Week 5 Flashcards
What is power French & Raven 1959 5 bases of power within organisations
Legitimate (formal authority within the organisation)
Referent (ability to persuade/influence)
Expert (possessing needed skills and experience)
Reward (ability to give valued benefits)
Coercive (punish/ withhold reward)
What is medical power
The ability to impose ones will on others even if they resist in some way (eg demand compliance)
The real or perceived ability or potential to bring about significant change in peoples lives through one’s actions- often seen as beneficial but there are risks
The power to define illness and accordingly manage those who are ill- especially relevant for mental illness but also legitimising illness absence from work
How does power operate
Through professions and their organisations
Institutions of knowledge
Institutions or practice
In personal interaction with patients
In wider society (status of doctors)
Key sociological fields of study
Professions as social organisation
Social effects of being diagnosed
Learning to behave as a patient
Power in the consultation
Institutions
Characteristics of professions
A body of knowledge: theory and skills
Regulated training overseen by the profession
Monopoly of practice through registration
Autonomy- self regulating, making own rules
However:
Interaction with government (resources, contracts)
“Interprofessional” care; team work
Social role of profession
Within the profession:
-self interest (staying autonomous, dominance over other professions/ groups)
-upholding ethical values (fitness to practice, prohibiting abuses of power)
- sense of belonging, collegiality
Outside the profession:
-embodying wider role of service
-social status
Medical dominance (Freidson 1988)
Medical dominance: the authority that the medical profession can exercise
-over other occupations within healthcare system
-over patients
- over society, through being cultural authorities in matters relating to health
Advantages of diagnosis/label
Expectation of treatment
Offers a socially acceptable explanation eg for individuals behaviour
Sympathy, excused normal social roles
May aid coping with the illness
Sick pay
Access to prescriptions
Insurance payments
Disadvantages of diagnosis/label
Major change in status from person to patient
Must accept the asymmetry of relationship with doctor
May not be able to get cheaper insurance, mortgage, employment
The ‘sick role’ for the patient (Parsons 1951)
Must want to get well as quickly as possible
Should seek professional advice/ co-operate with the doctor
Are allowed (may be expected) to shed some normal activities and responsibilities (eg work, household, care for others)
Should be regarded as being in need of care and unable to get better by their own decisions and will
Expectations from the doctor (parsons 1951)
Apply a high degree of skill and knowledge
Act for welfare of patient and community rather than for own self interest, desire for money advancement etc
Be objective
Be guided by rules of professional or practice
What this means for power
Sickness a ‘problem’ for society which needs to be managed by medical profession
Power imbalance between doctor and patient who submits to medial authority
Recognises doctors are allowed interventions in patients lives not given to others
Potential for abuse of power- why standards/regulations are needed
Socialisation in general
Mechanisms by which people learn the rules, regulations and acceptable ways of behaving in the society or group they belong to
Often taken for granted/ invisible
Primary socialisation occurs in the family- gender roles
Secondary socialisation continues throughout life eg school
Anticipatory socialisation- rehearsing for future position eg applying to medical school
Patient socialisation
Learning ‘correct’ behaviour as a patient and how to interact with health systems; for example from:
-own experience of healthcare system
-family and friends
-other patients
-materials published by organisations/ charities
-hospital leaflets for patients
The patient career
Initial contact with medical services
Hospital admission
Hospital discharge
Displace present role with patient role
Secondary socialisation adapt old rules/ develop new rules
In chronic illness patient career
Closer links to practice/ staff, continuity
Ongoing prescriptions- sense of dependency
Self management; main responsibility goes to the person managing the condition
Change in identity
Patient organisations/ self help groups can be powerful and also provide socialisation
Imbalances of power
Difference in level of/ access to information
Social position of the patient relative to the doctor
Eg difference in social class can lead to some patients being ‘silenced’ ( Waitzkin 1991)
Easier to interact if life experiences are similar
Cultural health capital (shim 2010)
Knowing how to interact with the system
More difficult for migrants people ‘less likely to be listened to’
More affluent/educated better at this
This can contribute to inverse care law: those who most need medical care are least likely to receive it (Tudor Hart 1971)
Consider intersectionality
Developed to challenge discrimination initially in employment law (crenshaw 2011)
At the structural level different power differentials overlap and compound
At the individual level the experience of discrimination is shaped by where people ‘sit’ on the spectrum of race/ethnicity, class, gender, sexuality, education, migrant status
Social role of the ‘good patient’
Premium on being polite/ uncomplaining
This can lead to problems eg in medication adherence many people stop taking meds or change their dose without telling the doctor
Relationship breakdown can lead to sanctions
NHS as a social good- fear of taking too much
Mental illness and the concept of the ‘total institution’
Social patterns in large mental institutions provided rich material for medical sociologists
Characteristics of total institutions (Goffman, asylums)
All aspects of life are conducted in the same place and under a single authority
Daily life is carried out in a group with others (“batch living”) with scheduled activities
Sharp distinctions between the managers and the managed between whom there may be little communication
There is an institutional perspective; therefore the assumption of an overall rational plan
Mechanisms used in institutions to facilitate management of inmates
Physical and psychological reminders of a persons identity are stripped by removing personal possessions and restricting privacy and individual responsibility
