Medical Personnel

I. PHYSICIANSEliot Freidson

BIBLIOGRAPHY

II. PARAMEDICAL PERSONNELEliot Freidson

BIBLIOGRAPHY

I. PHYSICIANS

The physician is the most prominent among members of the generally recognized professions. He is seen by the public as possessing a higher standard than any other professional,and by the sociologist as the virtual prototype of his kind. While it would be a great mistake to confound what is peculiar to medicine with what is characteristic of professions in general, the study of physicians does offer the sociologist the opportunity to test both thetruth and the utility of various orientations toward the concept of a profession.

One orientation sees a profession as an aggregate of people finding identity in sharing values and skills absorbed during the course ofintensive training through which they all have passed in order to become professionals. In this view the professional is primarily a particular kind of person; one determines whether or not an individual “is” a professional by determining whether or not he has internalized certain given professional values. One explains a “bad” professional by reference to his inferior education, his defective character, or similar variables. In short, one explains the behavior of members of a profession by reference to individual attributes and experiences bearingon conformity to a given set of norms.

Another orientation sees the profession as a group of workers joined together on the most general level by virtue of sharing a particular positionin society and by common participation in a given division of labor. More specifically, the behavior of the profession is interpreted by reference to the way in which its work life is organized and the pressures toward conformity or deviance implicit in that organization. Here, the general assumption is that one defines a professional by his status, irrespective of the norms to which he subscribes, and explains his behavior by reference to the work structure in which he participates.

One difficulty in assessing the virtues of each of these orientations is the fact that there has been little attempt at testing them by sustained and detailed analysis of any single profession. And there has been littleof the comprehensive comparative analysis that must be the ultimate goal ofthe sociology of medicine. Furthermore, because one of the marked characteristics of established professions is their relative freedom from lay intervention, from the conventional discipline exercised by industrial employers,and from the detailed directives of crafts unions, both organization and structure have been difficult to perceive. Professional organization is usually taken to be synonymous with the formal professional association, and the actual organization of work or practice has gone largely unnoticed.

This article, by attempting a detailed analysis of the medical profession and by focusing particularly on the way the performance of medical work is controlled, will try to clarify both the sociological characteristics of the medical profession and some of the issues germane to the sociology of the professions. (For a more extended analysis, see Freidson 1966.) Because of the paucity of systematic empirical studies from other countries, it is regrettably necessary to run the risk of parochialism and concentrateon medicine in the United States.

Medicine and the state

The foundation on which the analysis of a profession must be based is its relationship to the ultimate source of power and authority in modern society—the state. In the case of medicine, much, though by no means all, of the profession’s strength is based on legally supported monopoly over practice. This monopoly operates through a system of licensing that bears on the privilege to hospitalize patients and the right to prescribe drugs and order laboratory procedures that are otherwise virtually inaccessible to the layman. It is the state that grants this monopoly, the exact form of which varies widely throughout the world.

In the United States the profession, through its private associations, has very largely been given the right to determine how political and legal power bearing on medicine shall be exercised (see especially Hyde et al. 1954). In such countries as Great Britain, where the state has set up a national health system, representatives of the independent and private professional associations sit on both policy-making and administrative boards and negotiate with the state on various issues influencing practice (Stevens 1966). In the national health system of the Soviet Union there is no really private or independent representation of the profession that can negotiate with the state, although advisory and administrative councils do include physicians (Field 1967).

Clearly, the economic and political autonomy of the medical profession varies from country to country. What seems invariant, however, is its technological or scientific autonomy, for everywhere the profession appearsto be left fairly free to develop its special area of knowledge and to determine what are “scientifically acceptable” practices. In national state health systems, although laymen do serve in policy-making and administrative positions, physicians tend to be administrative heads of practicing units and to be responsible for the determination of technical standards of equipment, procedures, and performance. Thus, while the profession may not be everywhere free to control the terms of its work, it is free to control the content of its work. Similarly, it is free to control the technical instruction of its recruits.

Medical training

The medical profession, quite as much as most sociologists, considers medical education to be the major single factor determining the performance of the practicing professional. By the content of his education the studentis “socialized” to become a physician. The assumption is thatin the course of such an education a new kind of person is created. Medicaleducation in the United States is perhaps unparalleled by any other conventional professional training in its duration, its detail, and its rigidity.Medical school lasts four years after under-graduate college, followed by afifth year of supervised practice in an accredited teaching hospital (the internship), and even more years for those seeking certification as specialists. It would seem reasonable to think that such intensive exposurein fact molds the student into a particular kind of person. The Columbia University study of medical education (Merton et al. 1957) sought to demonstrate that the student, in the course of his training, develops a conceptionof himself as a doctor, absorbs the knowledge he needs in order to be secure enough to deal with patients without too much anxiety, and attains the capacity to cope with basic uncertainty in clinical practice.

Nonetheless, the students’ perspective on their educational experience differs from that of their instructors. Indeed, one may expect there to be some kind of conflict between students and faculty by the very nature of their different roles. It is the unique contribution of the University of Kansas study (Becker et al. 1961) that it demonstrated the clash ofperspectives in medical school and showed that the differences in orientation leading to “restriction of production” are not limited toindus-trial organizations. The consequences of this for the educational process were followed up in some detail. But the study also emphasized that the existence of this clash of orientations did not mean that there was nothing in common between the performance of students and the demands of faculty. It was discovered that two dominant values, held by the faculty, were adopted by the students and used by them to guide their learning experience and select their careers. These were the values of medical responsibility and of clinical experience (ibid., chapters 12 and 13).

