of reference from their previous language
experiences. These frames of reference structure the exchange that
Scheff's work in levels of coorientation suggests a different
design that this study might have taken. Festinger's "Social Comparison
Theory" lends support to an assumption that it is inevitable that the
patient population and doctor population of this study will tend to
become more homogeneous in their behaviors, including their language
behaviors, by reason of the tendency to compare oneself with those who
are similar. Volkart pointed out how limited radical behavior is. The
potential for radical behavior within language norms is limited by the
desire to be understood.
Jones and Davis, building upon earlier work done by Heider, have
developed the "Theory of Correspondent Inferences." This is based on
the notion that observation permits an observer to make decisions about
the ability and knowledge of the observed individual and, from these,
to make inferences about his intentions. Where ability and knowledge of
the consequences are evident, intentions are inferred which are used in
turn to infer personal stable attributes.
Jones and Davis' theoretical approach was considered in relation
to current medical practice. A trend in medical practice involves a
rapid turnover of patients, the use of intermediaries between the
patient and the doctor, and a minimum of time allotted to each patient.
It was suggested that this trend might leave some patients with a sense
of unease and lead to their making an inference that the doctor had
failed to allow sufficient time for thorough assessment of their
problem. Having made this inference Jones and Davis' theory suggests
that the inference may be carried one step further. From the inference
that the doctor is disinterested in his patients' welfare, since he
fails to allot them sufficient time, the next level of inference con-
siders his stable attributes, i.e., he is a good or bad person. The
patients in the present research made inferences from the behavior of
the student-physicians which led them to the inference that the student-
physicians were "nice people."
THE PATIENT'S COMMUNITY
Group norms make possible communication among its members. People
can act without any common body of norms but they cannot communi-
cate in the sense of sharing meaning through their interaction. A
cat and a canary can interact and so can a mother and her newborn
child. . The norms of a group are equivalent to the filtering
boundary of any system. The way in which members' roles are
articulated at any point in time is equivalent to the state of any
social system (Berrien, 1968:113-16).
Group norms do not just happen. They involve behaviors that are
repeated often enough so that they come to have an air of inevitability
about them. They become part of a pattern of behavior that, once begun,
stimulates its own completion. In one sense this patterning is similar
to Mead's idea that the meaning of a gesture is in the behavior of the
organism which perceives it. Group norms whether they be language
norms, courtesy norms, or economic norms become in time interlocking,
interacting, and systematic.
This chapter moves from the specific normative behavior of
coding and coorientation to the more general normative behavior of a
community. The data have been arbitrarily divided into two rough cate-
gories which seemed to correspond without too much laboring with
W. I. Thomas' definition of the situation.
The first category Thomas might have described as the pre-
existing situation'. Within it are included age; education; occupation;
kinship and family patterns. The second category Thomas might have
considered to be objective conditions. Within it are included housing
facilities and community health and health care.
The Community as a Pre-existing Situation
Problems with Language Norms Again
The same kinds of problems with coding style that beset the col-
lection of the doctor-patient data equally hampered the collection of
data descriptive of the community. Answers tended to be without
elaboration. Respondents were anything but secretive. They were often
simply puzzled by some of the researcher's questions.
Whenever possible, information was obtained about all members of
a household. Sometimes other members of the household were present and
supplied the information themselves. Some respondents and some house-
hold members were much more informative than others.
The comments and tables which appear in this chapter, for the
most part, refer to households in order to indicate that the data
include residents of The District other than the seventy-two
respondents. Since all respondents were not equally skilled informants,
the tallies of tables often do not add to seventy-six households or
multiples of seventy-six. The tallies represent all the information the
respondent was able to give the researcher about himself and other mem-
bers of his household; and all of the information obtainable by other
means such as clinic or school records and comments by other residents
of the community.
The patient and non-patient households have been kept separate
in order to determine whether they differed in areas other than their
attitudes toward health care.
Age and Sex Distribution
Children's role in clinic attendance
The age-sex pyramid for District residents (see Figure 1) sug-
gested that the households of patients had more children. The possi-
bility that the children might have introduced their households to the
clinic seemed reasonable. Pursuant to this idea, the record of visits
that had been accumulated for black patients over a period of seven
months was checked. Of 142 individual black patients who visited the
clinic, sixty-eight were under fifteen. The total number of black
patients amounted to 285. The children accounted for only eighty-five
of these visits, since in most cases the children had visited only
once. Thus the children amounted to almost half of the individuals who
visited the clinic but accounted for only one-third of the visits.