Information about the individual and the institution is controlled
Mobility is restricted
Can lead to institutionalisation- patients become unable to undertake simple tasks on their own or make decisions
Adapting to total institutions
Goffman identifies five modes of adaptation which an inmate may employ at different stages in their career in the institution or alternate between during one point in that career
- situational withdrawal: no contact with others
-intransigent line: patient refuses cooperation
-colonisation: hospital preferable to alternative
-conversion: becoming a model patient
-playing it cool: using a variety of strategies including the above depending on the situation
Janet Frame (faces in the water)
Novel based on Janet Frame’s experiences as a patient in New Zealand mental institutions (1945-55)
Use of medical power in mental institutions to enforce social conformity
‘Shock treatment’
The “permeable institution” Quirk, Lelliott & Seale 2006
evidence for permeability: ward membership is temporary or ‘revolving’, contact with outside work is maintained, institutional identities are blurred
Consequences of permeability: reduced risk of institutionalisation, potentially increase risk to staff and patients
Management of permeability: limiting unwanted movement, using discretion, patient input: negotiation and subversion
Examples of threats to medical power
Shifting intra-professional division of labour (annandale 1998); team based approaches
Complementary and alternative healthcare
Technological developments
Availability/ accessibility of info
Patient empowerment
Erosion of autonomy
Social cognition
Attribution theory
Attitudes
Group behaviours
Conformity/ obedience
Stereotyping
Prejudice
Stigma
What is social cognition
People are motivated by 2 primary needs (Heider 1958)
-form a coherent view of the world
-gain control over the environment
Social cognition encompasses all processes that involve people
“The process by which people think about and make sense of other people, themselves and social situations” (Fiske & Taylor 1991)
“The perception of others, the perception of self and interpersonal knowledge” (Beer& Ochsner 2006)
Why is social cognition important in medicine
Medicine deals with people
-people are not information-processors in the absence of social influence
-people are not influenced by society in the absence of thinking
Social cognition is an important determinant of behaviour
Provides an understanding of how people think and behave which can help us influence how people think and behave
Attribution theory (Heider 1958)
Based on locus of causality
Internal/dispositional: any explanation that locates the cause as being internal to the person (personality, mood, abilities, attitude and effort)
External/situational: any explanation that locates the cause as being external to the person (circumstances; action of others, nature of situation, social pressures, luck)
Dimensions of attribution
Internal vs external
Stable vs unstable
Global vs specific
Controllable vs uncontrollable
Locus of control in health beliefs
External: whether i am well or not is matter of luck
Internal: i am responsible for my health
External: i can only do what my doctor tells me to do
Making attributions: Kelley’s convariation theory
Causality is ascribed to the cause that co-varies with the behaviour
Three types of information to arrive at internal or external attribution
-consensus : do other people do the same in this situation
-consistency: does the behaviour occur in the same way on different occasions
-distinctiveness: does the behaviour occur in the same way in other situations
Fundamental attribution error
The tendency to attribute behaviours to a persons internal qualities while underestimating situational influences
Actor-observer bias
The tendency to attribute other people’s behaviour to internal causes and our behaviour to external causes
Self serving bias (hedonically- based attributions)
The tendency to deny responsibility for failures (situational attribution) but take credit for successes (dispositional attribution)
Heuristics (rules of thumb)
Representative heuristic: the tendency to allocate a set of attributions to someone if they match the prototype of a given category
Availability heuristic: the tendency to judge the frequency or probability of an event based on how easily examples come to mind
False Consensus effect: the tendency to see one’s own behaviour as typical and to assume that under the same circumstances others would react the same way as oneself
Anchoring heuristic: the tendency to be biased towards the starting value in making quantitative judgements
Importance of attributions to doctors
Understanding the causes of health/illness behaviours of patients means you may be able to predict and influence their behaviour
Understanding your own attributional processes means you may be able to commit fewer biases/errors
Types of illness attributions by patients
About symptoms: self diagnosis is not accurate, self serving attributions leads to delays in consulting, defensive avoidance due to fear
About cause: biological, emotional, psychological, environmental, self inflicted, inflicted by others. Affect patients decisions about controllability, affect coping and adaptation.
About illness management responsibility:internal vs external attributions have very different outcomes depending on illness. High levels of internal control can lead to personal blame if illness is uncontrollable
Role of attributions in cardiac event recovery
External locus of control- lower rehab attendance
Behavioural cause- increased perceived control over preventing reoccurrence
Internal and controllable attributions- faster return to work, decreased depression/anxiety and improved lifestyle choices
Attributional styles and long term effects on health
Characteristic and stable attributional styles eg:
-internal attributional style—> good health practices
-pessimistic attributional style—> negative events are internal, stable, global
This is a characteristic of depression and a risk factor for physical illness, may be linked to reduced immune function
Attitudes of HCP
Respecting patients autonomy
Valuing diversity
Demonstrating integrity, candour
Protecting confidentiality
Demonstrating non-judgement
Awareness of unconscious bias
Communication skills
Active listening
Asking questions
Giving info
Developing empathy and rapport
Appropriate language
Paralinguistic communication
What are conditions for genuine rapport
Mutual attentiveness
Positivity -warmth and compassion
Coordination- listening and mirroring