The value of medical responsibility refers to the traditional ideals of medicine, according to which the physician holds the life of a patient in his hands. It is the personal responsibility held by the physician workingdirectly with a patient that requires him to take the blame for bad results. In the Kansas study, it was found that this value was impressed on the student by frequent faculty lectures about the way in which mistakes of omission or commission endanger the patient’s life. Further-more, faculty members frequently asked students how they would handle an emergency soas to avoid serious consequences to the patient. The value also featured inthe organization of the training hospital, where the hierarchy of medical staff was ordered by differential access to medical responsibility, so that the unlicensed student was restricted to routine work having little relationship to life-or-death issues and the highest-status person was free to carry out the most complicated and dangerous procedures.

Clinical experience refers to first-hand contact with patients anddisease. Such contact is the ultimate justification for deciding to use oneprocedure for a treatment rather than another, and the experience so gained is valued because it provides a basis for therapeutic choice that is believed to be superior not only to the abstract considerations posed in textbooks but even to general, scientifically verified knowledge. It was observed in the course of the Kansas study that argument from experience was unanswerable except by the same type of argument from someone with greater experience.

These two values, Becker and his colleagues argued, order the choices the student makes from the range of experience offered by the medical school. These choices limit and direct his efforts in ways not anticipated or approved by the faculty. One of the student’s most difficult problems is to select from the enormous mass of facts presented to him the information he is really to learn, for he cannot learn all of it. The idea of clinical experience, it was suggested, guides his selection of facts and information, leading him to discount basic science and focus on classes in which instructors give practical information not found in books—information that adds to his store of vicarious experience. By the same token, he struggles for personal clinical experience in his training, seeking opportunities for expanding it and deprecating routines he has already mastered. Similarly, he seeks tasks in which medical responsibility is apparent—reflecting some risk or danger—and avoids those in which it is not. And, finally, he responds positively to some patients as cases presenting him with valued responsibility and experience, and to others negatively as cases that take up a great deal of time without any valuable recompense (Becker et al. 1961, chapters 14 and 16).

The evidence seemed to show that choice of career also hinges on how farspecialties provide the opportunity for medical responsibility and clinicalexperience. Thus, a desirable specialty is one which offers a wide variety of experience and in which responsibility is symbolized by the possibility of killing or disabling patients in the course of making a mistake. Internal medicine, general surgery, and pediatrics are therefore the most popular specialties, although the potentially “mechanical” character of surgery and the necessity of liking to work with childrenin pediatrics qualify their desirability for some students. At the other extreme, specialties like dermatology and allergy are unpopular because they are thought to involve little danger (and therefore little responsibility) or little variety (ibid., chapter 20).National surveys of medical students in the United States have accumulated a fair amount of data on specialty choice, most of which are compatible with thisinterpretation of the values underlying the choices of the majority of students. In the case of those choosing the less popular specialties—the best-investigated of which is public health (Coker et al. 1966)—specification of more detailed patterns of values is of course necessary.

Empirical types of practice

Unmentioned in the course of the discussion of medical training is one element of great relevance to performance: the technical knowledge and skill learned by the student. Here, it is necessary to say only that the student does in fact gain command over a great deal of knowledge and skill; what we must dwell on is the fact that this knowledge and skill is not necessarily retained or used after graduation from medical school. While ina modern industrial country like the United States all physicians share the same basic technical education, they do not all practice in the same way. In the few systematic studies of medical practice that have been made, the association found between medical education and subsequent performance was at best very weak. While the available evidence is scanty and poor, it points to variation in the organization of practice—that is, in the organized setting in which the professional works—as a more important influence than medical education or variation in performance. (For a summary of this material, see Freidson 1963; for theparallel case of the lawyer, see Carlin 1966.) Indeed, the analysis ofwork organization or practice is a critical problem for the sociology of the professions.

The central issue in the analysis of work is how performance is controlled. This issue constitutes a special problem for the analysis of professional work because professions, unlike other occupations, have successfully gained freedom from control by outsiders. Indeed, a profession is said to control its own performance. This is a rather unusual arrangement, worth understanding both in itself, as one type of control, and in its bearing on how, in our complex world, freedom and autonomy can be joined with responsibility. Let us examine the various organized practices in which medical work takes place to see how control over performance can be exercised. (For a more extensive examination, see Freidson 1963.)

One type of practice that is frequently held up as the ideal by professionals is one in which the individual is an entrepreneur, free to do whathis own conscience and knowledge dictate. This is so-called solo practice. While pure forms of solo practice are quite rare—invoking it as a norm reflects the individualistic ideology of the profession more than itreflects reality—we might ask what conditions must be met to assure that individuals practicing entirely on their own conform to professional standards. Assurance of adequate performance on the part of solo practitioners seems to require exceedingly careful recruitment policies and extraordinarily effective educational procedures. In essence, the practitioner must be able to resist all temptations to ethical or technical lapses by virtue of his inner resources alone, resources which must also motivate him to continue to keep up-to-date. In solo practice the burden of control rests solely on individual motivation and capacity.

