Download Institutional Trends in Medical Sociology

Institutional Trends in Medical Sociology
Author(s): Samuel W. Bloom
Source: Journal of Health and Social Behavior, Vol. 27, No. 3 (Sep., 1986), pp. 265-276
Published by: American Sociological Association
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InstitutionalTrends in Medical Sociology*
SAMUEL W. BLOOM
ofNew York
CityUniversity
Journal
of Healthand Social Behavior1986, Vol. 27 (September):265-276
ofmedicalsociology.Thissubfieldis
history
Theemphasisofthisanalysisis on thesocial institutional
in its currentdiscipline,(2) as
describedas (1) closelyconnectedwiththepatternsof development
containinga dual thrustbetween applied and basic science, and (3) as strugglingwith
eitherinmedicineorfromroles
theworkofsubgroupsworking
involving
ambiguity
"insider-outsider"
from
fragment
thesociologyofmedicine.Tracinga detailedhistorical
externaltomedicinebutstudying
of an acceptedpositionfor
the decade followingWorldWar II, it is predictedthatthe continuity
medicalsociologyis assured even thoughthe styleand qualityof its professionallife are full of
uncertainty.
Medicalsociologyis todaya specializedfieldof
learningthatappliestheconceptsand methodsof
studyof medicineas a
sociologyto thesystematic
thefabricof thehealthsystem,
social institution,
and problemsof health and illness. It is an
in every
activityfullyinstitutionalized
intellectual
sense (Ben-David 1965; Shils 1970; Oberschall
1972): thereis an organizeddemandforteaching
and research;thereare professionalassociations
and scholarlyjournalsspecificallydevotedto the
its mainlocus of
field;bothwithintheuniversity,
and privateorganizaactivity,
and in government
tions,medicalsociologyis supportedwithfinancial and otherrewardsforperformance.
Medical sociologybegan to achieve this full
about 1950.
identification
measureof professional
Earlier,therewere individualscholarswho engaged in similarwork,but notas membersof or
contributors
to a recognizedspecialfield.Todayit
thatfunctions
has becomea "learned" profession
of a "practicing"profession
in the environment
is
(Freidson1970a)andwhich,likeall professions,
a combinationof achieved, highly developed
knowledgeand an organizedprofessionalsocial
Medical sociologistsnow have both a
structure.
professionalidentityand shared problems of
factorsdo not,however,
inquiry.These unifying
bydiversepathswhichattract
prevent
development
andmethodsof investigaconceptions
independent
tion.
The trendsof medicalsociology'sinstitutional
growout of its past. To understand
development
them,I presentthreepropositionsabout where
medicalsociologyhas been,as buildingblocksof
myanalysisaboutwhereit is going:
* Direct all correspondence
to: Samuel W. Bloom,
Departmentof CommunityMedicine, Mount Sinai
School of Medicine,One GustaveL. Levy Place, New
acknowledges
York,N.Y. 10029. The authorgratefully
Fundand theRussell
thesupportof theCommonwealth
of thismanuscript.
Sage Foundationin the preparation
The originaldraftof this paper was presentedat the
EasternSociologicalSocietyAnnualMeeting,1986.
1. Medical sociologyis closelyconnectedwith
in its
ofdevelopment
andfollowsthepatterns
parentdiscipline.Unlike some specialized
intellectualactivitieswhich take sharply
'
directions
awayfromtheirorigins,
divergent
medical sociology's theoryand research
sociolfollowclosely those of mainstream
structure
similarly
ogy, and its institutional
withthose of
has been stronglyintegrated
generalsociology.
toward
its history,a dual thrust
2. Throughout
on theone hand,
social reform,
progressive
of knowledge,on the
and the development
other, has existed. The tension between
advocacy and objectivity,betweenapplied
andbasic science,has alwaysbeenpresentas
a dialecticalchallenge.
a
3. Therehas been, formorethana century,
substantialoverlap between the work of
subgroupswithinmedicineand social scientistswho, fromroles externalto medicine
itself,conductedresearchaboutproblemsof
medicine. The two subgroupshave had
relations,at timescourtingand
tempestuous
265
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JOURNALOF HEALTH AND SOCIAL BEHAVIOR
266
collaborating,
at otherscompeting
or excluding. Two medicalspecialtieswere particularlyinvolved:community
medicine,including public healthand preventive
medicine,
and psychiatry,which has tried to fit
"behavioralscience" withinits knowledge
base. This "insider-outsider"2
has
ambiguity
beencentralto thestruggle
forlegitimacy
by
medicalsociologyin boththemedicalworld
and theacademicworldof sociology.
From such determinants,
severalmajor roles of
medicalsociologists
havegradually
emerged:basic
scientistof behavior;university
teacherin sociolwithphysiogydepartments;
teachingcollaborator
cian colleagues in medical schools; and policy
analystand consultant.
Today,medicalsociologyis one of sociology's
mostactivesubspecialties.
Foroverfifteen
years,3
theMedicalSociologySectionhas beenthelargest
sectionof the AmericanSociologicalAssociation
(ASA), witha membership
of 993 in 1985,or 8.6
percentof the 11,485 total.This was almost400
morethanthe nextlargestsection,Organizations
and Occupations,which contained597, or 5.2
percentof theASA membership.
