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The Sociology of Medicine: Viewpoints and PerspectivesAuthor(s): David MechanicReviewed work(s):Source: Journal of Health and Human Behavior, Vol. 7, No. 4 (Winter, 1966), pp. 237-248Published by: American Sociological AssociationStable URL: http://www.jstor.org/stable/2948770 .

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238 JOURNAL F HEALTHANDHUMANBEHAVIOR

brought o the physician.3 he more generaland central problem-which has been of vi-tal concern to social theorists for genera-tions-involves the whole range of conse-quences of change from social relationshipsbased on primary ontacts o ones more de-pendent n secondary rganization.

Even in societies which highly value bu-reaucratic forms, t is generally recognizedthat personal growth and nurturance re-quire a certain degree of intimacy; andvarious roles-if they are to be fully effec-tive-must be organized o insure the oppor-tunity for the expression of intimate feel-i n g s and attitudes. Yet, simultaneously,there are bureaucratic pressures o regulateor at least formalize many of the socializingand sustaining professional relationships.This pressure s a consequenceof the needfor more efficient rganization nd distribu-tion of services, a standard definition ofquality, nd the ike. t is not clear, however,to what extent such relationships can bebureaucratized without seriously damagingthe emotional-sustenance unctions f theseprofessions. ince there s a limited pool ofprofessional persons, some degree of effi-cient organization is essential. However,there may be a point where the degree oforganization may subvert ome of the basic

functions nd value of professional ervice.When we think of providing ureaucraticcontrols n medical practice, we usually con-ceive of medicine n its more narrow per-spective-that is, as an applied sciencerath-er than as a sustaining profession. The re-sult of introducing uch controls, s Freid-son has so nicely hown, s a high quality ofcare in a technical-scientific ense, but alsoa certain degree of inflexibility n dealingwith patient definitions, xpectations, nddesires.4 hus, as you ncrease the efficiencyand rationality f medical care in a scientif-ic and organizational sense, you limit thepossibilities for the emotional medical con-text. And this is why the clamor contin-ues concerning he loss of the general prac-titioner, ven though scientific medicine spracticed on a higher evel than ever beforeand medical services now reach more people.

The social process have been describing snot at all unique to medicine; indeed, weknow for example that large impersonal u-reaucratic schools and colleges can providev e r y excellent vocational and technicaltraining. Such organizations seem to suf-fer, however, n the communication f morepersonal and professional values and view-points which cannot usually be dispensed nan impersonal ashion.5

Although medicine has achieved consid-erable maturity s an applied science, andalthough more good care is available tomore people than ever before (who, as agroup, are continuously ncreasing t h e i rlevel of utilization), the fact is that medi-cine is very deficient n dealing n any ade-quate way with many patients who comeseeking motional upport. Giventhe dimen-sions of demand, the available medical re-sources, and the nature of medical organi-zation, it is unlikely hat the situation willbecome any better; it will probably becomea good deal worse in the future. Some or-ganized plans of medical care, such as theHealth Insurance Plan, have been innova-tors in attempting o experiment with or-ganizational devices that provide good so-cial and physical medicine simultaneously6but patients have been quite reluctant to

present their problems in a nonmedicalframe of reference, nd they re clearly par-tial to the physician.7 Much criticism ofmedicine and m a n y malpractice s u i t sagainst physicians reflect the impersonalnature of doctor-patient elationshipswhichstir patient doubts as to whether doctorsare really behaving s their gents.

Medicine, hus, represents classic exam-ple of the traditional sociological observa-tion concerning he advantages and costs ofbureaucracy.8 Bureaucracy allows a moreefficient nd effective tandard of medicalpractice and a wider distribution f medicalservices. But bureaucracies a 1 o developcertain rigidities nd inflexibilities n deal-ing with specific unique problems. The di-lemma we face is that while the bureau-cratic form is especially worthy from the

3. Balint, M., The Doctor, His Patient, and theIllness, New York, International Universities Press,1957.

4. Freidson, E., "Medical Care and the Public:Case Study of a Medical Group," Annals, 346:57-66, March, 1963; and Freidson, Patients' Views ofMedical Practice, New York, Russell Sage Founda-tion, 1961.

5. Clark, B., The Expert Society, San Francisco,Chandler, 1962, Chapter 6.

6. Silver, G., Family Medical Care, Cambridge,Harvard Univ. Press, 1963.

7. Freidson, E., "Specialties Without Roots: TheUtilization of New Services," Human Organization,18:112-116, Fall, 1959.8. Merton, R. K., Social Theory and Social Struc-ture, New York, Free Press, 1957, pp. 195-206.

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THE SOCIOLOGYOF MEDICINE 239

objective scientific-medical erspective, t isa rather poor organizational form to dealwith the emotional sustenance aspect ofmedicine.9 n a purely heoretical asis, thelogical step would be to attempt o separate

these various functions hat medicine per-forms. The difficulty ith such an approachon a general societal level is that emotionalproblems re viewed by many patients s in-dications of "moral" weakness, nd they reonly willing to present these problems n aphysical basis which implies no such moralresponsibility.