Much more common than solo practice in the United States today is practice involving a loose network of interdependent practitioners who refer cases to each other-an informal organization that has been described as a “colleague network” (Hall 1946). Backed by a stable clientele relatively loyal to them, the practitioners in such a networkcontrol access to that clientele and thus access to work on the part of newyoung practitioners. In the rather well-organized case he studied, Hall showed how an “inner fraternity” of practitioners controlled access to practice settings and desirable patients and how, through the mechanism of sponsorship, newcomers were obliged both to take on minor tasks and to turn to their sponsors for consultation. While it may be doubted that professional services in large cities can be wholly dominated by any single informal fraternity, the sociometric studies of Coleman and his colleagues (1966) suggest that there are systematic and persistent patterns of interrelationships among practitioners even in so loosely organized a system as exists in the United States. These patterns of inter-action suggest two of the most important prerequi-sites for control of the practitioner’s performance by colleagues rather than by clients: by referring patients to each other, each practitioner has theopportunity to observe some of the other’s performance; by being economically and technically interdependent, each practitioner has someleverage to influence the other’s performance.

Finally, one may mention the less primitive structures of practice that are characteristic of some European countries and are represented in the United States by large group practices and university clinics. These are essentially bureaucratic organizations, although the variations in actual administrative detail are countless. We may point to one logically distinct type of bureaucracy that has received some theoretical attention in the literature because of its systematic deviation from the classical rational-legal model of bureaucracy. It has been called professional bureaucracy, and it has been characterized as a form of organization in which the hierarchy of professional practitioners is set apart from the hierarchy of the administration itself or (as in many European countries) a form of organization in which all important positions of organizational authority are filled by professionals. In both cases, professional work is free from the exercise of the authority of nonprofessionalseven though the working professionals are technically subordinates in a bureaucratic system and lack the freedom of the entrepreneur. The exact theoretical importance of such a logical construct and the degree to which it mirrors enough of reality to be useful are by no means clear, but by pointing to the bureaucratic elements of organization it does indicate that here, more than in other forms of practice, physicians are in a position of interdependence that implies opportunities to observe and to exercise influence over one another’s performance. Of all the types of practice reviewed, the bureaucratic type provides the best opportunity for professional self-regulation. Indeed, this is the type exemplified by high-prestige academic institutions in the United States andelsewhere.

Analytical types of practice

Thus far, it has been suggested that there is a range of practice organizations, from purely individual practice to bureaucratically organized practice. To understand how colleagues or clients may gain access to observe and influence performance, it is useful to distinguish those features of practice which determine both the source and the content of control. Inthis way it becomes possible to analyze the differential significance in the division of labor of various forms of specialization. The lay client’s perspective on the service he seeks differs from that of the colleague group of professionals: this may be taken as axiomatic. Let us therefore distinguish practices by the degree to which they are amenable to lay or colleague control. It is clear that two types of medical practice form the logical extremes of the medical division of labor. At one extreme is practice wholly dependent on lay choice for its existence: it may be called client-dependent practice. Such a practice survives by using its own resources to attract and satisfy a lay clientele. Since the client uses lay standards in deciding that he needs professional services and in evaluating the services he gets, the practice must conform to lay standards in order to be patronized. Furthermore, when wholly dependent on client choice, the practice cannot be observed by colleagues, nor is its survival dependent on their cooperation. In consequence, all the pressure on the practice is toward conforming to lay rather than professional standards. At the other extreme is colleague-dependent practice. It does not attract its own lay clientele but, rather, obtains clients through the referrals of other colleagues. Thus, in order tosurvive it must honor the prejudices of colleagues, and so is likely to conform more to professional than to lay standards.

How closely do actual practices conform to these logical types? Thelogical extreme of client-dependent practice does not seem fully applicable to any professional practice, although the “independent” solo neighborhood or village general practitioner comes close to it. Also close are specialists who must attract a clientele directly and do not have to make everyday use of hospital facilities- for example, inurban areas in particular, some internists, pediatricians, ophthalmologists, and gynecologists. In these instances lay standards may be expected to have some force. Empirical examples of the logical extreme of colleague-dependent practices are easier to find in modern medicine. Specialists like pathologists and radiologists, for instance, are almost completely dependent upon colleague referrals and therefore have little need for such client-oriented techniques as a good bed-side manner. Here, we should expect considerably greater pressure to honor colleague rather than lay or patient standards.

This typology is based on the division of labor within the profession and is therefore applicable to analysis of the control of performance of individual practitioners in any kind of organized practice, from solo to bureaucratic. It might be pointed out, however, that in bureaucratically organized practice it is frequently the organization as a unit, not individual practitioners, that attracts a clientele and that all practitioners in the organization are therefore dependent on it for their work. Insofar as the organization is of the “professional” type discussed above, this means that dependence on it is actually dependence on the colleagues running it. Encouragement to meet professional standards of performance will therefore be considerably stronger than encouragement to meet lay standards. And insofar as work is at once more visible andamenable to control in such an organization than in less well-organized forms of practice, it is here that we should expect to find the highest professional standards. Indeed, it is the general opinion of teachers of medicine in the United States, Great Britain, and elsewhere that this is the case, although adequate evidence to test this opinion has not yet been gathered.

All else being equal, then, we may hypothesize that colleague-dependent practices, in which the physician’s performance is observable to and his work dependent on colleagues, will also be most likely to conform to professional standards. Insofar as bureaucratic practice is colleague-dependent, the same conclusion may be drawn for it. But this conclusion masks several assumptions the truth of which is not self-evident: first, that colleagues will exert control over performance; second, that the mechanisms of control used by colleagues are effective; third, that standards are homogeneous throughout the profession. The remainder of this article will explore these assumptions.