Althoughmembershipin ASA began to decline in 1975, the
MedicalSociologySectioncontinued
to growuntil
of declinein Section
1979;sincethen,thegradient
membershas been the same as the ASA. As a
TABLE 1. Membershipof Medical SociologySection
in Relation to AmericanSociologicalAssociationMembership
Year
1971*
1972
1973
1974
1975
1976
1977
1978
1979
1980
Medical
Sociology
Section
Section
ASA
PerCent
Membership Membership of ASA
697
4.7%
14,827
759
14,934
5.1%
843
888
928
944
969
1,026
1,061
1,018
14,398
14,654
14,387
13,958
13,755
13,561
13,208
12,868
1982
916
12,439
1985
993
1981
1983
1984
957
885
846
12,599
11,600
11,223
11,485
5.8%
6.0%
6.7%
6.8%
7.0%
7.6%
8.0%
7.9%
7.5%
7.4%
7.6%7
7.5%
8.6%
* The Sectionbeganin 1962,butmembership
figuresare availableonlysince 1971.
proportion
of the generalmembership,
medical
sociologyremainedsteadyat about7.5 percentfor
sevenyears,increasing,
in
however,to 8.6 percent
1985.
TENSION BETWEEN ACADEMIC AND
APPLIED ORIENTATIONS
The tension between academic and applied
orientations
endemicto sociologyhas beenexacerbated by a recent negative growthrate. A
continuingpatternof decline in the numberof
forthefirsttimesincethe
sociologists,occurring
mid-thirties
(Table 2), is to someextentundermining sociology's image of itselfas a primarily
academicdiscipline.The factthatmedicalsociology seemsto be thriving
underadverseconditions
in some quartersas evidence
has been interpreted
thatsociologyshouldbe moreapplied.The debate
is highlighted
by the remarksof KennethLutterman(1975, p. 317), whofromhisvantagepointas
a careersociologistin federalprograms
of support
forsocial sciencetraining,
has witnessed
disciplinary resistanceto change. Speakingfirston this
tenyearsago, Lutterman
matter
asserted:
If we want to understandthe sociology of
knowledge,
thesociologyof sociology,we must
see thedisciplineforwhatit is. At thepresent
time, sociologyis almostentirelya teaching
discipline.Most sociologists(over 80%) spend
thevastbulkof theirtimeteachingratherthan
doingresearch.Theyget paid forteachingand
writingtextbooks . . . When they do research,
andmanydo not,itis typically
on theindividual
scholarbasis as a part-time
researcher.
Since then, marketchanges have produced a
surplus of Ph.D. sociologistsrelative to the
conventional
academicdemand,and federalsupportchangedto placeexplicitemphasison training
forresearchcareersin appliedsettings,"such as
mentalhealthcentersand state,federal
community
and privateresearchsettings"(Lutterman1983,
p. 436).
In 1983, Lutterman
(p. 436), then Associate
Director,Mental Health Services PlanningResearchand ResearchTraining,Divisionof BiometryandEpidemiology,
NationalInstitute
ofMental
Health, found no reason to alter his earlier
observations
aboutthebarriersto changein most
sociologydepartments:
A major concernof the seventieswas the
deliveryof mental health services and the
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267
INSTITUTIONAL TRENDS
TABLE 2. Membershipof theAmericanSociological
SocietyDuring its First EightyYears*
Year
1906
Number of Members
115
256
1910
751
1915
1,021
1920
1,086
1925
1,558
1930
1,141
1935
1,034
1940
1,309
1945
3.241
1950
4,454
1955
6,875
1960
8,892
1965
14,156
1970
1975
14,387
1980
12,868
11,485
1985
* FiguresfromtheExecutiveOfficeoftheAmerican SociologicalAssociation.Note thatthe name
was changedfrom"Society" to "Association"in
1959.
susceptibleto the "pyramidal sales scheme"
mentioned
byLutterman.
Nevertheless,
thetension
betweenacademicandappliedorientations
persists
in medical sociology as well as in general
sociology.
Althoughtheresistance
describedby Lutterman
remains,therehave been signs of change. For
example,the applied sociologyworkshopsponsored by the ASA in 1981 reflecteda new
awarenessof the reducedmanpowerdemandfor
academicsociologistsand of theincreasedopportunitiesin applied, nonacademicsettings(Freeman,Dynes,Rossi,andWhyte1983). Atthesame
of graduatesand severelycut
time,largernumbers
fundsfor university
teachingprogramsexerted
strong pressureon the ASA to take action
concerningthe employment
of new recruitsto
and most
sociology.Perhapsmostunprecedented
controversial
has been the movement
to establish
certification
procedures,based on the argument
thattheformallegitimacy
of licensingadds to the
of sociologistsin nonacademic
employability
jobs.
The questionsraised by the 1981 workshop
showtheeffects
of thechangesin thesituation
for
social sciencethatwereso sharplycrystallized
by
the Reagan administration
(Freemanet al. 1983,
evaluationof serviceprograms.
By 1980, about
half the programs[NIMH supportedtraining]
concerned services research and evaluation
research and involved trainingfor applied p. ix).
settings.Facultymemberswithexperiencein
Should there be an increasedemphasis on
applied researchare hard to find,and often
Whatarethe
appliedsociologyinthediscipline?
or hostile to
are unenthusiastic
departments
forconventional
and
implications
undergraduate
developingtrainingprogramswithan applied
of developingsociologyprograduatetraining
to
focus.It is mucheasierand less threatening
grams?Will the growthof applied sociology
deal withdisciplinary
problemsratherthanthe
seriouslyhinder theorybuilding and basic
problemsof theclient;itis simplerto reproduce
research?What does sociologyhave to offer
one's selfand to continuethe"pyramidalsales
in nonacademiccareers?Are
personsinterested
scheme" than to train studentsto work in
ampleand diversepositionsreallyavailablefor
appliedsettings.
sociologistsoutsideacademia? Will sociology
if it
withintheuniversity
lose its respectability
thatthe
Lutterman
(1983, p. 436) acknowledges
resistanceis structuralas well as attitudinal: encouragesappliedwork?To whatextentmust
applied sociologistscompromisepersonalval"Unlike schools of public health and public
ues? Can applied sociologistsreallyhelp the
lackstrong
generally
policy,sociologydepartments
groups and organizationsthat employ them
nonacademic
research
other
ties to agencies or
achievetheirgoals?
successfully
to place studentsas
settings.Thus it is difficult
is
by thefactthat
interns,to supervisetheirresearch,and to help The matter complicatedfurther
sociology,like mostof theworldof science,has
themfindjobs in nonacademicsettings."