A related but somewhat different end-ency in medical p r a c t c e concerns thegrowth of a variety of third parties. Al-though hird parties can be extremely ene-ficial n improving he organization nd dis-tribution f medical services, hey may alsopose particular threats for the physicianand his patient. Economic third parties areinevitably oncerned not only with qualitycare but also with the extent to which ser-vices are efficiently sed and distributed;and efficient rganization requires controlsover both quality nd the use of unnecessaryservices. The fact that third parties maycontribute o the medical care bill does notnecessarily mply that they will have con-trol over the conditions of practice;10 but it

is also unlikely hat they will be totally dis-interested n such matters. And if medicalorganization s to have any semblance f ef-

ficiency, conomic hird parties will increas-ingly become concerned with the organiza-tion nd provision f medical ervices.

Economic third parties are usually insti-tuted to protect patients against costs of

illness; and although hey may at times beperceivedby physicians s threatening, heytend to be acceptableto patients. Third par-ties which are much more disturbing o pa-tients are those that make the physician'srole ambiguous. The stability of doctor-patient relationships rests upon the factthat the physician acts as the patient'sagent. However, hould the physician be un-der the control or committed o a thirdparty having interests which may opposethe patient, the physician's role may becompromised. he possible complications fpatient-practitioner elationships re exem-plified by Mark Field's"1observations on-cerning Soviet manipulation of illness anddisability o insure a stable manpower flowand to protect gainst unforeseen hortagesin manpower. Although he Soviet physicianmay in many other circumstances e nur-turant nd useful s an agent of the patient,here we have a clear example of the moraland social implications f the interests ndpower of one kind of third party. n short,the definition f h e a 1 h and illness may

serve different masters and different ocialfunctions; nd the question of who is defin-ing disease, under what conditions, nd forwhat agents is especially mportant n un-derstanding he role health nstitutions layrelative to other social institutions n so-ciety.

In attempting o discuss some of the dif-ficulties n delimiting he concepts f healthand disease and their relationships o val-ues, and the organization of medical sys-tems, possible perspectives n this problemhave hardly been developed. We have nottouched on considerations hat influence helegitimation f particular disease states andthe withdrawal rom ocial and occupationalobligations in various social systems. Thehealth of people theoretically s always onlyone value to be weighed against other ocialgoals. Thus, in different conomic, ocial,and political systems, ndividual health maybe subjugated to other social needs definedas more important. imilarly, he degree towhich resources are allocated to the healthsector depends on the general availability f

9. There may be some objection to definingbureaucracy as the villain in this case. It may bethat the bureaucratic form itself is not the majorconsideration, but rather that the different com-ponents of medical practice require differentbureaucratic organizations. Thus, while technical-scientific medicine can be handled most efficientlywith a scheduled progression of patients usingsmall-time ntervals, dealing with social-emotionalproblems may require much greater intervals. Thishas been attempted, o some extent, hrough pecial-

ties such as psychiatry. However, it then becomesobvious that only small numbers, f patients can beseen, and that the expense of treatment for theindividual patient is high.

The bureaucratic form itself appears to be apoor one for dealing with social-emotional roblems.Since bureaucracy encourages specialization, androutinized procedures and modes of operation, ittends to present barriers to the development of aprimary relationship between the practitioner andhis client. This does not necessarily imply thatsuch relationships exist outside the bureaucraticform; but it does appear that bureaucracy presentsadditional barriers to dealing with intimate per-sonal problems in a flexible fashion.

10. Anderson, 0. W., "Health-Service Systemsin the United States and Other Countries-CriticalComparisons," New Eng. J. Med., 269:839-843,896-900, October, 1963.

11. Field, M., Doctor and Patient in Soviet Rus-sia, Cambridge, Harvard Univ. Press, 1957.



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240 JOURNALF HEALTHANDHUMANBEHAVIOR

resources, nfulfilled eeds in other ectors,and the place of health in the hierarchy frelative values.

Finally, health must always be judgedagainst the social and technical tructure fa society, nd the style of life of its people.As Dubos12 has noted with such elegance,physical and mental fitness have no abso-lute meaning; these concepts nly have rele-vance when we specify he demands personsmust cope with and the kind of life theywish to live. Health is not a state of being;it is a process of adaptation o the changingdemands of living and the changing mean-ings we give to life tself.

SOME THOUGHTS ONATHEORY

OF HELP-SEEKING ANDILLNESS BEHAVIORThe difficulty ith much work in the so-

ciology of medicine nvolves the failure todevelop a sociological context for viewingdisease processes n relation o interpersonalrelationships, ommunity rocesses, nd sub-cultural patterns of behavior. Too muchwork has been organized round the medicalperspective f disease which may be practi-cal, but t is often uperficial n a sociologi-cal sense.

Much of the theory required for under-standing medicine and medical institutionscan be derived from general sociological ndsocial-psychological heory. Although medi-cine has a special content nd special prob-lems, valid generalizations bout status re-lationships, oluntary ersus nvoluntary e-lationships, perception, nterpersonal rela-tions, and the like should apply equally wellto medicine s to other areas of sociologicalconcern. Thus, for example, the general so-cial-psychological rinciple- that when peo-ple participate voluntarily n decisions, heyare more likely to become committed tothem nd implement hem-should be valua-ble in understanding he acceptance of orfailure to conform o medical regimen. im-ilarly, adequate knowledge of client-practi-tioner relationships n other fields, r of or-ganizational effects, hould have bearing onthe medical context, especially if we areclear in specifying he characteristics fthe contexts in which the knowledge hasbeen derived, nd those n which t is beingapplied. Many of the ways in which medi-

cal practitioners nd patients respond to

various organizational pressures and prob-lems have good analogues in government,educational institutions, ndustrial organi-zations, nd churches. n short, many of theprinciples hat we might regard as intrinsicto medical sociology nvolve a reapplicationof principles lready prevalent n the socio-logical literature generally. Although medi-cal systems-like all subsystems-have someunique features, do not believe t is neces-sary to rediscover nd retest all social hy-potheses n this context.

