Title: Bilateral consensus in doctor-patient transactions
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 Material Information
Title: Bilateral consensus in doctor-patient transactions
Alternate Title: Doctor-patient transactions
Physical Description: xvii, 188 leaves : ill. ; 28 cm.
Language: English
Creator: DiCanio, Margaret Brien, 1929-
Publication Date: 1971
Copyright Date: 1971
 Subjects
Subject: Social medicine   ( lcsh )
Medical care   ( lcsh )
Hospital care   ( lcsh )
Physician and patient   ( lcsh )
Sociology thesis Ph. D   ( lcsh )
Dissertations, Academic -- Sociology -- UF   ( lcsh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Thesis: Thesis - University of Florida.
Bibliography: Bibliography: leaves 184-187.
Additional Physical Form: Also available on World Wide Web
General Note: Manuscript copy.
General Note: Vita.
 Record Information
Bibliographic ID: UF00097664
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 000551529
oclc - 13356247
notis - ACX6008

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Bilateral Consensus in Doctor-Patient Transactions


By

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
1971















ACKNOWLEDGMENTS


Thanks are due:

To Dr. Gerald R. Leslie for guidance, and for discovering a

research opportunity.

To Dr. Richard Reynolds for the opportunity of using clinic

facilities.

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.














PREFACE


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

when necessary.

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

his health;

(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

follow advice.

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-

looks it.

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.

She says:

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

v








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,
1959:31).

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

content.















TABLE OF CONTENTS


Page

ACKNOWLEDGMENTS . . . . . . . . . . . . ii

PREFACE . . . . . . . . . . . . . . i

LIST OF TABLES . . . . . . . . . . . . xiii

LIST OF FIGURES . . . . . . . . . . . . xv

ABSTRACT . . . . . . . . . . . . . . xvi


Chapter

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

vii








Chapter


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 . .


21


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


viii


Page











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


Page


Chapter








Chapter


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


62

62
64
65
68


. . . . 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


Page


I I I j I


i j









Chapter


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


reject .


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 .


S. 97


. . 98
. . 98


VII. MEDICAL MELANGE . . . . . . . . .

Defining and Coding . . . . . . .

Preface . . . . . . . . . .
Definition of a Situation . . . . .
Physician Coding . . . . . . .
Patient Coding . . . . . . . .
Coding Criteria . . . . . . . .


. . 105

. . 105


105
105
106
108
110


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 . . . . . .


. 111


Page







Chapter


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


125
125
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


xii


Page















LIST OF TABLES


Page


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 . . . . . .


xiii


Table

1.


2.

3.


57


58


59


60


61


63


66

68









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


xiv


Table


Page































LIST OF FIGURES


Figure Page

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
TRANSACTIONS

By

Margaret Brien DiCanio

June, 1971

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.


xvii















CHAPTER I


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;






3

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

him;

(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-

action.

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

times.

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

charge.


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

Appendix E.

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.


Data Collection

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.





9

Respondents, patients, and households sampled.--The distribution

of interviews that was obtained is included in Tables 1 and 2.


TABLE 1

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.


TABLE 2

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





11

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
Doctor-Patient Transactions

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






12

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

temptation.


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

asked were:

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
Discourses Comparable

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

the details.

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

coder.

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-

toms.

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

diarrhea returns.






15

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.--


Patient #4.

Medical Record Version

History:

7 months gestation



Symptoms:

Malaise for 1 day

Vomiting, one episode

Diarrhea

Diagnosis:

Viral Gastritis

Treatment:

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 pain or

discomfort.


Patient's Version


History:

Is pregnant, approximately six

or seven months

Symptoms:

Felt terrible

Stomach was upset

Vomited

Diagnosis:

Virus

Treatment:

1) Not eat till I felt better.








2) Drink a lot of fluids.









Follow-up:


Return to clinic as necessary

if nausea or vomiting or

diarrhea returns.


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.