Professional regulation

Variation in the organization of medical practice bears on such necessary conditions for the exercise of professional regulation as the observability of performance to colleagues and the structural vulnerability of the practitioner to control by colleagues. However, while observability and dependence are necessary conditions for the effective exercise of supervision, they are not sufficient. What is needed in addition is the willingness to exercise supervision and exert effective influence over performance. What slender evidence there is suggests that rather less influence over performance is exercised than the organization of practice actually allows, and that the little regulation which does exist has properties that establish and maintain organized differences inperformance standards.

The basic property of the system of control that seems to exist in the United States is its reliance upon what Carr-Saunders and Wilson, speakingof British medicine, call the “boycott”—that is, therefusal by individual practitioners to enter into a referral or collaborative relationship with those of whom they do not approve (1933, p. 403; seealso Hyde et al. 1954). This device does not control the boycotted person’s behavior so much as it pushes him outside the boundaries of observability and influence, to practice as he wishes in the company of those with similar standards. There seems to be a certain reluctance to exert active influence over another’s performance—a reluctance that results in avoiding him rather than in seeking to change him.

There is, unfortunately, little systematically collected empirical information bearing on the process of supervision and control among physicians. A study by Freidson and Rhea (1963; 1965) of a large academically oriented group practice in the United States indicated that while performance was visible along the axes dictated by the interdependence of specialties within the over-all division of labor, each practitionertended to keep his complaints about others to himself, so that what he could observe of others’ performance in the division of labor was nottransmitted to other col-leagues. Since bits of information were scattered piecemeal through the colleague group, no really organized control of performance could be initiated unless a man behaved so outrageously as topersonally offend everyone. Furthermore, attempts at control were largely individual and hortatory, and there were no control devices intermediate between remonstration and outright ejection from the organization (the latter being the structural equivalent of the boycott). While the physicians studied were aware of the looseness of supervision and control in this ostensibly well-organized practice, they were inclined to feel it adequate and appropriate for ordinary circumstances.

Another American study (Goss 1961; 1963) is particularly instructive because it was done in a setting into which supervision was built. There were clear bureaucratic as well as professional supervisory responsibilities allocated through hierarchical ranks. The superior physician in the hierarchy had the right and perhaps even the obligation to review case records and evaluate case management. Furthermore, he had the right to give advice to subordinates about the way a caseshould be handled, even when advice was not solicited. However, even though the supervisor was officially responsible for the care given to patients in his unit and therefore had the formal right to order that certain procedures be followed for a case, he very rarely gave such orders. Instead, he gave advice, which incurred no obligation to obedience. The only obligation the subordinate had was to consider the advice in the light of his personal experience with and responsibility for the case. So long as he could justify his management of the case by reference to medical knowledge and his clinical experience, and so long as it was he who took personal responsibility for the outcome, he could reject the advice of his superior. In short, even here, where supervisory inspection of performance was routine, the exercise of control over performance was quite loose and permissive. If this is so in hierarchically organized practice settings, it should be even more the case in the informal, small-scale community practices that are far more common in medicine. Thus, we may say that the medical profession, which has gained freedom Physicians from regulation by others,regulates itself in ways whose effectiveness is not self-evident. The analytical problem here is tounderstand what contributes to shaping this peculiar process of regulation and to point up its structural consequences.

Professional values

Obviously, when a social structure permits certain kinds of behavior but that behavior does not occur, we must explore the situation further to explain why it does not. Our first question might be why, in such a loose system, the physician does not routinely abuse his privilege.Here, the internalization of general professional values postulated byParsons (1951, chapter 10) seems a plausible explanation. Parsons defines the professional as someone who is supposed to be recruited and licensed on the basis of his technical competence rather than his ascribed social characteristics; to use generally accepted scientific standards in his work rather than particularistic ones; to restrict his work activity to areas in which he is technically competent; to avoid emotional involvement and to cultivate objectivity in his work; and to put his client’s interests before his own [see Professions]. These normative expectations are intended by Parsons to apply to all professions, not only to medicine, since he treats the medical practitioner as the archetype of the professional. But it may be objected that the same expectations are applicable to all technical service occupations, not only to professions. Plumbers, too, are supposed to be recruited and licensed on the basis of achievement, to employ universalistic standards in their work, to be functionally specific and affectively neutral. And while plumbers are expected to make enough money from their work to gain a decent income (just as are physicians), they are not expected to do this by cheating the customer. Thus, such values constitute only the most general foundation of conscientiousness in occupational practice.

Our second question, however, may be more specific to the medical profession. Why, if it so conscientious, does it not exercise more regulation over its members’ performance? Such an extraordinarily loose regulatory structure has been explained by Carr-Saunders and Wilson (1933, pp. 399–400) and by Parsons (1951, pp. 470–471) by reference to the character of professional work. Instead of a set routine, medicine requiresthe exercise of complex judgment; instead of caution, the taking of risks. Therefore, regulation can only be loose. But of all the old established professions medicine is the one most based on fairly precise and detailed scientific knowledge. Indeed, the practice of medicine involves considerably less uncertainty than many other technical occupations. As the use of the doctrine of res ipsa loquitur in American courts implies, there are some very clear rights and wrongs in medicine, even if there are also some uncertainties, and these rights and wrongs have not brought forth any formal regulatory mechanisms from the profession as such (as opposed to concrete organizations like teaching hospitals, in which regulatory mechanisms do exist). Without denying that there is a degree of uncertainty, we must conclude that the precision possible in much of modern medicine and the trivial routine of much of everyday medical practice call into question the adequacy of explaining the peculiarly loose structure of controls to be found in the profession by reference to the character of its work. However, it may be that the peculiar nature of the work of the practicing professional encourages a characteristic sense of uncertainty that reflects considerably more special values than those described by Parsons.