Medical sociology,because of its association become increasinglydependenton the federal
As federalfundinghas been cut or
of medicine,mightbe government.
withtheserviceprofession
arebeingforced
sociologydepartments
expected to escape from the constraintsof withdrawn,
To some extentit to either change their conventionalacademic
academicinstitutional
patterns.
does, when the roles assigned to it are in perspectives,or accept a reduced scope of
Eveninmedicalschools, operations.
Thus,questionsofprofessional
nonacademic
institutions.
identity
been
to thesurfaceof consciousness.
have
pushed
thenormsforfaculty
emphasizeresearch;teaching
not so
Medical sociology, as in the past, follows
and therefore
is largelyinterprofessional,
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268
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
This linkageof professionaland personal-moral
choices appears as part of his sociology of
knowledge;but,is thisreallya choicethatis based
on normsinherently
requiredfor the effective
in a professionalrole, or is it a
performance
personalvalue choice?
Freidson'spersonalthoughts
aboutwhatsociology shouldbe revealhis ambivalenceaboutwhat
medicalsociology,in substantial
part,includes.He
is not alone. Ratherhe represents
one side of a
PROFESSIONAL IDENTITY CONFLICT:
conflict
that
has
been
not
present
only
formedical
INSIDERS AND OUTSIDERS
sociologybutforitsparentfieldsinceitsinception.
It is theconflictbetweenactionand reflection,
or
Freidson,in his discussionof how he came to
whatFurner(1975) calls advocacyandobjectivity.
and thereasonsfor
studymedicineas a profession
For sociologyand forsocial sciencegenerally,
his choice of a work role in an institution
thisconflicthas createda dual identity.
The first
"outside" of medicine,is a case exampleof both
of sociologywas createdat
graduatedepartment
situation
anda characteristic
individual
theconflict
the Universityof Chicago in 1893 (Columbia
response.It is a modelof thefundamental
identity
followed the next year), and the American
challengeto sociologists
who,intheearlystagesof
Sociological Society was createdin 1906. The
chosemedmedicalsociology'sinstitutionalization,
formalinstitutional
of Americansociology,
history
ical sociologyas a fieldof concentration
(Freidson
however,can be dated, togetherwithits fellow
1978). In this biographicalstatement,
Freidson
social sciences,from1865, when the American
explicitlyinvokesan insider-outsider
perspective.
Social Science Association(ASSA) was created.
Offered
thechoiceof working
outsideor insidethe
The firstleaders of the ASSA were amateur
himof medicine,Freidsonidentified
institutions
FrankB. Sanborn,one of thefounders
reformers.
self with mainstreamsociology, and therefore
and its secretary
forhalfa century,
was typical.
situationmost
chose to work in the structured
Educatedin theclassicelitepattern
of thetime,at
arts and
typicalof sociology,in the university
Exeterand Harvard,he was unitedwiththeother
science college. He (1978, p. 128) viewed his
ASSA foundersin the earlierantislavery
movechoicenotas a methodof declassifying
himselfas
ment.Gradually,however,someleadersof ASSA
a medicalsociologist,but ratheras necessaryfor
shiftedtheirattention
fromthe victimsof social
thesociologicalstudyof themedicalprofession:
change to the processes affectingsocietyas a
By adoptingthe approachof the sociologyof whole: "They embarkedon empiricalstudiesto
boththeknowledgeand the
knowledge,....
discoverhow societyworked" (Furner1975, p.
ethicalityof the professionbecome ideologies
and
which
had
to
whichwere problematic
be 2). In the new researchuniversities-Chicago,
and JohnsHopkins-theytookthefirst
evaluatedby the sociologistas one who stands Stanford,
outsidethesystem.In thissense,I deliberately steps towardprofessionalization
as social scienchose thestanceof theoutsiderratherthanthe tists. The emphasisof organizedsocial science
stanceof the collaborator.It is also a stance shifted
fromreform
to knowledge.
compatiblewithmybiography.
The victorythatacademicsocial sciencewon at
in effect theturnof thecentury,
Freidson(1978, p. 128) goes further,
however,was nevertotal.
denyingthe validityof the role of a sociologist The ideological dualism took differentnames
workingwithinmedicine:
theterm"applied" came into
(insteadof reform,
thesame.
I thinkit wouldtakean extraordinary
personto favor),buttheconflictwas essentially
be able to workfulltimeina medicalsetting
and
Freidsonrepresents
theacademicor knowledge
at thesame timedefinehisproblemssociologi- side of this dialectic.Althoughhis best known
callyratherthanmedically[emphasismine].He work(1970a, 1970b)criticizesthebulkof medical
would also have to be ratheramoral, since he
fortreating
medicineprimarily
as a bodyof
wouldhave to resistthemoralobligationto be history
and
for
the
of
knowledge,
emphasizing
importance
of some help to thosearoundhim,help which
theydefinebytheirownpracticalcapacitiesand scientificdiscoveryto the neglectof the quite
needs.
of medical
separatedynamicsof theorganization
closely the developmental
patternsof its parent
field and, in this instance, it has perhaps
anticipated
thetrend.Yet, theexperienceof each,
thesubfieldand theparent,are notidentical.Any
attemptto anticipatethe futureof sociology,
or of itsspecialties,mustunderstand
the
therefore,
elementsof thisconflict.It is a roleconflict.
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269
INSTITUTIONAL TRENDS
practice,he fallsintothesametrapwhenhe (1978)
looksat sociology.