Coding Form

Patient #4


SECTION A
General History


Dr. DUM Match PUM Pt.
Al Family history of this
or relevant illnesses)
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXX
XXXxXXXXXXXxXXXXXXXXXxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxxx
Preg. x M x A2 Factors in patient's own
history relevant to his
present illness, for example
is pregnant or diabetic
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
A3 Treatment by doctors)
previously for the present
illness or condition
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxYxxxxxxXXXXXXXXXXxxxxxxxxxxxxxxxXXXX
XXXXX XXXXXXxxxxXXXXXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxXXXXXXXXXXXXXxxXX
A4 Previous occurrence(s)
of this illness that were
untreated

SECTION B
Coping Behavior Pertaining
to the Present Illness

Dr. DUM Match PUM Pt.
Bl Remained at home and/or
in bed


Follow-up:








SECTION B--Continued


Dr. DUM Match PUM Pt.
B2 Went to a physician
(other than the one he is
dealing with in this record)
XXXXXXXXXXXXXXXXXxXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXxxxxxxxxx
xxxxxxxxxxxxxxxxxXXXXYXXXXXXXXXxxxxxxxXXXXXXXXXXXXXXXXXXXXX xxxxxxxXX

or home remedies
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXOXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXx
B4 Ignored

SECTION C
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
doctor
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXYXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxxx
___________ C2 Did not take medication
________ previously prescribed for
him
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
C3 Did not follow diet,
that is, weight reduction,
nutritional, diabetic,
bland, etc.

SECTION D
Symptoms

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.)









SECTION D--Continued


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
usually is."
X XXXXXXXXXXXXXXXXXXXX XXxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXX
XXXXXXXXXXXXXXXXX(xXXXXXXXXXXXXXXXXXXXXXXxXXXXXXXXXXXXXXXXXXXXXXXX
D3 Symptom elaboration:
details about duration, for
example, has had for 3 days,
10 years. . .
xxxxxxxxxxxxxxxXXXXXXXxxxxxxxxxxxxxxxxxXXXXXXXXXXXXXXXXXXxxxxxxxXxxxxX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
D4 Progress of symptoms
this episode, for example,
gradual increase . .
apparent disappearance and
reoccurrence on and
off . etc.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XIXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
D5 Symptom circumstance,
that is, ". . appears
when ."
XXXXXXXXX XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxxxxxxx XXXX
xxxxxxxxxxxxxXXXXXXXXXXXXX XXXKXXXXXXXXXXXXXXXXxxxxxxxxxxxxxxxxxxxxXXX
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.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
.xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
D7 Type of pain--radiating,
dull, throbbing, sharp.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
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.








SECTION D--Continued


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
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxxxx


D10 Patient makes an
unmatchable statement, for
example, "got to feeling'
bad, got to hurtin' so."


SECTION E
Diagnosis


Dr. DUM Match PUM Pt.
El Record mentions one
diagnosis.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxX
XXXXXXXX XXXXXXXX XXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXX
E2 Record mentions at least
one diagnosis with compli-
cations, or it mentions
multiple diagnoses.
XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
E3 Patient says, "He didn't
XXXX,XXXXXXX XXXXX XXXX XXXXXXXXX X XXX XXX say."_ Record
doesn't mention


SECTION F
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.


----------









SECTION F--Continued


Dr. DUM Match PUM Pt.
F3 The patient can specify
that the medicine was
liquid, pills, ointment,
etc.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxxxxxxxXXXXX XXXXxxx
xxxxxxxxxxXXxxxxxxxxxxxxxxxxxXXXXXXXXXXXXXXXxxxxxxxxxxxxxxxxxxxxxxxxx
F4 The patient can specify
the specific dosage.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxxxxxxxxxxxxxxxxxX
XXXXXXXXXXXXXXXXXXXXlxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxXxxxxxxxxXxxxxxxxxxx
F5 Patient says, "He didn't
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxx give me anything."
Record mentions no medi-
cation


SECTION G
Treatment--Home Care


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
match;
(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.