One such value is that of independence, or autonomy, which is significant for physicians in countries as different as Finland andthe United States. Insofar as this value refers to social and economic independence, it reflects the entrepreneurial and individualistic ideology of the bourgeoisie, who are the prime source from which physicians are recruited in virtually all industrial countries. Insofar as the value refers to technical or professional independence—that is, the freedom to practice one’s craft without interference, advice, or regulation by others—it seems more closely related to a state of mind encouraged by the character of professional work.

The aim of the practitioner is not knowledge but action, and while successful action is the aim, the tendency is to assume that any action at all is better than none. Furthermore, to take action requires faith in oneself and even a will to believe in what-ever one does instead of maintaining a skeptical detachment. Dealing with individual and concrete cases, the practitioner is inclined to emphasize in-determinacy rather than lawful regularity and to be radically pragmatic, relying more on the results he associates with his own actions than on theory. These seem to be the orientations that contribute to the emphasis on clinical experience mentioned earlier in connection with medical education.

Given that the work of the medical practitioner is with individuals and that it is believed to be based on individual clinical experience, it follows that responsibility for the work can be perceived only as individual and personal. In assuming that responsibility, the practitioner does gain gratitude for success, but he also gains reproach for failure. Given the risk of blame, he evidences a certain sensitivity and defensiveness in the face of any outsider’s evaluation of his performance. This defensiveness is manifested in imputing more uncertaintyto the work than in fact exists and in insisting on using his own personal, clinical experience as the ultimate criterion for evaluating his own performance. Thus, collective responsibility for regulation is diminished, and the inclination to rely on individual responsibility and personal experience is augmented.

These, of course, are merely suggestions of the complex task that has still to be done in picking out and interrelating strands of whatmight be called the ideology of the practicing professional. Instead of dwelling on values of such generality that they have doubtful analytical utility for under-standing the quality of professional self-regulation, sociologists should determine the specific values attached to different types of professional work. Such an approach would supply one of the critical elements for an adequate explanation of the peculiarities of professional organization.

Informal organization of the profession

Even without detailed information it seems possible to suggest that the notion of informal organization serves as a vital link between the formal structure given to the American medical profession by the national, state, and county medical associations (see Hyde et al. 1954) and professional performance in the concrete setting of medical practice. By focusing on the characteristic way in which practitioners assert control over each other’s performance, one can delineate the relation of one local practice to another and the loose groupings of practices that both carve up a community and extend outside its boundaries. When these informal groupings and the mechanisms of control they express areseen to be intertwined with the formal structure of the profession as a whole, much more of the character of the profession can be understood than by reference to formal associations and codes alone.

Recalling that ordinarily the ultimate mechanism of control is the personal boycott, we can begin to indicate the informal structure of the profession by following out the implications of the boycott’s operation on the interrelations of practitioners. Let us assume that individual practitioners are free to select the work they will undertake and to choose the colleagues with whom they will work in the division of labor.In this situation, control of professional standards is exercised largely by willingness to work with one man and to exclude another. But since exclusion as such neither changes a man nor prevents him from working, one may assume that he will eventually find a circle whose standards are such that he is not excluded.

There is thus a tendency for the control process to develop a stable set of colleague networks or fraternities. Each network, by the nature of its creation, is fairly homogeneous within itself. Its members share about the same professional standards, participate in each other’s work, and participate in, if not dominate, the particular organizations and practices in which they work. But while each colleague network is likely to be fairly homogeneous, many differences are likely to exist between networks by virtue of the process of selection and rejection that differentiates them into separate networks. Thus there is not only likely to be little interaction between many contiguous networks, but also marked differences in technical and normative standards and in the practices and institutions in which the members of each network participate.

In a structure of this nature there is comparatively little opportunity for those in one network to be very much aware of the existence of other standards; and even when awareness may exist, there is little leverage by which one network could influence another because each has severed connections with the other and is independent of the other. Since it is a segregating process that leads to and maintains such networks, and since the individual’s behavior is less regulated by such a process than classified and assigned to a self-maintaining collectivityof like people, we can see how within a single profession, even one quite free of lay interference, organized variations in professional performance can occur. While there are certainly social links between adjacent fraternities in the form of practitioners with connections in both, it does not seem to require a very large city to find individual practitioners who know nothing about each other.

The characteristic control mechanism of professional regulation, then, paradoxically operates to place offenders beyond the control of those who disapprove of their performance. Moreover, the in-formal organization of internally homogeneous colleague networks segregated from interaction with each other sustains, if not reinforces, the differences in standardsbetween networks. Apart from civil suit, which is a nonprofessional source of control over practice, and regulatory devices established in the limited milieu of teaching hospitals, all that is left to concerned members of the profession in the United States is exhortation and, it is hoped, instruction by means of articles in professional journals that may or may not be read and that, if read, may or may not be influential on behavior.