In regardingmedical sociologymainlyas an
academic discipline that develops knowledge,
Freidsonis typicalof thosewhohavelookedat the
sociologyof medical sociology.A considerable
about
body of criticalappraisalhas been written
medicalsociology,but it is mostcompleteabout
in thestudyof
anddeficient
theintellectual
history
history.Mechanic (1983) has
its institutional
reviewof theresultsof
compileda comprehensive
researchin healthservices,the professions,the
and
social organizationof medical institutions,
health-related
behavior.The handbookof Freeman,Reeder,and Levine,in threeeditions(1963,
1972, 1979) showsthefieldmorein termsof its
as a basic scienceof behavior.Ruffini
aspirations
(1983, 1984) publishedtwo volumesof commissionedpapers,each of whichreviewsin deptha
different
aspect of "advances in medical social
science." Review articleshave appearedabout
special topics in medical sociology, including
current
trendsin bioethics(Fox 1974, 1976), the
relationship(Levine and Kozloff
doctor-patient
(Bloom
1978),and socializationfortheprofession
1979). New textbookshave summarizedthe
knowledgeof thefield(Mumford1983; Hingson,
Scotch,Sorensen,and Swazey 1981) and, as part
of thebehavioralsciencesof medicineforwhich
medical studentsmust be examined (by the
NationalBoard of Medical Examiners,Part I),
review books and chaptersare
comprehensive
available(Pattishall1986; Pattishalland Kennedy
1983).
of medical
development
Yet, on theinstitutional
sociology,historicalanalysisis both sparse and
Textbookshave eitherleft it out
disappointing.
itin shortchapters
(Mechanic1978)orcompressed
(Mumford1983; Twaddleand Hessler1977). An
effort
to fillthisgap was madebytheASA whenit
formed
theso-calledFletcherCommissionin 1969
to reviewthefieldof medicalsociologyin all its
was devoted
aspects.One chapterof itsfinalreport
to the institutional
history(Badgley and Bloom
1973), but only in medicaleducation.Building
from the data of the Fletcher Commission,
Kennedyand colleagues (1983) have writtena
viewof behavioralsciencein medical
book-length
education,but again, the social historyis secondaryto theanalysisof theacademicroleof social
science, and medical sociology is not studied
separately.
An explanation
forthisnarrowand partialview
may be foundin the factthat,in its earlyyears
(especially from 1945 through1960) medical
sociologywas installedinmedicaleducationon the
model of the basic sciences. It was expectedto
takeitsplace in thepreclinicalyears,as thebasic
scienceofhumanbehavior.In bothitsresearch
and
its major role assignment,therefore,medical
sociologywas identified
by thehostenvironment
in itspredominantly
academicrole. Reinforcement
came fromtheresearchof majorscholarsat that
time.ExamplesincludeParsons'(1951) studyof
medicineas a social system,the researchon the
sociologyof medicaleducationby Mertonand his
associates at the Bureau of Applied Social
Research (1957); the professionalsocialization
studiesof Howard Becker,EverettHughes and
theirUniversity
of Chicago team(Becker,Geer,
Hughes, and Strauss 1961); and the social
stratification
on mentalillnessin the
perspective
workof Hollingsheadand Redlich(1958). These
studiesemergedfromthe intrinsicinterestsof
outstanding
sociologistswho chose medicineonly
as thesourceof relevantdata. The researcher
and
the problem, in each case, was within the
conventional
focusof mainstream
sociology,and
the main aspirationwas to contributeto the
of basic knowledge.
development
This academicorientation
has remaineddeep in
thecollectiveconsciousness
of bothsociologyand
medicalsociologyas theprocessof institutionalizationproceeded.Change,however,did occur, as
will illustrate.
thefollowinghistorical
fragments
THE INSTITUTIONALIZATIONOF
SOCIOLOGY AND MEDICAL SOCIOLOGY
In thedecadeimmediately
WorldWar
following
II, therewas a remarkable
growthin all American
highereducation,includingthe developmentof
researchin the social sciencesas well as in the
physicalandbiologicalsciences,withthestrongest
supportfromgovernment
agencies.The war had
demonstrated
beyondany doubt how important
sciencecouldbe fornationalpolicybuttherewas
the need to create new peacetimeagencies to
wherethe
replacethosein theDefenseDepartment
wartimescience efforthad been concentrated.4
Stouffer's
famousResearchBranchof theArmy's
and EducationDivision is the bestInformation
knownwar-timeexampleof social science. The
actedimmediately
afterthewar
physicalscientists
to establisha federalagency,theNationalScience
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270
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
The CCMC was an expressionmainlyof two
Foundation(NSF), to supportbasic research.For
medicaleconomicsand publicthe social sciences,however,therewere special basic perspectives:
medicine.HarryH. Moore, described
barriers
to overcome.In a Senatedebate,Senator preventive
has as a "public healtheconomist"(Roemer1963, p.
arguedthat"no agreement
HartofConnecticut
to whatsocial science 53) was the directorof the studyand I. S. Falk,
beenreachedwithreference
was
reallymeans." Othersarguedthatsocial science who was trainedoriginallyin bacteriology,
was inherentlyapplied science and therefore associate director.Sociologistswere at firstin
minorroles;forexample,RobertLyndwroteone
outsideNSF's missionto supportpurescience.
On July3, 1946, theSenatevotedby 46 to 26, of the reports.However,Moore's major book,
with24 membersnotvoting,to excludethesocial AmericanMedicineand thePeople's Health,was
sciencesfromsupportby NSF (Lyons 1969, p. influencedby the theoryof social lag (Roemer
1963, p. 53), enunciatedby WilliamOgburnin
127) althoughlatertheycame to be included.
