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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 Stable URL: http://www.jstor.org/stable/2136746 . Accessed: 10/10/2014 00:15 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. . American Sociological Association is collaborating with JSTOR to digitize, preserve and extend access to Journal of Health and Social Behavior. http://www.jstor.org This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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, This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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. This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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 This content downloaded from 210.212.93.44 on Fri, 10 Oct 2014 00:15:19 AM All use subject to JSTOR Terms and Conditions 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. 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