What has been suggested, in short, is that the disjunctive process of social control characterizing the concrete, everyday practice of American physicians creates an informal structure of relatively segregated, small circles of practitioners, the extremes of which are so isolated from each other that the conditions necessary for each influencing the other’s behavior are missing. Furthermore, the mechanism of control that produces and sustains this situation is no aberration—rather, it is characteristic of the profession, an outcome of itsorganization and of the way it sees itself and its work. The consequence is that a single profession can contain within itself, and even encourage, markedly different ethical and technical standards of performance, limited in a very superficial way by the minimal standards imposed by selective recruitment, a basic core of training required for licensing, and the writings of the leaders of the medical profession.

Tasks of a sociology of medicine

The problems of analysis described in this article are not unique to the sociology of medicine but affect the sociology of professions in general. If they can be solved for medicine, we will have taken a long step toward solving them for all professions. The central problem here, as in the study of society in general, is social control. The problem is particularly important for the professions because by definition they are freeof the controls common to most occupations. In addressing the problem of control, it was necessary to assess the role of the state and of politico-legal institutions, the manifest and latent functions of professional education, the organization of work, the control processes operating in work, and the norms or values that bear on the exercise of social control in work. The outcome of that analysis was the suggestion that a fragmented structure underlies the serene facade of unity and homogeneity implied by the notion of a single profession joined by common values and a community of identity.

To extend, correct, and refine such a trial analysis of the organization of medical work is one of the prime tasks of a sociology of medicine. In the course of extending it, one would be led quite natu-rally into a more detailed examination of another major problem of analysis: the client-practitioner relationship. This problem, too, might be seen as one of control. The practitioner wants the client to seek him out for professionally appropriate reasons, without visiting quacks and without untoward delay. He wants the client to accept his recommendations and follow them scrupulously. In seeking compliance on the part of his client, the professional cannot always rely on his influence as an expert. The character of this influence and of practitioner-client interaction has barely been explored in other than psychological terms, and poses a challenge both to the taxonomy of types of social influence and to the conceptualization of social interaction.

Finally, we may mention a problem of analysis that has not yet received much attention—the role of the professional in creating and defining his own work. In the case of medicine (more than of law or religion) this analytical problem has been confounded by the reification of “scientific knowledge,” a viewpoint in which disease is taken toexist independently of human action and the physician is regarded as merely a diagnostician and therapist of what is objectively “there.” However, disease that exists independently of human awareness and action is irrelevant to the sociologist, while biologically nonexistent “disease” in which people believe is quite relevant. What is sociologically relevant is a social definition of disease or any other kind of deviance, not the biological fact or fancy. If this premise be adopted, then it follows that physicians are responsible for the social creation of disease in the course of “discovery” and diagnosis [see Health]. It would follow, further, that in medicalpractice the social organization of work biases the way in which diseases are created and shapes the way in which patients are managed and even created by diagnosis. Thus, a major task of the sociology of medicine is to study the causes and consequences of physicians’ conceptions of disease, showing how disease as a social object is createdor formed by medical institutions (Scheff 1966). If this task should be performed as something independent of the conventional study of the processof scientific discovery, and with different premises, we will have come a long way toward understanding the social institutions of medicine as one of the modern professions.

Eliot Freidson

[See alsoHealth; Illness; Medical Care; Professions; Publichealth; Science, article on Scientific Communication; and the biography ofHenderson.]

BIBLIOGRAPHY

Becker, Howard S. et al. 1961 Boys in White: Student Culture in Medical School. Univ. of Chicago Press. Carlin, Jerome 1966 Lawyers’ Ethics: A Survey of the New York City Bar. New York: Russell Sage Foundation.

Carr-Saunders, Alexander; and Wilson, P. A. (1933) 1964 The Professions. London: Cass.

Coker, Robert E. JR. et al. 1966 Medical Careers in Public Health. Milbanh Memorial Fund Quarterly 44:143–258.

Coleman, James S. et al. 1966 Medical Innovation: A Diffusion Study. Indianapolis, Ind.: Bobbs-Merrill.

Field, Mark G. 1967 Soviet Socialized Medicine: An Introduction. New York: Free Press.

Freidson, Eliot 1961/1962 The Sociology of Medicine: A Trend Report and Bibliography. Current Sociology 10/11:123–192.

Freidson, Eliot 1963 The Organization of Medical Practice. Pages 299–319 in Howard E. Freeman, Sol Levine, and Leo G. Reeder, Handbook of Medical Sociology. Englewood Cliffs, N.J.: Prentice-Hall.

Freidson, Eliot 1966 The Sociology of Medicine: A Structural Approach. Unpublished manuscript.

Freidson, Eliot; and Rhea, Buford 1963 Processes of Control in a Company of Equals. Social Problems 11:119–131.

Freidson, Eliot; and Rhea, Buford 1965 Knowledge and Judgment in Professional Evaluations. Administrative Science Quarterly 10:107–124.

Goss, Mary E. W. 1961 Influence and Authority Among Physicians in an Out-patient Clinic. American Sociological Review 26:39–50.

Goss, Mary E. W. 1963 Patterns of Bureaucracy Among Hospital Staff Physicians. Pages 170–194 in Eliot Freidson (editor), The Hospital in Modern Society. New York: Free Press.

Hall, Oswald 1946 The Informal Organization of the Medical Profession. Canadian Journal of Economics and Political Science 12:30–44.

Hyde, David R. et al. 1954 The American Medical Association: Power, Purpose, and Politics in Organized Medicine. Yale Law Journal 63:938–1022.

Merton, Robert K. et al. (editors) 1957 The Student–Physician. Cambridge, Mass.: Harvard Univ. Press.