Therewas also soon to followthebackwashof 1922. Ogburnwas a memberof CCMC, and
the Cold War which, equatingsociology with Michael M. Davis was on the eight-member
Theircontributions,
labelled"social" into executivecommittee.
together
socialism,swepteverything
were hardlyminor
itswake. The effectsof theCold War on medical withthose of Sydenstricker,
sociology were critical to both the value- (CCMC 1972).
that
The CCMC gave influentiallegislativetestistructures
orientationand the institutional
dominatedthepost-warperiod.Theyblockedthe monyon the issue of healthinsuranceand the
betweensociologyand public organizationof health care. The Committee
close collaboration
yearsearlier,and favorednationalhealthinsurance.On healthcare,
healththathad developedtwenty
therebyset the conditionsfor the academic theyreachedthethenradicaljudgmentthatgroup
practiceand groupprepayment
phase.
plans should be
emphasisin theearlyinstitutionalization
The Cold War constrainedthe directionsin allowed to compete equally with individual
fee-for-service
healthcare. Also emwhichmedicalsociologycould move. The image practitioner
of medical sociology prevalentin the early phasized were the needs for comprehensive
to all sectorsof the
fifties-as only a field of inquiryor scholarly servicesequally distributed
discipline-was distorted.This perception,how- population,and improvededucationforall health
By creatingan agendaand buttressever,madeit easierformedicalsociologistsat the professionals.
time to fit into a trainingethos dominatedby ing it with supportivedata, CCMC made it
foracademicand scientific impossibleformedicineand the federalgoverntheoryand thestruggle
with mentto avoid intensedebateabout the issue of
Yet thisimagewas notconsistent
legitimacy.
the role that medical sociology had played in public policy thatCCMC so clearlyarticulated
twodecadesearlier.
(Stevens1971,p. 176).
development
public-policy
the OgburnCommitteeprovided
Two benchmarkevents were centralto this
Concurrently
earlier phase: the Committeeon the Costs of forsociologyin generalthetypeof legitimization
MedicalCare (CCMC) andtheOgburnCommittee functionthat CCMC did for medical social
chapters
(The President'sResearchCommitteeon Social science.Moreover,twoof thethirty-four
ofitsinfluential
RecentSocial TrendsintheUnited
Trends).
The CCMC was createdin 1927 at a meetingin States were concernedwith health. Lazarsfeld
Washington,D.C., of some sixty individuals regards this report(The President'sResearch
on Social Trends1933) as "the cradle
comprisingphysicians,health officers,social Committee
as well
of thepublic.For the of themodernsocial indicators
movement
scientists
andrepresentatives
exampleof anotherissue which
next five years, the CCMC, consistingof 15 as an outstanding
today:therelation
members,met twice a year and produced28 commandsincreasingattention
and social data in the
studies.They were sup- between historiography
reportson fact-finding
to demoof eightprivatefounda- broadestsense-fromculturaldocuments
portedby a consortium
tions,includingtheMilbankMemorialFund,the graphiccalculations"(Lazarsfeldand Reitz 1975,
Russell Sage Foundation,the CarnegieCorpora- pp. 5-6).
Withinthe nextten years,by the timeWorld
tion, and the RockefellerFoundation. Their
aggregatesupportto CCMC was $750,000, an War II broke out in 1939, "social research
enormousamountof moneyforresearchat that activitieshad become so ubiquitousthat the
turnedto thesocial researchers
almost
time.
government
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271
INSTITUTIONAL TRENDS
as a matter
ofcourse" (LazarsfeldandReitz1975, questionsof professional
and legitimacy,
identity
p. 6). Once theUnitedStatesenteredtheWar,all affects
andacquisition,
roleassignment
determines
of professional
government
agenciesstartedsocial researchactivi- attitudes
acceptanceand rejection,
ties on a substantialscale. All of the research and createslabelsof insiderand outsider.
was inoperation:
In bothgeneralsociologyand medicalsociolarmamentarium
content
analysis,
laboratory ogy, this has been the case withthe continuing
samplingsurveys,detailedinterviews,
experiments,
groupdynamics,and so on. Clearly, tensionbetweenwhat are called academic and
withtheothersocial applied perspectives.In fact, both approaches
sociologywas a majorpartner
in theUnitedStates.
alwaysexistsideby side,and areneverfreeof the
sciencesinstitutionalized
Medical sociology,althoughpartof thisdevel- influence
of theirsocioeconomic
and sociopolitical
as a subfieldin its contexts.
opment,was notyetidentified
From the vantagepoint of the present,how
own right.The major participantswere more
associatedwithpublichealthand social shouldtheseearlyproblemsbe seen?Can theybe
accurately
of thefuture?
medicinethanwithmedicalsociologyas it would consideredindicative
evolve afterthewar. Sydenstricker,
Davis, Falk,
and Moore made major contributions
to the
shapingof the Social SecurityAct of 1935, THE TRENDS OF DEVELOPMENT:
to the states for
includingfederalgrants-in-aid
IMPLICATIONS FOR THE FUTURE
maternaland child health and for crippled
children'shealthservices(Title V), and the first
In his editorialof March6, 1981, theeditorof
permanentauthorizationto the Public Health
the Journal of the American Medical Association
Serviceforgrantsto the statesforpublichealth
(JAMA)wrote(p. 955):
of fundsforPHS "investiworkand authorization
The questionshouldno longerbe: Should the
ofsanitation"(Falk
gationofdiseaseandproblems
social sciences have a role in undergraduate
theirworkcontinued
after
1977,p. 168). Although
medical
education?Rather,it shouldbe: How
their
efforts
enactment
of theSocial SecurityAct,
can we moreeffectively
bringthe lessonsand
to deal withproblemsof medicalcare services,
insightsof the relevantsocial and behavioral
costs, and burdens failed. Even though they
sciencesto our students?