It is possible that the children served as an introduction to
the clinic through the affiliation of the clinic with the school. Each
morning the student-physicians and student-nurses held "sick-call" at
the school. Teachers referred children for evaluation. If medical care
seemed necessary, notes were sent home to parents advising them that
they might bring their children to evening clinic.
Sex ratio differences
The sex ratio of the non-patient group is 141. This could indi-
cate that more women than would be normally expected have migrated from
this group; however, the absolute numbers involved are small and there-
fore the chance of error is large. The patient group has a sex ratio of
eighty-two which is low considering the fact that this is a rural area.
The sex ratio for rural area black populations has long remained near
100,reflecting a rural urban difference by a consistent disproportion of
E 82 Residents of non-patient households
197 Residents of patient households
Figure 1. Age Distribution for the District: 1969
black women in urban areas (Bogue, 1959:158). The sex ratio for the
patient group is even lower than the ratio of ninety-one which Bogue
claims prevailed for four out of the five censuses preceding the 1960
census (1959:159). Bogue also mentioned that young men in the age
categories twenty through thirty-four consistently seemed to be under-
In an effort to discover where the sex ratio imbalance lay,
age-sex percentages were shuffled through various assortments. The
clearest pattern is arranged in Table 3. This pattern was sorted to
examine the category mentioned above, the disappearance of males ages
twenty through thirty-four. The outcomes suggest that either sex is
about equally likely to be not present. The pattern also indicates that
approximately half of both the patient and non-patient group are under
twenty. There are twice as many under-twenty males in the non-patient
group as there are females.
PERCENTAGE DISTRIBUTION OF DISTRICT RESIDENTS
BY AGE AND SEX CATEGORIES
Male Female Male Female
0 19 33 16 23 32
20 34 7 7 8 11
35 64 17 15 8 11
65 and over 2 3 4 3
Total 100 (N=82) 100 (N=157)
The marked difference in fertility ratio between the patient and
non-patient groups indicated in Table 4 can probably be explained by the
greater likelihood of mothers to seek medical care for family members.
Their being a part of the patient group is a reflection of this interest.
FERTILITY RATIOS OF DISTRICT RESIDENTS
Ages Women of Child Bearing Years
15 19 3 7
20 24 1 7
25 29 3 5
30 34 2 7
35 39 3 4
40 44 1 4
45 49 2 2
Children under 5 1/15 x 1,000 = 66 20/36 x 1,000 = 180
Dependency and aging
The impact of the distribution of age and sex is reflected in
the difference in dependency and aging presented in Table 5. The index
of aging implies that the patient population is younger than the non-
patient population. The dependency ratio for the patient population
indicates that for every 100 persons in the active population there are
120 persons in the dependent category. The dependency ratio for the
non-patient population indicates that for every 100 persons in the
active population there are fifty-six persons in the dependent category.
C + CM
Educational levels did not demonstrate any remarkable difference
between patient and non-patient households as had the dependency ratio.
During tabulation of the information, it was subsorted into male and
female to determine whether the often reported longer schooling for
black females would be evident in the community. The results are in
PERCENTAGE OF RESIDENTS OF THE DISTRICT
BY YEARS OF COMPLETED SCHOOLING
FOR THOSE WHOSE EDUCATION HAD TERMINATED
Male Female Male Female
No schooling 5 4 3 6
1 3 years 7 7 6 3
4 8 years 8 25 21 21
9 13 years 17 27 12 28
Total 100 (N = 59) 100 (N = 33)
Since there were more females than males and the numbers were small, the
patient and non-patient categories were collapsed to determine whether
females would retain their advantage when their greater number was con-
trolled for. Table 7 shows that the advantage is still evident but it
is not statistically significant. Surprisingly 42 per cent of the entire
group had had at least a grade school education or better. Some of the
older respondents were careful to explain that in "their time: school
lasted only a few months out of every year. One woman explained it
matter of factly. She said, "Five months for the white children, and
three months for the colored children. It cost the parents a dollar
PERCENTAGE OF TOTAL NUMBER OF EITHER SEX
OF DISTRICT RESIDENTS FALLING INTO
YEARS OF SCHOOLING CATEGORIES
Male Female z
No schooling 11 7 .20 not significant
1 3 years 17 9 .14 not significant
4 8 years 33 39 .76 not significant
9 -13 years 39 45 .46 not significant
Totals 100 (36) 100 (56)
Employment and Sources of Income
Occupations of residents of The District fall into unskilled
categories with only a few exceptions that might be called semiskilled.