There are, however, ome areas so intrin-sic to health problems that they constitutespecial concerns for the sociologist who isinvolved n medicine. believe that the so-ciologyof help-seeking nd its consequences

is one such major concern. We already havea number f studies of some significance nthis area, and although much needs to bedone in developing general theory, we dohave some good hints as to how to approachsuch a theory. As I see it, the study of help-seeking nvolves number f small theories(or middle-range heories, f you like) thatare linked together n a logical chain. Theinvestigator ould construct uch a chain byspecifying number of sets of independentand dependent ariables that can be tied to-gether by a number of empirically basedpropositions. n a sense, the investigatorwould construct a funnel beginning withsome important dependent variables andtheir predictors, w o r k n g back to othervariables that predict the predictors. Thuswe might view illness behavior or some as-pect of it (for example, the tendency toadopt the sick role) as one predictor f help-utilization atterns. But we might lso wishto work back to examine the variables thatexplain differences n patterns f illness be-havior.

Whether we concern ourselves with thetraditional physical disorders or those moreclearly characterized by behavior problems,it appears that there are two distinct ues-tions involving phenomena which are em-pirically ntertwined n the data we usuallywork with. Yet we can profit by recogniz-ing that these two questions are logicallyvery different. irst, we seek to understandwhat particular aspects of a person or hisenvironment ead to aberrant states of theperson. Implicit in the statement of the

question s that we have some adequate cri-terion for differentiating he class of aber-rants from he class of nonaberrants. n at-

12. Dubos, R., Mirage of Health, New York, Har-pers, 1959.



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tempting o answer this question we usuallyshare the inquiry with a variety of otherdisciplines, nd our contribution n helpingto answer such questions of etiologymay bevery modest. There is little question hat wecan contribute more to illuminating theetiology f behavior disorders han to tradi-tional physical problems, but in each casethe approach to etiology is logically thesame.

The second major question we often at-tack assumes a certain degree of aberrantbehavior as given, nd we attempt o ascer-tain what factors ead to differential denti-fication, efinition, nd treatment. hus ourconcern s with the social processes nvolvedin recognizing aberrance, labeling it, anddealing with it. The logical model is moreeasily stated than utilized, ince we rarelyhave a group of persons with equal devianceof a specified kind who can be studied inreference o these social processes. But ifthe model is clear in our own minds, therewill be many opportunities o study suchprocesses n a relatively igorous ashion.

In general, an examination of the litera-ture dealing with llness and deviance howstremendous onfusion s to which of the twoquestions s being attacked; and often hereis no recognition hat there are two ques-tions involved here. This failure results, nlarge part, from adopting a clinical modelwhich assumes that aberrant persons cometo the practitioner's ttention because theyare aberrant rather than as a consequenceof an interaction between personal traitsand social processes. Any study which be-gins with "known" or "treated" cases of aparticular disorder may, thus, confuse etiol-ogy with social processes eading to care. Itmay well be that for particular kinds ofproblems such samples of "known" casesare good approximations f all such cases.13But at this point we have very little evi-dence concerning most disease states whichwill allow us to reach any firm conclusionsas to the relationship between "known"aberrance nd "true" total berrance.14

Lemertl5 s one of the few social theoristswho has attempted o attack n a systematicfashion the distinction between individualaberrance and deviant social careers. He es-sentially argues that "known" deviance isan extremely ow estimate of the actual ex-tent of deviant behavior. But much deviantbehavior s situational, ransitory, elf-limit-ing, or sporadic, and constitutes ratherinsignificant art of the individual's devel-opment and significant r o 1 enactments.Thus, he believes, t is extremely mportantto separate the occasional deviant behaviorof large numbers f "normal" persons fromdeviant behavior which is organized as acentral part of a person's social identity. AsKinsey16 so clearly howed, for example, heprevalence of single homosexual xperiencesis relatively igh among males, and such ex-periences may occur naturally n normal de-velopment. Certainly t is important o dis-tinguish people with a transitory xperiencefrom he exclusivehomosexualwhose entiresocial identity or long periods of time maybe organized around his deviant sexual pat-tern. Lemert designates sporadic, situation-al, and unorganized deviance as primary;while deviant behavior which is organizedas part of a deviant identity, e calls sec-ondary deviance. Primary deviance in his

terms may stem from large number f dif-ferent ndividual and social conditions; de-viance may result from conventional cul-tural learning, from particular psychosocialforms of development, r from physical orgenetic spects of the person. Thus, primarydeviance of any particular type has nounitary aspect. Secondary deviance-thatis, deviance organized as a social career-presents the sociologist with a distinctivesociological question: What are the socialforces that lead from primary deviance tocareer deviance?