contributed
to the WagnerNationalHealth Act
of the behavioralsciences
proposed in 1939, and therebyforced their Similarendorsement
reportof the
researchdata and analysisintotheconsciousness appearsin themorerecentsummary
Association
of
American
Medical
Colleges
(AAMC
of Congress,the Act itselfwas not passed, and
Panel
on
the
General
1984)
Professional
Education
theirworkwas pushedoffthenationalagendaby
of the Physicianand College Preparationfor
otherpriorities
associatedwiththewar.
vitalprepara- Medicine, more popularlyknownas the GPEP
Whattheydid was, nevertheless,
of medicalsociologythatwas Report.
tionforthehistory
While a significantrole for the social and
a separate
to followafterthe war. It represents
patternfrom the more academic intellectual behavioral sciences in medicine and medical
thereare
thatwas occurring
parallelto itin the educationappearssecuredforthefuture,
development
limitations.
a
medical
article
Discussing
sociology
The eventsfollowingthe war, howuniversities.
in
the
same
the
editor
issue,
above
adds
quoted
within
social
the
kind
of
struggle
ever,especially
influence"as repre- (1981, p. 955):
scienceagainst"government
and Feinstein
My only quarrelwithPetersdorf
sentedbythecreationof NSF, andexternal
forces,
[is that]by usingtheterm"medicalsociology"
suchas theCold War,thatwerehostileto applied
insteadof the "social and behavioralsciences"
in which
social science,createdthecircumstances
to cover subjectsdescribingthe natureof the
becamedominantin the
the academicorientation
to the society
professionand its relationship
of medicalsociology.
earlypostwarhistory
aroundit,theytendto narrowtheperspective
of
This historical
to convey
analysishas attempted
the readerfor whom "sociology" may be a
of whatis oftenseen as a simple
thecomplexity
loadedword.In factone ofthepointstheymake
in sociology betweenorientations is thenegativechargeof theword"sociology"
confrontation
towardinquiry.Whatat firstappearsto be strictly withmanyof themedicalfaculty,
andthistends
forone typeof
a matter
ofvalues,ofthepreference
to correlatewithdiminished
involvement
of the
social sciencesin theeducationalprogram.
researchratherthan another,spills over into
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272
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
in the
thissituation,it is necessaryto psychobiologyand psychopharmacology
To understand
within early 1970's this situationchanged radically.
of orientations
look closelyat theplurality
did notrelinquish
itsown
psychiatry
medicine. As Petersdorfand Feinstein(1981) Significantly,
overtheteachingof behavioral
somespecialtyareasfindmedicalsociology claimto hegemony
report,
moreappealingthanothers.In theirstudyof three science,lobbyinghardto keep thisresponsibility
specialties, family physicianswere the most foritselfbutwithoutsocial sciencecolleagues.
andinternists
theleast,withpediatricians The result,nevertheless,was not a reduced
favorable
therewas generalagreement overall demandfor sociologistsin medicine.In
Although
in-between.
medicine,the pre-warharmonybein thewholesamplethatmedicalsociologyshould community
medibe includedin medicaleducation,therewas strong tweensocial science and public-preventive
thatwere cine found renewal. Also, in graduate and
ambivalence,based on value-conflicts
forty undergraduatesociology departments,medical
different
fromthoseexperienced
notterribly
These
sociologybecamean acceptedsubspecialty.
yearsago.
morethanmade up thegap caused
A specialtyarea whose opinion of medical developments
of psychiatry.
sociologyhas radicallyalteredbetweenthenand by thedefection
Whatwas affected
was therole of themedical
Directlyrelatedto advancesin
now is psychiatry.
mentalhealthduringthe war and the prominent sociologistas a basic scientistin medicaleducaroleplayedin thoseadvancesby researchsociolo- tion.Withsome notableexceptions,like Howard
of MentalHealthwas Kaplan at Baylor School of Medicine, Elliot
gists,theNationalInstitute
formedin 1946. The firstdirector,RobertFelix, Mishlerat HarvardSchoolofMedicine,andEmily
to socialresearchat theJohns Mumfordat the Columbia PsychiatricInstitute,
hadbeenintroduced
HopkinsSchool of PublicHealthin 1939 and his sociologyhas beendisplacedfromtheroleofbasic
interest
was reinforced
duringthewar.As a result, behavioralscientistin medicine,and its place
who have less interestin
Felix includedsociologistslike JohnClausenand takenby psychiatrists
RaymondV. Bowers as close advisorson his social or psychologicalfactorsin mentalillness.
probablywillnotlast.The pressures
by This situation
earlieststaff.Similarexperiencesare reported
mentally
ill,
like FredrickC. Redlich. to careforthehomeless,theuntreated
academicpsychiatrists
in sociologytohismiddle and drug-or alcohol-induced
disorder,will build
Redlichdateshisinterest
school in Vienna,wherePaul Lazarsfeldwas his up and force a returnto basic collaboration
in theeffort
teacherof mathematics.When Redlich (1983) betweensocial scienceand psychiatry
mentaldisorder.
migratedin 1938, he did not forgethis interest, to understand
at
But if I am correctin believingthattheamount
ofpsychiatry
andwhenhe becamethechairman
by medicalsociologyin medicine
Yale, he acted to integratesociology with of participation
is
psychiatry.Hollingsheadbecame his close re- is assured,and, in nonacademicinstitutions,
andtheNew Havenstudiesof even expanding,thereremainsthequestionof the
searchcollaborator,
Is Freidson
and mentalhealthwerebegun. natureandqualityof thisparticipation.
social stratification
role as a brokerof correct in his warningsabout the structural
Also playingan important
was DonaldYoung,a requisitethat good medical sociology must be
socialscienceandpsychiatry
sociologistwho became in 1950 the Presidentof based outsidemedicine?Or, are Freeman'sand
the Russell Sage Foundation.Young became a Lutterman'sassertionsof a false dichotomy
consultant
to Felixat NIMH, andat thesametime, betweenacademic and applied sociology more
the valid?
to stimulate
at RussellSage a program
initiated
side of
of sociologistsin the professions.