Table 8 shows that there were few remarkable differences between the
patient and non-patient household, except perhaps that 22 per cent of
the females from patient households worked in the tobacco fields while
-only 9 per cent of the females from non-patient households worked
in tobacco. Since tobacco is a seasonal source of income, it may be
the extra income that permits these households to obtain medical
The area of work designated "Lumber" includes a variety of jobs
residents refer to simply as "in the woods." It includes driving a
truck, chopping down trees, marking trees, and work in a saw mill.
Among the miscellaneous jobs, the researcher included the jobs that
might have been considered semiskilled; a licensed practical nurse, a
cook, a teacher's aide, a boat factory worker, and carpenter's helper.
PERCENTAGE OF THE DISTRICT RESIDENTS
EMPLOYED IN VARIOUS OCCUPATIONS
Occupation Male Female Male Female Totals
Lumber 11 11 22
Tobacco 1 22 3 9 35
Domestic service 6 1 4 11
Farm and dairy 4 3 10 2 19
Miscellaneous 1 5 3 4 13
Totals 17 36 28 19 100 (N = 80)
The sorting problems for occupations or employment, and sources
of income were troublesome. Some men picked up odd jobs when the mill
had layoffs. Some women worked part-time during the growing seasons,
and worked as domestics occasionally. Other women worked full-time
during tobacco season, and now and then during other growing seasons.
Other individuals worked full-time during the tobacco season and any
other time that planting or harvest work was available. One young
widow who supported five children had two full-time jobs. She reported
to her job as a maid on her way home from the hospital where she worked.
Thus Table 8 included many people who were likely to work, at least on
occasion, at some other job.
Employment and education.--High school graduates worked in the
fields or in the woods right alongside those who had had no schooling.
It did not seem to the researcher that there would be much incentive for
children to stay in school under those conditions. Indeed a question
that proved puzzling to many parents was, "Why did your son or daughter
leave school?" After a few minutes of mulling it over they usually
shrugged and said, "I don't know. He wanted to get a job I guess."
Some did go on though. Three or four had graduated every year since the
high school was integrated three or four years ago. Before integration,
high school students made a sixty mile round trip every day to a neigh-
boring county. Those who go to junior college continue to make the
sixty mile trip.
Not everyone in The District was able to work. Table 9
shows those whose major income was derived from nonoccupational sources.
The information in the first two columns of Table 9 came from
statements such as: "I draw Social Security," or "I get 'ADC' for
the children," or "The children's daddy sends me money." (Most Aid
to Dependent Children recipients refer to it as "ABC" reflecting the
tenuous nature of language ties even with agencies that are dealt with
regularly.) Some of those people worked part-time. The last two
columns included those who made statements such as: "Since my legs
give out and I ain't able to work, I gets a check," or "I'm too old and
wore out to work so I gets welfare." For this latter group, however
they phrased it, the blow to their pride was obvious. Not all of this
group "wore out." Some were hurt on the job. One man, for example,
was working for a wildcat lumber company when a tree fell on him. A
few weeks after he was hurt, the company went out of business.
Aside from the blow to their pride, the existence of a steady
income, however small, for approximately half of the patient population
may also have been a contributing factor in their having sought medical
care. Another plausible explanation for the significant difference
between the patient and non-patient groups is that the patient group
contains more of the vulnerable who are more likely to need medical
care, the old, the "wore out," and the children.
Interviewer Avoidance of
Income Amount Question
Questions about amount of income were avoided since the combi-
nation of a white, female stranger who asks about money would become a
social worker in people's minds. Sometimes people mentioned it anyway
as a normal part of the conversation in specific enough terms so that a
few comments can be made about it. One man who works at a saw mill in
another county asked the rhetorical question, "What can you do with
$50 a week take-home pay?" Another commented about setting out pine
tree seedlings, "You can make up to $125 a week by beginning work at
six o'clock in the morning and working six days a week." Beginning at
6:00 A.M. meant finishing at 6:00 P.M. For a seventy-two-hour week,
that worked out to be about $1.66 an hour. This sounded like a com-
fortable wage until two other facts were taken into consideration. The
jobs in the community, with only a few exceptions, are subject to
seasonal fluctuations and daily weather whims and are without fringe
benefits such as health insurance.