Lem er t' s contribution s important nthat he points so clearly to the fact that ca-reer deviance may be dependent n a varietyof social influences n addition to those thatproduce the or g i n a 1 aberrant behavior.Thus given the same degree of primary de-viance, subsequent social experience maysubstantially determine wh e t h e r the de-13. Mechanic, D., "Some Implications of Illness

Behavior for Medical Sampling," New Eng. J. Med.,269:244-247, August, 1963; and D. Mechanic andE. H. Volkart, "Illness Behavior and Medical Diag-noses," J. Health and Human Behavior, I:86-94,Summer, 1960.

14. See J. Kitsuse and A. Cicourel, "A Note onthe Uses of Official Statistics," Soc. Prob., 11:131-139, Fall, 1963.

15. Lemert, E., Social Pathology, New York, Mc-Graw-Hill, 1951; also, see T. J. Scheff's excellentattempt to state Lemert's hypotheses formally in"The Role of the Mentally ll and the Dynamics ofMental Disorder: A Research Framework," Soci-ometry, 6:436-453, December, 1963.16. Kinsey, A., et al., Sexual Behavior in theHuman Male, Philadelphia, W. B. Saunders, 1948.



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242 JOURNAL F HEALTHAND HUMANBEHAVIOR

viance is transitory, r whether t becomesorganized to a greater extent s part of thesocial identity f the person (and such con-siderations are often important n under-standing disabled people). Lemert's theoret-ical approach is not without ignificant if-ficulties, nd it remains to be seen to whatextent his formulation ill receive empiricalsupport. One of the basic propositions ofLemert's position s that the amount nd de-gree of deviancy re important n determin-ing who becomes ubject to particular ocialdefinitional processes. Thus, it may ulti-mately be that the best predictor f careerdeviation s the extent and degree that theperson suffers to begin with) from partic-ular psychological and social incapacities.Whatever the outcome of Lemert's theory,he has attuned us to various significant o-cial variables in the formation f deviantcareers, and thus he has provided us withthe perspective necessary o make a distinc-tive sociological ontribution o the study ofdeviant behavior.

Even Lemert-as sophisticated s his ap-proach has been-has not fully differen-tiated from theoretical erspective he eti-ological aspects of individual aberrance, onthe one hand, and the social factors charac-terizing he societal reaction o deviance,onthe other. t is not clear, for example, whatrelationships xist or are posited betweenprimary aberrance and the various condi-tions which presumably et the course of adeviant career. Since primary deviance hasnot interested Lemert and his followers oany great extent; it is just treated as oneof many variables leading to a deviant ca-reer. Furthermore, t is not clear whetherprimary deviance is a necessary conditionfor career deviation, nd what degree of de-viance may, by itself, onstitute sufficientcondition or a chronic deviant state. Giventhe state of sociologicaltheory, ny generaltheory that is meant to cover such variedforms of behavior as crime, mental illness,and sexual deviation will pose knotty prob-lems. The fact that Lemert's theory ppliesas well as it does to so many diverse socialforms s indeed remarkable.

Returning o the more imited oncerns fmedical sociology, he importance of sepa-rating the conditions urrounding he etiol-ogy of illness from hosesurrounding llnessbehavior becomesespeciallyclear if we look

at the problem from he clinician's perspec-tive. The clinician finds himself n a par-ticularly unstrategic position to recognize

the social processes by which patients areselected for his scrutiny. Thus the clinicianmay fail to separate the disorder tself, orthe symptom he patient presents, rom thepattern of illness behavior, or the societalprocesses that bring the patient to a treat-ment facility. As one study suggests, hemay interpret he emotionality f the pa-tient as an indication f the severity f ill-ness rather than as an indication of a pat-tern of illness behavior which encouragesemotional omplaint.17

The particular model I am proposing n-volves the following k n d s of questions:Who attempts o define the condition? Un-der what circumstances re particular con-ditions defined? W h a t factors influencehelp-seeking? What factors influence thesource of help chosen or imposed? What fac-tors influence he evaluations of "helpers"and subsequent r e f e r r a 1 processes? Alsothere re a variety f other related questionswe can pose concerning reatment rocessesand the return of the patient to a "nor-mal" state of being: How does the practi-tioner perceive various kinds of patients?What factors affect conformity ith medi-cal regimen? And how is the kind, quality,and degree of patient care related to organi-zational contingencies

In order to explicate this approach, Ishould comment more specifically on someof these matters. Let me make clear thatthe social processes affecting care-seekingdiffer n a variety of ways depending onwhether we concentrate n traditional hys-ical disorders or mental disorders. For ex-ample, they vary as to the extent he typicalpatient defines he need for care himself, ncontrast o care being provided under pres-sure or involuntarily. n the whole, how-ever, the general variables affecting help-seeking, or the external provision of care,are similar regardless of the type of "dis-ease" involved.

Generally, t appears that the major varia-bles affecting elp-seeking an be categorizedinto seven major classes of factors: (1) theamount, persistence nd recurrence f aber-rance 18 (2) the visibility r recognizabilityof aberrance;19 (3) the extent to which the

17. Zola, I. K., "Problems of Communication,Diagnosis, and Patient Care: The Interplay ofPatient, Physician and Clinic Organization," J. ofMed. Educ., 38:829-838, October, 1963.