My own readingis thatthe intellectual
participation
without
respectto the
From that program,many of those who later medicalsociologyis thriving
medicalsociologists structural
positionof the scholar.Certainly,the
became the mostprominent
work is influencedby the greatersociopolitical
gottheirfirststart.
expanded climatein whichthe sociologistacts. Therefore,
The role forsociologyin psychiatry
of researchemphasis
quicklyfromresearchto includemedical school whenone chartsthepatterns
teaching. Throughoutthe fiftiesand sixties, in medical sociology'sgrowingbody of knowldemand
oftheincreasing
remainedthechiefsponsorof medical edge,thereis a reflection
psychiatry
sociology in medicine,particularlyin medical forappliedresearch,andof thechangingnatureof
and-Medicaid
shiftedits medicineitselfinthispost-Medicare
education.When,however,psychiatry
In Figure1, I suggestfive
towarda primaryemphasisin healthcareenvironment.
own orientation
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273
INSTITUTIONAL TRENDS
FIGURE 1. IntellectualTrends in Medical SociologicalInquiry
TO
FROM
a social psychologicalframeof reference
institutionalanalysis
small-scale social relationsas subject of research
large social systems
role analysis in specificallylimitedsettings
complex organizationalanalysis
basic theoretical concerns with classic social
analysis of behavior
policyscience directedtowardsystematictranslation
of basic knowledgeinto decision-making
analysis
a perspectiveof humanrelationsand communication power-structure
broad intellectual
trendsin medical sociological in thestyleof theindividualacademicscholar,as
inquiry(Bloom 1978; Bloom and Zambrana1983, exemplified
by Freidson,Fox, and Freeman.All
p. 109).
outsidare insidersto sociology,and, structurally,
suchpatterns
of inquiry,
to add thatthey
By abstracting
I do not ers to medicine.It is important
meanto suggestthatimportant
acceptancefor their
researchis lacking have achieved outstanding
in thetypeslistedin Figure1 in theleft"From") scholarship
in themedicalworld.
The second site is what Straus(1955) called
column. Quite the contrary,new work of the
by Elinson,
highest
in socialization,
qualityis appearing
adding "sociologyin medicine,"exemplified
significantly
to ourunderstanding
of internship
and Scotch,and Goss.6 Theyworkinsidethe instituresidency(Bosk 1979; Mizrahi 1986), on the tionsof medicine,and therebyare to thatextent
interpersonal
relationsin settings
suchas neonatal outsidersto sociology.
Thethird
majoremployment
siteis innonacademic
intensivecare (Guilleminand HolmstromForthin hospitals,and in the
coming), on doctor-patient
relations(Mishler, settings,in government,
Amarasingham,Hauser, Liem, Osheron, and privatesector.
willinclude
The manpower
patterns
ofthefuture
Waxler1981; BeckerandMaiman1983),on basic
itis not
theoreticalconcernsas they apply to medicine all threecategoriesbutin whatproportion,
(Waitzkin1983) and on the social psychologyof possibleto estimatefromexistingdata.
illnessbehavior.Nevertheless,
Certainlysociologistswill continueto study
thetrended
emphaandinsiders.Whatis at
sis appearsto be in the directions
chartedin the medicine,as bothoutsiders
of their
risk,however,is thecriticalindependence
Figure1.
As partof thesetrends,sociologyhas shifted intellectual
workwhichis againbeingattackedby
attention
to questionsabout the organizationof conservativeideologists.Like all sociologists,
healthcaredelivery.Whilequalityof medicalcare medical sociologists must face in university
remainsthedependent
variable,theshiftis to the teachingtheso-called"truthsquads" of theright,
determinants
of quality and the veryreal possibilityof influenceby a
analysisof organizational
thatis tryingto actualizethe sentiof care, as represented
by corporateand labor government
yearsago against
organizations
(Starr1982;Leyerle1984;Mechanic mentsof thosewho arguedforty
NSF supportof thesocial sciences.
1979, 1985).
Whereare thesescholarsemployedwhilethey
Medical sociology's further
developmentwill
conducttheirscholarlywork?The rangeis wide, occur withoutthe benigneffectof institutional
in its formative
fromconventional
academicpositions(Mechanic, forcesand personagesimportant
Starr,and Bosk) to a school of social work years.Followingare some of the mostimportant
examples.
(Mizrahi),a schoolof publichealth(Becker),and historical
a medicalschool(Waitzkin).This is thesame for
First, there were leadership,guidance, and
At the Russell
thescholarswho represent
boththeolderand the supportfromprivatefoundations.
neweremphases.
Sage Foundation.theworkof Donald Young,
To predictthefuture,
one mustallow forthree Leonard S. Cottrell,and EstherLucille Brown
sites for medical sociology. benefitted
major employment
manymedicalsociologistsas the field
Thereis, first,
thesubspecialty
in theconventional was becoming established. Similarly, at the
tradition,where the role is mainlythatof the Commonwealth
Fund,LesterEvansreachedoutto
likeRobertMertonandGeorgeReader,
and graduate individuals
teacher,focusedon undergraduate
sociologystudents,and whereresearchis largely settingthe prioritiesfor research but never
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274
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
or definingtheir inquiry. At the
obstructing
MilbankFund, AlexanderRobertsonand Robin
Badgleyexertedthesame influences.
in the
Second,thereweremedicalprofessionals
NIMH and in medical educationwho showed
of the potentialcontribuunusualunderstanding
tions of sociologyand were able effectively
to
bringphysicians
andsocialscientists
intointerprofessionalpartnership.