Parsons, Talcott 1951 The Social System. Glencoe, III.: Free Press.

Scheff, Thomas J. 1966 Typification in the Diagnostic Practices of Rehabilitation Agencies. Pages 139–147 in Marvin B. Sussman (editor), Sociology and Rehabilitation. Washington: American Sociological Association.

Stevens, Rosemary 1966 Medical Practice in Modern England: The Impact of Specialization and State Medicine. New Haven: Yale Univ. Press.

II. PARAMEDICAL PERSONNEL

The term “paramedical” refers to occupations whose work is both organized around tasks of healing and ultimately controlled by the authority of physicians. Ultimate control by medical authority is manifested in a number of ways. First, much of the technical knowledge learned by paramedical workers during the course of their training and used during the course of their work tends to be discovered, enlarged upon, and approved by physicians. Second, the tasks performed by paramedical workers tend to assist, rather than directly replace, the focal tasks of diagnosis and treatment. Third, paramedical workers tend to be subordinate in that their work tends to be performed at the request or “order” of, and is often supervised by, physicians. Finally, the prestige assigned to paramedical occupations by the general public tends to be less than that assigned to physicians.

The paramedical occupations may be distinguished from established professions by their relative lack of autonomy, responsibility, authority, and prestige. However, the fact that they are by definition organized around an established profession and in varying degrees partake of some, but never all, of the elements of professionalism allows us to distinguish them from many other occupations and, indeed, argue that they represent a sociologically distinct form of occupational organization.

Furthermore, it may be noted that paramedical occupations are not adequately distinguished by reference to their health-related tasks. Occupations usually called paramedical do participate in a functional division of labor, but what is distinct about this division of labor is that it is ordered by the authority of a prime profession. Other occupations which may actually perform some of the same technical tasks but which stand in a different relationship to the dominant profession (as does, for example, a herbalist compared to a pharmacist) are not called paramedical, but rather quack or irregular. Differences between the paramedical and the quack do not necessarily arise from the actual tasks each performs, but rather from the relations each has to the dominant profession. Thus, the paramedical worker is less easily distinguished technologically, by the relation of his work to that of others, than sociologically, by his relation to medical authority.

However, distinct as it is, this “paraprofessional” pattern is not common. For example, while there is a fairly elaborate division of labor revolving around law, it would not be appropriate to use the term “paralegal” for bailiffs, accountants, clerks, real estate brokers, and bankers in the same way that we use “paramedical” for nurses and laboratory technicians. Nor does the prefix seem properly employed to designate the division of labor connected with any other established profession. Medicine alone seems to have imposed such definite order on the occupations surrounding it. We can but guess the reasons for this, citing such variables as the comparative specificity and technical complexity of the tasks involved, which can only be exercised in a medical setting. Whatever the reason, this mode of organizing a division of labor is taxonomically distinct, and if it is true that labor is in general being “professionalized,” the paramed- ical model may become more widespread in the future. Both practically and conceptually it is worth close study. How did it develop? What are its present characteristics?

Development of the division of labor

A division of labor in the task of diagnosing and treating human ills has always existed in one form or another in every human society. There have always been diagnosticians, herbalists, midwives, and nurses, even if only on a part-time, amateur basis. However, the distinctive division of labor labeled paramedical—which is to say, one organized around the authority of the medical profession—is relatively new and is complex only in the highly industrialized societies of the world where the modern medical profession arose. Even in these countries it varies a great deal in the completeness of its integration around and control by the medical profession. Unfortunately, there are few adequate cross-national comparisons of the organization of health workers to provide even the basic descriptive information necessary for analysis, and so much of the indication of the types and sources of variation must be based on scattered bits of information (for one comparison, see Glaser 1966).

In Europe a distinctly paramedical division of labor, organized around the authority of a medical man, had begun to emerge at least by the time of the development in cities of the corporate guild and the university. The city provided the population density necessary for the support of a variety of full-time specialists, thereby allowing true occupations to arise. The guild provided the health-related occupations with a workable type of organization through which a distinct occupational identity, visible to officials and public alike, could slowly be established and through which they could press for exclusive rights to that identity and the work it involved. However, the right to have something of a monopoly of title and function—that is, to be licensed—and to control in a fairly strict way access into and progress through the occupational career was obtained from the state. Thus, the occupation gained organization, but it also became subject to assignment, by a political process, to a relatively well defined official position in a larger division of labor—a position that could involve en-forced subordination to members of quite another guild.

The significance of the university in this situation is that occupations trained in one had a stronger claim, by virtue of their aura of learning and science, to a superordinate position in the occupational structure. University training gave physicians and surgeons a strong political position for persuading the state to subordinate to them such competitors as apothecaries, grocers, and barbers, and to allow them to prosecute irregular practitioners. This could be so even when it was doubtful that the actual knowledge and skill of the average university-trained practitioner in those days equipped him to practice any better than his self-taught or apprenticed competitor.