18. Lemert, op. cit.19. Lemert, E.,. "Legal Commitment nd Social

Control," Soc. and Soc. Res., 30:370-378,May-June,1946.



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bution to understanding he processes withwhich we are concerned,we must move be-yond si mp 1 social-demographic ompari-sons and concern ourselves with social psy-chological nfluences s well.

Thus far I have concentrated n the studyof illness behavior and its concomitants. o-cial scientists, however, have always beeninterested n the social etiology of variousforms f aberrance s well as the conditionswhich bring such behavior to the attentionof the community r treatment ersonnel.do not in any way mean to suggest that so-ciologists should give up their traditionalconcern with the etiology of various disor-ders. But I do encourage hat such questionsbe carefully eparated from the illness be-

havior questions.The study of social etiol-

ogy involves dentifying y valid, independ-ent procedures group of cases of the dis-order n question, nd attempting o accountfor the presence, mount, nd persistence fthe disorders.25 ere there may be a wide va-riety of biological,psychological, nd socialvariables that are relevant; for many ofthese aberrations, he sociologicalcontribu-tion to etiology may be very imited. But thesociologist, n viewing such problems, mayconcern himself with the role of social andfamilial s t r e s s and conflict, mploymentdifficulties, rowding, ocial isolation, ocialmobility, nd the like. Important potentialareas for sociologicalcontributions ncludethe following: he consequences f illness nterms of future disability; the developmentand maintenance of coping abilities whichinvolve earning nd socializationgenerally;the adequacy of subgroup cultural prepara-tion for societal roles; and the qualitativenature of family and work demands. Inpointing ut the contribution f the sociolo-gist to such areas, it should also be empha-sized that sociologists should perhaps bemore generally eceptive o studies and evi-dencethat meet usual standards of scientificwork. t has been somewhat puzzling to mewhy so many sociologists re so receptive ospeculative sociological and psychoanalytichypotheses-much evidence to the contrary-but tend to be so skeptical bout findingsfrom the areas of biology and genetics,which often re based on much more mpres-sive methods nd data.

Returning o the area of illness behavior,we need more than a theory xplaining un-

der what conditions berrance is identifiedand defined. We need a further et of propo-sitions explaining why alternative modes ofhelp are sought or made available to variouskinds of persons, once a problem has beenidentified. ere we would be concerned withstill another set of variables: available al-ternatives or dealing with stressful ircum-stances offered by various cultures andgroups, or utilizable by a particular ulturalgroup; alternate routes to treatment; tti-tudes and group pressures toward variousalternatives; past experiences nd learningrelevant o help-seeking; ocial distance fac-tors linking particular kinds of patientswith particular kinds of practitioners, vail-able means for achieving intimacy withinone's social group, nd the ike.

SOME THOUGHTS ON THESOCIOLOGICALPERSPECTIVERELEVANT TO EVALUATIONS

OF ILLNESSThroughout his paper I have referred o

some of the basic differences etween clin-ical and a sociologicalperspective; wouldnow like to elaborate on these differences osome extent. Because the clinical approachhas such great currency n popular and in-tellectual

thinking,t

requiresconsiderable

e f f o r t to maintain a perspective whichmakes s o m ewh a t different ssumptionsabout the processes we call illness. Implicitin the clinical approach s that patients uf-fer individual aberrations characterized bya defect n physiology r intrapsychic unc-tioning. And it is assumed that such disor-ders can be understood hrough n explora-tion of the individual's physiology r psy-chology. Thus illness is seen as a deviationof the person from a state of normality sdefined y current nowledge.

Perspectives hemselves re neither rightnor wrong; but varying perspectives raisedifferent uestions and open somewhat dif-'ferent reas of investigation. rom the so-ciologicalperspective, he arrival of the pa-tient at a medical context usually comes asa result of a difficulty he patient has and avariety of social, cultural, nd psychologicalforces which nduce the patient or others opresent his case for intervention. s we ob-served earlier, the clinician thus cannot al-ways easily separate the problems f illness

from llness behavior (the manner n whichillness is perceived, evaluated, and actedupon). Within the traditional medical mod-

25. See R. Blum, "Case Identification in Psy-chiatric Epidemiology: Methods and Problems,"Milbank Mem. Fund Quart., 40:253-288, July, 1962.



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el, the clinician does attempt o make an in-dependent ssessment of the patient's diffi-culty. Through a history, hysical examina-tion, and evaluation of laboratory studies,he attempts to ascertain whether he canfind an objective basis to account for, us-tify, or explain the complaint presented.Thus in the classical medical model we havetwo s e t s of facts-those surrounding hecomplaint, nd those surrounding he physi-cian's inquiry nto the complaint. At leastlogically peaking, he set of facts that char-acterizes the patient's pattern of illness be-havior is distinct rom the one that charac-terizes the diagnostic procedures.