When and Why of Migration
The question of when residents had come to live in Meccaville
was a puzzling question from which few respondents escaped since
seventy out of seventy-two respondents had been born elsewhere. Many
of the responses came in forms such as "When my sister and her husband
came here," or "When my husband came to work on crossties." Questions
about when other members of the household had come to live in The
District were even more troublesome. Table 10 refers only to sixty-
three respondents. Even to arrive at this many involved cross-checking
of siblings. Residents tended to locate events in their lives by using
bench marks such as the arrival of the turpentine factory, work making
crossties, the closing of the saw mill, and the flood. None of these
events were recent. The flood was during the thirties and the saw mill
closed in 1925.
The non-patient respondents differ from the patient respondents
only to the extent that a greater percentage of them have lived longer
in The District. Almost half of the patient respondents have lived more
than twenty years in The District. Almost three-quarters of the non-
patient respondents have lived in The District more than twenty years.
All of the non-patients have lived there more than five years. Two of
the patient respondents had lived in The District as children and had
returned within the previous two years to live in The District once
Migrants are sometimes characterized as having more initiative,
ambition, and innovativeness. Since almost the whole community has
migrated from elsewhere, this is not a particularly helpful explanation
for distinguishing one group from the other. On the other hand, the
length of time that has elapsed since migration may make some dif-
ference. Thomlinson comments along these lines. He says:
Insofar as migrants differ from nonmigrants, how long after the act
of migration do the differences persevere? . Answers to these
questions are not fully known. . Usually migrants tend to adapt
part-way; that is, they no longer resemble the stayers they left
behind but fail to adopt completely the coloration of their new
Seventy-one per cent of the non-patients have lived in The
District over twenty years while only 41 per cent of the patients have
lived in The District that long. Statistically this difference is sig-
nificant at the .02 level of significance. This difference may be
reflected in a greater willingness on the part of the patient group to
allow an innovation such as the new clinic to intrude upon their "folk"
"Why did you come to Meccaville?" was almost as puzzling as
"When did you come to Meccaville?" The answers filtered down to two
categories: people came because there was a job here, or because there
was a relative here. The jobs people had come for included; "Public
Work" (road construction), making crosstiess" (railroad ties), working
in the turpentine factory or the saw mill. None of these jobs was
available any longer. The second reason appeared to have more staying
power. Kin are not lacking in The District. See Table 11 below for kin
ties. Four of the households which appear in the "related to no other
households" column have no blood-related kin, but their former spouses
live alone in other households within The District.
CONSANGUINEAL TIES AMONG DISTRICT HOUSEHOLDS
Percentage of Households Related to:
Percentage of Other Households Totals
0 1 2 3 4 5
Patients 25 20 4 5 2 9 65
Non-patients 8 17 5 1 2 2 35
Totals 33 37 9 6 4 11 100 (76)
Male-Female Roles in The District
Discussions about the lives of blacks often include comments
about the subordinate role of the male, matriarchal dominance, and
female-headed extended families. The researcher looked for the expected
Male dominance.--It was anticipated that the traditional taboos
of the South that had in the past prevented black males from talking at
length with white females would prevent the acquisition of interviews
with males. However, males enjoyed being interviewed and were relaxed
and informative. Ten men were interviewed with no one else nearby. A
chair was dusted off and the researcher was invited to sit awhile.
Another two men were interviewed with neighbors for company. Three male
interviews were accompanied by wives, and one by an adult daughter. The
women were silent for the most part. Two brothers were interviewed
together and alternated answering questions. Five interviews with wives
were accompanied by their husbands who ranged from silent listening to
active participation. The men seemed unaware of their subordinate role
if they have one.
Although a lady "Bishop" may suggest matriarchal dominance, only
one of the four District churches was directed by a woman. Even she
spoke in glowing terms of her gratitude to her husband for helping her
to build the church that the Lord had wanted her to build. If females
dominate this community they hide it well behind a role of a deferential
Family patterns.--Expected patterns did not coincide well with
the patterns of family living arrangements that emerged. See Table 12.