SECTION H
Follow-Up

Dr. DUM Match PUM Pt.
HI Patient told to return
PRN (as need be)
xxxxxxxxxxxxxxxxxxxxxxxxxxxxx- xxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXX XXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXxxxxXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxXX
H2 Patient told to return
for lab tests, further
evaluation, referral
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
H3 Patient told to return
on a specific date for check
in -- days








SECTION H--Continued


Dr. DUM Match PUM Pt.
H4 Patient told to phone in
a progress report.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
H5 Patient comments that he
doesn't intend to return.


GRAND
TOTALS 10 7M IA 8

History 1 IM 1

Symptoms 4 1 3M 3

Diagnosis 1 iM 1

Treatment:

Meds. and

Clinic 4 1 2M 1A 3

Follow-Up 0 0 0




Coding Rationale

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

doctor's language.


Methods for circumventing
patient's brevity

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
examination findings

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

possible.


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.


Coder Reliability

Because the coded material to be treated statistically was so

dependent upon the accuracy of the coders, a search of the literature






25

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-

nated.

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.














CHAPTER II


COMMUNICATION THEORY


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





27

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






28

verb have been altered; that is, the relationship of signs to signs has

been changed.

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.


Pragmatics

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)?







Coding

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,
1966:405-06).


Different Structures
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.





33

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






34

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

layman.


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,





35

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

pooling information.

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

and comprehending.

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.















CHAPTER III


SOCIOLOGICAL THEORY


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

reasonable.


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

second organism.


The interplay of the present and the pre-existent.--W. I. Thomas

has said:

Every concrete activity is the solution of a situation. The
situation involves three kinds of data: (1) the objective





40

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

attitudes.


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

Theory."


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

external factors.

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.





43

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.


Normative Influences

Another Communication
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.

Scheff remarks:

. 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

orientations.


Festinger's Specification
of Coorientation

Similar to the notion of coorientation, Shaw and Costanzo, in

the same chapter in which they discuss Sherif's work, consider





45

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

purposes here:

. 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
(1970:279-81).


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
a conformer.

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

Heider.

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

less correspondent.


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

which:

(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

patient;

(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."


Summary

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

follows.

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





51

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."














CHAPTER IV


THE PATIENT'S COMMUNITY


Preface

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







































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Per cent


I
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95

90

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E 82 Residents of non-patient households

197 Residents of patient households


Figure 1. Age Distribution for the District: 1969


771








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-

counted.

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.


TABLE 3

PERCENTAGE DISTRIBUTION OF DISTRICT RESIDENTS
BY AGE AND SEX CATEGORIES


Non-Patients Patients
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)




57

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.


TABLE 4

FERTILITY RATIOS OF DISTRICT RESIDENTS


Ages Women of Child Bearing Years

Non-Patients Patients


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.












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Education

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

Table 6.


Table 6

PERCENTAGE OF RESIDENTS OF THE DISTRICT
BY YEARS OF COMPLETED SCHOOLING
FOR THOSE WHOSE EDUCATION HAD TERMINATED



Patients Non-Patients

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

a head."


TABLE 7

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

services.

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.


TABLE 8

PERCENTAGE OF THE DISTRICT RESIDENTS
EMPLOYED IN VARIOUS OCCUPATIONS

Patients Non-Patients

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)



Underemployment

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.


Non-employed

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,


















































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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
to Meccaville

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

again.

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




















































































tt r-


4-








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
neighbors (1965:230).

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"

life style.

"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.








TABLE 11

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

patterns.


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.





69

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

female.


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

adjust.


The Community as an Objective Situation

Housing

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

really was.

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















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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

cold anyway.

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

through."







Maternal Care

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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76

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






























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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.


Mass-Conservative Migration

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

present residence.


TABLE 16

CITIES OR TOWNS OF BIRTH OF DISTRICT
HOUSEHOLDS' CHILDREN


Birth in Births in
Nearby Birth in More Than
Meccaville Hospital One Other One Other Totals
Cities City City


Meccaville 24 6 30

Smaller than
Meccaville 2 2

Larger than
Meccaville 37 3 40

Totals 24 6 39 3 72



Why Meccaville?

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.














CHAPTER V


THE STUDENT-PHYSICIAN COMMUNITY


Student-Physician Socialization

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

scientists.

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-
culture (1957:288).

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

(1961:297-312).

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




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