To take typical psychiatric ractice as acontrast, t is much more difficult o log-ically or empirically istinguish etween hepatient's pattern of illness behavior on theone hand, and the facts which determine hediagnosis on the other. n the absence of au s u a 1 repertoire of objective-standardizeddiagnostic devices, the psychiatrist s muchmore dependent for his evaluation on thepatient's complaint or the social circum-stances surrounding the definition of thecase.26Thus the psychiatrist aces a muchgreater risk than the "classical clinician" ofdiagnosing a pattern of illness behavior ascompared with an objectively determined

condition.The typical psychiatric practitioner willequally assume that the patient's complaintarises from some underlying psychologicalor developmental roblem. He thus directshimself o the complaint s an indication fthe need for psychological ntervention ndanalysis. But the study of illness behaviorimplies another possible interpretation fsuch a complaint; t may be the result of anexaggerated llness behavior pattern or anexaggerated receptivity to the physician.

There are certainly ome cases where thepsychiatrist might more profitably spendhis time discouraging llness behavior andteaching the patient to focus less ratherthan more on his psychological tate.

I do not wish to give the impression hatthe most meaningful distinction xists be-tween psychiatric nd nonpsychiatric rac-tice, although here are some obvious differ-ences. An examination of a typical medicalpractice n the United States or Britain willshow that most of the complaints hat phy-sicians deal with do not conform o the con-cept of the application of the medical modelas I have described t. Much medical prac-tice involves psychosomatic nd psychoso-cial problems, nd a variety of vague andundefinable omplaints. Another arge bulkof practice s made up of self-limited cutecomplaints f short duration rrespective fmedical intervention. hus, what differen-tiates a great many patients that physicianssee from hose who do not appear for treat-ment is not the presence of disease-sincemany of the complaints for which care issought are widely distributed among thegeneral population-27 but a pattern of ill-ness b e h a v i or which differentiates hosewho seek care from those who do not. Thewide differences n the use of the physician

in different ountries with similar stan-dards of health would also suggest thatmuch of medical practice has no great rele-vance to maintaining he physical health ofthe nation, lthough uch care may have im-portant sustenance functions.28

There are some data by which we can as-sess the extent to which disease is an ordi-nary condition of everyday iving. For ex-ample, White, Williams, and Greenberg,29on the basis of American and British mor-bidity studies, estimate that 75 per cent ofall adult persons report ne or more llnessesper month. Of these, only about a third eekmedical care during any given month. Al-though he severity f disease is likely o beone predictor in seeking care, it is wellknown that a variety of other factors areequally important and that many persons

26. Jahoda, M., Current Conceptsof Positive Men-tal Health, New York, Basic Books, 1958, who issympathetic toward efforts to arrive at a cleardefinition, writes that "There is hardly a term incurrent psychological thought as vague, elusive,and ambiguous as the term mental health.'" (P. 3)Further it is observed that ". . . apart from ex-tremes, there is no agreement on the types of be-havior which is reasonable to call 'sick.'" (P. 13)Also see A. B. Hollingshead, "Some Issues in theEpidemiology of Schizophrenia," Amer. Sociol.Rev.,26:5-13, February, 1961; T. S. Szasz, The Myth ofMental Illness, New York, Hoeber-Harper, 1961; F.C. Redlich, "Definition of a Case for Purposes ofResearch in Social Psychiatry: Discussion," inInterrelations Between the Social Environment ndPsychiatric Disorders, New York, Milbank MemorialFund, 1953,pp. 118-122;and Blum, op. cit.

27. Huntley, R. N., "Epidemiology of FamilyPractice," J.A.M.A., 185:175-178, July, 1963; andK. White, et al., "The Ecology of Medical Care,"New Eng. J. Med., 265:885-892, November, 1961.

28. Peterson, 0. L., "Quantity and Quality ofMedical Care and Health," paper presented at the57th Annual Meeting of the American SociologicalAssociation, August 29, 1962; and Anderson, op. cit.

29. White, op. cit.



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with only very mild symptoms eek atten-tion, while other eriously ll persons do notsolicit similar services.

It should thus be clear that a perspectivethat views both patients and nonpatients-their similarities nd differences-providesconsiderable information not easily avail-able from he perspective f the clinician. naddition to illuminating he selective nflu-ences bringing particular categories of per-sons for attention, his perspective lso pro-vides a clearer understanding f the way inwhich the presentation of physical symp-toms is used to justify seeking the physi-cian's support and sustenance, nd to pro-mote various social needs of the patient un-related to his medical problems. Such un-derstanding from the physician's perspec-tive allows a wiser course of action in thatit makes clearer the social and psychologicalconsiderations hat must be weighed n de-veloping a treatment trategy or in decid-ing whether o treat t all.

CONCLUSIONIf workers in the sociology of medicine

are to contribute n a more basic way to themainstream of sociological thought and tothe general ssues involving medicine n oursociety today, some redirection s necessaryin the kinds of problemswe choose to attackand in the methodological pproaches wemost commonly se. Thus in concluding hisdiscussion, t seems proper to suggest someof the major areas within medicine hat so-ciologists hould be concernedwith, and thepossible methodologies they might apply.Implicit, of course, n my entire discussionhas been the idea that the sociologist mustr e t a i n his basic professional perspective,and he must attune himself o the basic so-ciological considerations elevant to the or-ganization of medicine and the health pro-fessions generally, nd to the relevance ofhealth are for other nstitutional ectors.

1. In the c o m n g y e a r s sociologistsshould give more central concern o the po-litical context within which medical deci-sions are made. Politics are central to medi-cine on a national, tate, and local level; andeven within individual medical organiza-tions and agencies, power is of central rele-vance to the programs ffered, s well as tothe organization and qu a 1 t y of services.