Twenty-one per cent of the household heads in the community
lived alone. Twenty per cent of the household heads in the community
were female heads living with their own children, their grandchildren
or boarders. Forty-nine per cent of the community's households were
headed by a marital pair.
The augmented household had nonrelatives boarding or sharing
living costs. Among the twenty-six households headed by females, four
extended and two augmented household heads were beyond the childbearing
years. Of the twelve female heads of household living with their
children, only four fit the often-cited pattern of multiple common-law
husbands and illegitimate children. Among the other eight were six
widows, and two women separated from their husbands.
Among the marital pairs were some common-law marriages but they
appeared to have lasted several years. Despite the stability of these
marriages, the participants were embarrassed by them though they made no
attempt to hide the common-lawness.
One-half of Thomas' Gestalt
The first half of this chapter has covered some of the variables
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which seem to fit within what Thomas might have described as a pre-
existing situation. The second half of the chapter will deal with some
of the variables that Thomas might have called an objective situation,
the conditions of living to which The District residents have to
The Community as an Objective Situation
Twenty-four per cent of the community household heads were home
owners. Almost half of the houses they owned were trailers; therefore
they were not equity-accruing investments. However, they were an
improvement over other available housing.
Arbitrarily the researcher ranked housing in five categories.
See Table 13. This may suggest a wider range of choice than there
The good housing would be classified as low-cost housing in most
urban areas. Numerous repairs referred to items such as paint or
screens. The major repairs involved housing that needed extensive work
such as the addition of a flight of stairs to a porch, or complete
interior renovation. The dilapidated houses were maintained only
through the efforts of the residents who lived in them. The hazardous
housing which sheltered 25 per cent of the people of The District was
only slightly better than being outdoors. Its rustic charm was further
enhanced by the"slivery"outhouse which often accompanied it.
Forty-one per cent of The District's houses had outdoor
plumbing. Three households, one patient and two non-patient, lacked
even outhouses. The two non-patients shared facilities with a neighbor
while the one patient household used the fields. There may have been
more households that lacked outhouses. Naivete led the researcher to
ask, "Do you have an indoor toilet or an outdoor one?" Much later it
was discovered that one of the respondents who had answered "outdoor"
meant the great out-of-doors. There was no way to return and, try,
unobtrusively, to count outhouses to correct the error. The 55 per
cent with indoor plumbing had septic tanks, since Meccaville does not
yet have a sewage system.
Three houses had no electricity. The residents used kerosene
lamps. Several houses had diminutive wood burning stoves for heat.
Generally, they were so stubby that an unsteady toddler could scarcely
escape burning himself. The roaring of the little stoves amidst all
the old dried wood of the houses seemed to be a dangerous alternative
to being cold since the side of the body away from the fire stayed
A few houses had yards with fences and flowers. Most houses,
however, opened onto the streets which were hot and dusty or wet and
muddy, depending upon the weather.
Before leaving the topic of housing, two comments by District
residents about the quality of housing bear repeating. One comment by
a frail elderly man who lived alone was made while he chatted with the
researcher one brisk afternoon sitting on the edge of his sagging
porch. The researcher asked him if it wasn't a little bit breezy in his
house on cold days. He grinned, nodding his head, and replied, "When
it's not rainin', I can lie in bed and see the stars through the cracks
up over the fireplace." Another comment was made by a woman who lived
in one of the hazardous homes. In answer to a question about her house,
she said: "Oh that old raggedy thing. We keeps a cold the winter
The condition of the housing conveyed still more impact when one
began to count the number of babies who had been born in them. Mid-
wives are coming back in style in modern medicine. They only recently
went out of style in The District. Back when Meccaville had its own
physician, some women went up to his office to have their babies and
stayed overnight in his "back room." More, however, had them at home
with the assistance of a doctor, a nurse, or a midwife. See Table 14.
Only one-sixth of the non-patients had hospitalized deliveries
for their babies while almost one-third of the patients had
hospitalized deliveries. A test of the significance of this difference
yielded a z of 2.97 which is significant at the .01 level.
The difference between the two groups could reflect a difference
in attitudes toward health care. It could also reflect a greater impact
upon the patient group of the retirement of the local doctor and the two
midwives who at various times serviced The District.