One mustcontrast
thereceptiveness of psychiatrists
such as RobertFelix, Daniel
Funkenstein,
Milton Greenblatt,Eugene Brody,
and Harold Lief withthe currentleadersof the
disciplinewho, almostwithoutexception,have 2.
abandonedpsychosocial
orcommunity
problemsin
theirpursuitof theneurochemical
and 3.
explanation
controlof mentalillness.
Third, I cannot avoid comparisonsbetween
thosephysicianswho challengedthe structure
of
medical education-Hale Ham, George Reader,
GeorgeMiller,HilliardJason-withtheleadersof
medicaleducationtoday.Thereare some heirsto
4.
theirstyle, such as ArthurKaufmanand Scott
Obenshainat theUniversity
of New Mexico,Kurt
Deuschle at Mount Sinai, and the innovatorsat
McMaster;but,in all, I finda loss ofvisionamong
theleadersofmedicaleducationtodaythatis notin
keeping with the promise that stimulatedthe
of medicalsociology.
growth
Thereis todaya different,
less supportive
social
climatein whichmedicalsociologymustdevelop
both its "cognitive" and "social"
intellectually
identities(Mertonand Gaston 1977, p. 5). In
becoming useful to society and medicine in
we sharetheriskof all intellectualsparticular,
who venturebeyond the customaryacademic
theroleof independent
role-of subverting
critical
scholarto thatof theskilledtechnocrat.
If greater
medical acceptance means less loneliness and
isolation,it also calls fortha need to maintain
scholarlyindependence.
In sum,medicalsociologyneedhave no fearof
survival,but the styleand qualityof its professionallifeare fullof uncertainty.
gistat theHarvardSocial RelationsDepartment,
and
at thetime,a memberof theAlbertEinsteinMedical
Schoolfaculty.WhentheASA changeditsby-lawsto
create"sections" forsubspecialties,
medicalsociology was one of the firstto petitionformembership
and the processwas initiatedby the Committeeon
Medical Sociologywhich,in effect,asked its then
200-plusmembersto join the ASA as a section.
Kutner'sgroupwas vigorousin its opposition.The
at thetimeprintedlettersthat
Committee
Newsletter
werepredominantly
fromtheopposition
group,which
wantedmedicalsociologyto be separateand unaffiliated.Yet whenfinallya vote was taken,all but
about25 of theCommittee
membership
votedto join
ASA as a section.
Whenusingtheseterms,I referto thebasic paperby
RobertK. Merton(1973).
The Sectionon Medical Sociologyof the American
Sociological Associationbegan in 1962. However,
had itsoriginsin whatwas calledthe
thisorganization
Committee
on MedicalSociology,which-wasstarted
informally
in 1955bya groupofYale sociologistsled
by AugustB. Hollingshead.The committee,
though
tiestothe
independent,
gradually
developedunofficial
AmericanSociologicalAssociation.
A key role forsocial sciencebeganeven beforethe
United States enteredthe war. As Lazarsfeldand
Reitz describeit (1975, p. 6), "In 1939, Roosevelt
began cautious supportof the allied side through
Lend-Leaseand similarpolicies.The country
was in
no way unitedbehindthiseffort,
and apparently
the
Presidentwatchedpublic opinionpolls rathercareto
fully." HadleyCantrilhadleftPrinceton
University
head a special opinionresearchagency,originally
Cantril(1967) tellsof
financed
byNelsonRockefeller.
severalinstancesof how he providedthe Executive
Officewithinformation
on publicopinionhereand
abroad.Atthesametime,theUnitedStatesArmywas
greatlyenlargedand tookthe unprecedented
stepof
a Divisionof Researchand Information.
This
creating
became the well-knownresearchgroup headed by
Samuel Stouffer.Lazarsfelddescribes how, after
Pearl Harbor, all governmentagencies became
involved in large-scalesocial researchactivities.
"The OfficeofWarInformation
concerneditselfwith
civilian morale; the armed servicesworriedabout
training
of theOffice
soldiers;theoverseasoperations
of StrategicServices tried to anticipateenemy
moves" (Lazarsfeldand Reitz 1975). In the War
andtheForeignMoraleAnalysis
RelocationAuthority
Division,AlexanderLeightonorganizeda groupof
social scienceresearchers.
HadleyCantrilwas given
forthe ForeignBroadcastMonitoring
responsibility
Service.
NOTES
then head of the Milbank
5. Edgar Sydenstricker,
MemorialFund,wroteChapter12: "The Vitalityof
1. Most recently,this is the case for what is called
"clinicalsociology." It appearsto be settingitsown
theAmericanPeople." This was an extensivereview
sociolcourse,deliberately
separatefrommainstream
of healthindicators
of thehealthof
givinga portrait
ogy.In the1950's,thefirst
professional
associationof
the Americanpeople at thattime.HarryH. Moore,
medical sociology, "The Committeeon Medical
thenon the staffof the Committeeon the Costs of
Sociology,"was pressured
by a groupthatsoughtto
Medical Care, wrote Chapter 21: "Health and
maintaina professionalstatus separatefrom any
MedicalPractice."
existingprofessional
group.A leaderof thismove- 6. Jack Elinson is formerChairman,Departmentof
mentwas BernardKutner,trainedas an anthropoloSociomedicalSciences of the ColumbiaUniversity
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275
INSTITUTIONAL TRENDS
School of Public Health, now ProfessorEmeritus.
Norman Scotch is Dean and Chairman of the
Departmentof BehavioralSciences at the Boston
University
School of Public Health. Mary Goss is
Professorof Sociologyin the Department
of Public
Health,CornellUniversity
School of Medicine.
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