The American Medical Association, for ex-ample, has an interesting history of con-frontations with various other political and

social agencies. Not only does the A.M.A.have great influence on American medi-cine, but also its great power and successwouldmake t an excellent ase for sociologi-cal investigation. Political scientists, aw-yers, and historians have concerned them-selves with medical professional organiza-tions; but sociologists have been relativelytimid n approaching his area.30A compar-ative study of medical professional organi-zations within different medical contextswouldbe a valuablecontribution.

Indeed, he entire conomic ontext withinwhich medicine s organized requires morecareful sociologicalstudy. The behavior ofmedical professional groups is not surpris-ing since all professional roups attempt omaintain and retain control over the condi-tions of their practice and standards of re-muneration. As economic hird parties con-tinue to develop within medicine, nd havea greater stake in the medical care market,we will witness greater rumblings s themedical profession struggles to maintaincontrol over what it has traditionally e-garded as its own prerogatives. Within arelatively free market, without excessivecompetition, he medical groups, ike otherprofessional roups, have always had consid-erable power to define the conditions oftheir practice, and they have retained con-trol over standards, economics, nd organi-zational matters. Since doctors have dealtwith patients as individual agents, theyhave not been faced with very powerful d-versaries inasmuch as patients, like othertypes of small consumers, have relativelylittle counterpower; lso, since doctors havemaintained ome control ver entry nto theprofession, hey have been able to controlcompetition within the profession o a con-siderable ex t en t. As consumers organize,however, ither through he government rpowerful private third parties, they developconsiderable countervailing power relativeto the organized professions and can bemore influential n controlling he condi-tions of practice. In the coming years weshall see an increased struggle over suchpower, and it seems inevitable that thirdparties will increasingly e involved n de-

30. Hyde, D., et al., "The American Medical As-sociation: Power, Purpose and Policies in Organi-zed Medicine,"Yale Law J., 53:938-1022, May, 1954;H. Eckstein, The English Health Service, Cam-bridge, Harvard Univ. Press, 1958; and 0. Garceau,The Political Life of the American Medical Asso-ciation, Cambridge, Harvard Univ. Press, 1941.



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cisions relevant o the organization f med-ical care and conditions f medical practice.

2. Medical associations are also fascinat-ing contexts for the study of responses toorganizational threat, and it is probablethat these threats shall be leveled with in-creasing intensity t medical organizationsin coming years. It is not surprising thatthe medical profession reacts vigorously oexpectations of change which threaten tsposition. For all organizations-indeed, allpersons-tend to desire control ver the con-ditions that influence their activities andfate; and nowhere s such sovereignty, nceattained, asily abandoned. Even where suchpower has always been absent, we find per-sons exerting great pains to control theirown activities t h r o u g h informal groupmethods. Organizations which have univer-salistic service goals have special problemsin responding o threat. Unlike electricians,teamsters, a n d longshoremen, physiciansmust portray and identify heir self-inter-est within the context f the "social good."A good deal of the advertising which theAmerican Medical Association produces re-flects the atempt to make the doctor's self-interest ompatiblewith basic health values.

3. Since Hall's classic study of physi-cians,31 ociologistshave given far too little

attention o the community ontext of med-ical practice. From some universalistic tan-dards, m u c h professional behavior seemsperverted nd despicable.But the sociologistshould be particularly nterested n those so-cial strains that produce deviations fromprofessional norms. The practitioner whorefers his patients to specialists n a differ-ent neighborhood r locality, when amplespecialists are available in his own commu-nity, ften gives us some clue to the natureof medical competition; r the medical ser-vice that may keep patients omewhat ong-er than necessary n the hospital, n orderto retain its jurisdiction over a scarce sup-ply of beds, gives some clues as to the rela-tionships among services in the hospital.Medicine, ike other ocial contexts, nvolvesconflict, t r a i n, pressures, and problems.People in all circumstances evelop adapta-tions to the particular problems they face,and often hese adaptations uggest clues asto the social organization f practice.

4. Moving away from organizational s-sues to more social psychological ones, itseems clear that as sociologists move beyondthe study of traditional demographic aria-bles, far more complex methodologies ill berequired to study mportant ssues concern-ing etiology nd illness behavior. f we areto attack the problem of the social etiologyof disease (especially in the area of themental and behavioral disorders), t will benecessary to follow large cohorts throughpanel-type and longitudinal designs. Suchstudies, f they are to be adequate, requirea variety of demographic ontrols, nd suchresearch demands abundant funds and com-mitted rofessional taff.