Health Care Choices
Choice of physician.--The clinic does not deliver babies, but
the opening of the clinic helped to reduce the cost of medical care for
many households. Formerly, those without a car had to pay someone to
drive them to one of the cities where care was available. This added
about $5 to the overall medical expense. Even with the payment of a
transportation fee, choice of physician was often dependent upon which
direction the driver was headed.
Choice of being hospitalized.--It is likely that doctors in
neighboring cities were aware that District residents had limited funds,
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and therefore were sparing in their recommendations for hospitalization.
The researcher wondered one day if they were not a bit overzealous in
this respect after a lady had told her about the day she had her stroke.
After she had "passed out" her brother drove her the twenty-odd miles to
the doctor. The doctor was alleged to have told her brother she had had
"a light nervous stroke" and she would be all right in a few days. Her
brother drove her home again. The researcher asked if she had stayed
even overnight at a hospital. The question surprised her. She checked
with her brother to confirm that hospitalization had not been mentioned.
Some remaining facial, arm, and leg paralysis tends to substantiate that
she did have "a stroke."
Choice of waiting rooms.--In talking with people about the
medical care that had been available to them before the advent of the
clinic, a certain fondness was noted for a Cuban physician who had an
office in one of the two cities where care was located. Some gentle
probing elicited an explanation that Dr. "X" seemed to have some sense
of identification with the people of The District. Groping for a way to
get her point across to the researcher, a very earnest lady explained,
"He takes one from the white waiting room and then one from the colored
waiting room. He don't make no difference."
Budget choice.--On the whole there were few complaints about the
care that people had received in the past, although the best known story
in the community concerns a lady who was turned away from one of the
hospitals because she could not post security. She delivered her baby
on the trip between hospitals. Some respondents preferred to go to the
University's teaching hospital sixty-five miles away "even if it does
cost more because they let you budget for a longer time." One woman
added a postscript "besides they know more."
Health Care Problems
Dental care.--The area in which the health of The District's
residents suffered the most was in their dental care. It was also an
area in which respondents seem to know little about the needs of other
members of their families.
Thirteen of the patient respondents who had had extractions had
only been to the dentist once and four of the non-patient respondents
had been only once for extractions. An elderly woman who had had only
one tooth "drawn" in her lifetime showed the researcher her other teeth.
They were worn almost to the gum line. What was left of the teeth were
shells with empty hollows in the centers.
Parasites.--Shortly after the data collection had been com-
pleted, the clinic took a specimen for parasites from everyone in The
District. Approximately 90 per cent of the findings were positive.
Although the results were startling they did not carry nearly
the impact that a matter-of-fact conversation with a District resident
had carried. In discussing the impending visit of her little girl to
the clinic, upon the request of the school clinic, she commented she was
sure that her daughter had worms. She went on to explain: "Because at
night she bees all up on her all fours. And she just grits her teethes.
And she just jumps up like something scared her. And she be talking out
in her sleep." The researcher asked her what made her think that was
worms? Had she ever seen people with worms before? She answered:
I have . my sister . my baby sister. She have had them so
bad they used to just crawl out of her back part and her nose when
she was small. Momma was scared we'd get them. And I was scared
too. And she'd run around there and cry. We used to take a rag
and pull them out of her. And at night she would crawl on her all
fours and just grit her teethes. She had spells of them. Momma
would take her clothes and throw them in the fire.
Besides throwing the clothes in the fire, her mother had made a
candy from a weed found in the woods which she called Jerusalem. That,
and garlic, were the cures for worms.
While plans were being made for a possible community-wide
administration of medication for worms, the valid question was raised
about the wisdom of administration of medication without removal of the
cause. A parasitologist friend explained to the researcher that the
damp soil facilitates the perpetuation of the worm cycle. Rains wash
the eggs to places where children play in the mud. The children get the
eggs in their mouths and the cycle continues. When it has been raining
for several days, some parts of The District resemble a lake.
Seventy out of seventy-two residents had been born somewhere
other than Meccaville. The specific names of only fifty-six birth-
places were available. These were used to make a comparison of the
current size of cities and towns where District adults had been born
with the current size of Meccaville. Thirty-eight of the birthplaces
were larger than Meccaville.
Not only had District adults been born elsewhere. Some of their
children had been born elsewhere indicating that at least part of the
parental adult years had been spent in another location. A comparison
of the size of the cities and towns where District children were born
is presented in Table 16.