5. Although do not believe that sociolo-gists should be concerned with diagnosticerror in the technical sense, the fact thatphysicians deal with so many persons whosuffer from ills w h c h are self-limiting,opens a wide and relatively unexplored p-portunity or study of social decisions rele-vant to medical diagnosis and treatment.Scheff32 as presented an excellent discus-sion showing how medical diagnosis can betreated within a statistical decision-makingmodel. Very briefly, i n c e treatment n-volves both physical and social risks, thesemust be weighted gainst the possible risks

of limited reatment r no treatment t all.In order for these relative risks to be under-stood, we need considerable understandingof the course of disease in untreated opula-tions, and we must take into considerationnot only the physical consequences of theuse of particular herapeutic gents, but alsothe psychological and social consequencesfor the patient. Although medical decisionscan be conceptualized n a technical-scien-tific sense, t is folly o believe that techni-cal-scientific ecisions have no value impli-cations or consequencesfor the psychologi-cal, economic, and social life of thepatient.33

6. Various studies of illness behavior andmedicalcare utilization n a variety f West-ern countries uggest that the actual use ofmedical services beyond certain point hasno very large relationship o the level ofhealth. The medical care literature s pri-

31. Hall, O., "The Informal Organization of theMedical Profession," Canadian J. Econ. and Pol.Science, 12:30-44, 1946; "The Stages of a MedicalCareer," Amer. J. Sociol., 53:327-336,March, 1948;"Types of Medical Careers," Amer. J. Sociol., 55:243-253,November, 1949.

32. Scheff, T. J., "Decision Rules, Types of Er-ror and Their Consequences n Medical Diagnosis,"Behavioral Science, 8:97-107, April, 1963.

33. Mechanic, D., and M. Newton, "Social Con-siderations in Medical Education: Points of Con-vergence Between Medicine nd Behavioral Science,"J. Chronic Dis. 18:291-301,March, 1965.



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marily concerned with the practical issuessurrounding tilization, delay in treatment,and related matters. Much more serious,theoretical attention must be given-as Isuggested n the early part of this paper-to the kinds of societal changes and newpatterns of social relationships hat pro-duce high rates of utilization. Too few dis-cussions in the utilization literature havestruggled with the basic sociologicaldilem-mas of health care: How can a society pro-mote high levels of attention o symptomsand early symptom ecognition without, nsome measure, including hypochondriasis?;and how can medicine accommodate thelarge numbers f persons with psychosocialand psychosomatic omplaints wh en themost efficient ureaucratic form for scien-tific medicine is an alien one for dealingwith uch problems?

7. In the area of mental disorders t is in-creasingly lear that psychiatric osology svery inadequate. I believe that sociologistscan contribute onsiderably oward develop-ing better systems of classifying humaneffectiveness f both an instrumental ndemotional nature, linked to particular pat-terns of role demands. This, of course, s nomean task; but it is important hat someof us think along these lines. The inade-

quacies of psychiatric lassifications re im-portant handicaps n research tudies n thearea. In fact, t is peculiar that we have leftthe classification f effective nd ineffective

response o psychiatrists ho have had verylittle experience in systematic observationof normally unctioning ersons.

8. Finally, speaking in a methodologicalvein, t is apparent that we need both a rich-er slice of human and organizational xperi-ence in a variety of medical contexts, ndmore rigorous arge-scale tudies which sys-tematically ntroduce demographic nd oth-er controls. uch studies must be concernedwith a variety f behavioral measures n ad-dition o verbal statements; nd we must n-creasingly m ov e from m or e superficialsources of data to those which are morecarefully uarded against the casual investi-gator. The basic issue is not between rigorand depth; both are essential to a soundsociologicalapproach.

In short, t is my contention hat we haveyet to dig very deeply into the core andmeaning of medical systems, nd their rela-tionships to other social systems; and ourunderstanding f the social influences ondisease and disease processes have not yetgone far beyond that of the intelligent ndthinking nonsociologist. This is the chal-lenge; and it is not an easy or trivial one.The contribution hat the medical sociolo-gist will make to his own general disciplineand the value of his contribution o medi-cine will depend on the intensity nd scopeof the attack on the difficult, mportant, ndknotty roblems hat at this point look im-possible nd irresolvable.

A NATIONALSTUDYOF HEALTH BELIEFS1John P. Kirscht,* Don P. Haefner, S. Stephen Kegelesand Irwin M. Rosenstock

A probability sample of 1,493 adults was interviewed about beliefs concerningcancer, tuberculosis, nd dental disease. The beliefs studied ncluded perceived severityof, and susceptibility o, each disease, plus the benefits xpected from various actions.In addition to the expected perceptions of severity and likelihood for the disease, itwas found that Rs rated other people as more susceptible to each disease than them-selves. While many believed dental disease to be preventable, over half the sampleapparently did not believe that early detection f tuberculosis r cancer would be bene-ficial for them. Little evidence was found for a general preventive orientation towarddisease.

In the summer f 1963, a national surveyof health beliefs was conducted n an effortto explore further set of variables utilizedin earlier studies.2 The major belief varia-

bles, adapted originally from field theory,included the perceived n e g a t v e conse-quencesof disease, the perceived vulnerabil-ity to disease, and beliefs concerning the

*Department of Community H e a 1 h Services,Schoolof Public Health, University f Michigan.

1. This investigation was supported by PublicHealth Service Research Grant Number CH 00044from he Division of Community ealth Services.2. Hochbaum, G. M., Public Participation in Med-ical Screening Programs: A Sociopsychological

Study, Public Health Service, PHS Publication Num-ber 572, 1958; Heinzelman, F., "Determinants ofProphylaxis Behavior with respect to RheumaticFever," J. Health and Human Behavior, 3:73-81,1962; Kegeles, S. S., "Why People Seek Dental Care:A Test of a Conceptual Formulation," J. Health andHuman Behavior, 4:166-173,1963.

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