More than half of the households of The District had had babies
born to them in cities and towns larger than Meccaville excluding the
cities where Meccavillians went for hospitalized deliveries. It was
difficult to believe that District residents had departed to this extent
from the trend toward migration in the direction of more urban areas.
Scrutiny of the areas from which residents had migrated revealed that
50 per cent of the towns and cities had populations ranging from
approximately 700 to 2,700. Another 36 per cent of the towns and cities
ranged from 5,000 to 37,000. Thus 86 per cent of the residents had
migrated from small southern towns no larger than 37,000 in population.
Their migration can best be described as "mass-conservative" using
Petersen's term; that is, residents migrated from areas similar to their
CITIES OR TOWNS OF BIRTH OF DISTRICT
Birth in Births in
Nearby Birth in More Than
Meccaville Hospital One Other One Other Totals
Cities City City
Meccaville 24 6 30
Meccaville 2 2
Meccaville 37 3 40
Totals 24 6 39 3 72
Amidst a discussion of housing and health hazards, and the
absence of diversified job opportunities, one is bound to wonder why the
migrant selected Meccaville, and once selected why he chose to remain.
This is a hazardous area of speculation about which Petersen comments:
The process of migratory selection . is obviously of great
practical importance: to a large degree it defines the meaning of
any movement for the two areas concerned. Unfortunately . it
is a subject about which we know rather little. We have seen that
migrants are in most respects not a random sample of the popu-
lations they leave and enter. In virtually all cases adolescents
and young adults predominate. With respect to other char-
acteristics--sex and occupation, possibly intelligence and mental
health--selection usually seems to depend more on conditions at the
destination than on those at the origin (1961:603).
The conditions at the destination, i.e., jobs that existed in
Meccaville, brought many District residents to live there. These jobs
existed twenty or thirty years ago when District residents who came to
get them were young. Many of the jobs no longer exist. Many of The
District residents are no longer young. For those who are still young,
an additional factor not mentioned above complicates any decision they
make to migrate, that is, the long history of racial barriers which
mitigate efforts at economic improvement by reason of their being black.
THE STUDENT-PHYSICIAN COMMUNITY
Since the research design did not allow for interaction between
the researcher and the student-physician, an assumption of the homo-
geneity of the student-physician group was necessarily based on theory
and research developed and presented in the literature by other social
In the preface to The Student-Physician, Merton, Reader, and
Kendall point out that novices are presented the professional culture
of medicine within the social environment known as the medical school.
This setting acts as an agent between the previously trained capacities
of the novice and the emergence of the professional self. Thus the
student is not only given knowledge and skills, he is also presented
with a new identity. The authors consider this process affected by the
medical schools as socialization, a point that they make clear in
Appendix A where they compare their meaning of the word socialization
with other possible meanings. They comment:
In considering the "socialization of the medical student," then we
consider the process by which neophytes come to acquire in patterned
but selective fashion, the attitudes, and values, skills and know-
ledge, and ways of life established in the professional sub-
Renee Fox, describing the process by which students learn to
live with uncertainty, connects this learning with: ". . his
membership in the 'little society' of medical students, for a medical
school class is a closely-knit, self-regulating community . ."
(Merton, Reader, Kendall, 1957:220).
Becker, Reader, and Kendall describe medical school as being
organized in an authoritarian pattern to an even greater extent than
other schools. The greater the power exercised by the faculty the more
students are forced to adopt faculty perspectives, and the less able
they are, as a group, to develop their own student perspective. Stu-
dents do manage, to varying extents, to develop their own perspectives
comprised in part by medical ideals and values, and in part by
situational demands with which they are forced to cope (1961:435-43).
The operation of the student perspective is highlighted in the
chapter Becker, Reader, and Kendall call "Student Co-operation." The
students are often assigned work for which they are, in a sense, col-
lectively responsible. Although the faculty never formally specifies a
credo of collective responsibility, the students believe an incomplete
task will bring down the wrath of the faculty upon the group. Therefore
they develop collective work norms to distribute the work load.
Standards are kept reasonable by restraining individual members from
setting a standard to which other group members would be invidiously
compared. Students cooperate on assignments by quizzing each other, by
sharing completed work, and by devising short cuts. As much as possible
students shield each other from making bad impressions on faculty
Comments by Friedson suggest that the students' bifurcated per-
spective, proportioned between faculty and student views, continues to
flourish beyond the confines of medical school. The dilemma is