With the development of the university and the guild in European cities, then, there arose a rudimentary structure of full-time health workers, organized, at least in part, under the supervision of physicians and surgeons. For centuries this organization was highly unstable, weakened from within by undisciplined competition and from without by the persistence of a great variety of irregular practitioners (see King 1958; Turner 1959). As is the case with the health services in the noninqdustrial countries of today, the medical division of labor was fairly stable only in those parts of cities where a well-to-do gentry was likely to patronize it. In the city slums and in the countryside the poor and the peasantry persisted in relying on their own folk remedies, their own, largely part-time practitioners, and, on occasion, itinerant irregulars; the first two being part of their own culture, the last exploiting the naїvete of that culture. There were in essence two health systems: the dominant one was rooted in the peasant culture, while the other, which was available only to a minority, owed its greater prestige to its origins in the learned traditions of Western civilization. Before the latter could become at once stable and universal, the former had to be destroyed or at least severely restricted. Not until the twentieth century in Europe and North America did anything emerge resembling a stable and extensive division of labor dominated by physicians, that is to say, a genuine paramedical division of labor. In the nonindustrial countries of the world today, such a structure does not yet exist to any great degree.

Modern developments

The prime prerequisite for the development of a stable and extensive division of labor that is distinctively paramedical seems to be the eradication of great qualitative differences in culture and education among the major social strata of a society. This seems to be so because health services are used mostly on a voluntary basis. People choose to use one health service rather than another, and if only one organized service is available, they can choose not to use it and rely on their own informal resources instead. In this sense, while the application of political power can drive out of practice all but officially li- censed workers, it cannot make people use them. It seems no mere coincidence that the irregular health services declined greatly in industrialized countries about the same time that the institution of compulsory universal education arose. Contributory to this process, but by no means enough by itself (as experience in nonindustrial countries today indicates), was the rise of scientific medicine, which was capable for the first time in history of alleviating many complaints and symptoms consistently and predictably.

By the twentieth century the medical profession was at last able to establish a secure mandate to provide a central health service. In England the rural general practitioner had been drawn into regular medical ranks. In Russia the feldsher had been in part replaced by and in part subordinated to the physician. In the United States the many different kinds and qualities of practitioners, all democratically calling themselves doctor, had been reduced to some uniformity. Control over the focal tasks of diagnosis and prescription was thereby se-cured (Sigerist 1935), and by virtue of its major role as arbiter in the application of new scientific discoveries, the profession could order around itself the proliferating new technical personnel.

Some historical specialties, such as dentistry, survived fairly independently of the paramedical division of labor. Others, such as pharmacy and optometry, were not fully integrated into the para-medical division of labor, remaining at least partially independent of it. Still others, such as bone-setting and, in the United States, midwifery, were taken over by the physician himself, laymen and amateurs being driven out of practice. Others, the most prominent of which is nursing, maintained an ancient function while being brought firmly under medical control. And finally, with some few exceptions, such new specialties as laboratory technology, which arose with the new medical science and technology inside the walls of the hospital and medical school, developed unequivocally as part of an established paramedical division of labor.

Today’s paramedical division of labor is therefore a specifically historical construction, with some functionally related occupations falling inside it and some outside it; not all of the very old or the very new occupations fall inside it. The source of whatever order may be found in this division of labor seems to lie in the character of the relationships to be found between medicine, other occupations, and prospective lay clientele—central to which, perhaps, is the possibility of functional autonomy.

Relations with the medical profession

The interoccupational relations of paramedical workers can be seen clearly only as part of a larger, evolving structure that embraces physicians, health workers who are not part of the paramedical division of labor, and the institutions in which medical and nonmedical health services are provided. One of the major variables mediating interoccupational relations in the health services seems to be functional autonomy—the degree to which work can be carried on independently of organizational or medical supervision and to which it can be sustained by attracting its clientele independently of organizational referral or referral by other occupations, including physicians. On the whole, the more autonomous the occupation and the greater the overlap of its work with that of physicians, the greater is the potential for conflict, legal or otherwise. Such conflict is to be seen between chiropractors and physicians in the United States, homeopaths and physicians in the Soviet Union, and “native” practitioners and physicians in virtually all nonindustrial countries.

The most interesting conflicts, however, occur within the paramedical division of labor during the course of the growth of new occupations capable of attaining functional autonomy. In the United States, where the movement toward professional status is strong and extensive and there are not enough physicians to perform all the traditional functions demanded of them, such conflict is common; it focuses on the question of whether or not nonphysicians are to be allowed to offer health services independently of medical supervision. The outcome has been, in such increasingly successful cases as that of the clinical psychologist, virtual independence in practice, limited only by the legal inability to prescribe drugs. Impelled by the force of professionalization, the growth of new techniques and new occupations to practice them seems to be giving a new shape to the paramedical division of labor. Some years ago it could be visualized quite simply as a pyramid, with the physician at the apex. However, in the present-day United States the pyramid seems to be changing into a less clear-cut structure, at the top of which is a plateau along which are ranged physicians as well as other relatively autonomous, but consulting and cooperating, new professionals.

Recruitment and training

Obviously the paramedical division of labor is a stratified system, the occupations of which are in varying degrees integrated around the work of the physician. All occupations in the system are given less prestige than the physician by the society at large. It follows that the socioeconomic status of those recruited into all paramedical occupations is likely to be lower than the status of those recruited into medicine itself. Furthermore, there is a hierarchy of prestige and authority among the ranks of paramedical workers; nurses, for example, are higher than attendants and technicians. This hierarchy is also likely to be reflected in the socioeconomic backgrounds of the workers. In the grossest comparison between physicians and paramedical workers, the latter are to a disproportionate degree women and from the less valued ethnic, racial, and religious groups. With the special exception of sex, those differences in background and personal characteristics are also likely to be ranged in an order corresponding to the general hierarchy of prestige and authority.

Variability of training

Training follows a variable pattern, its order roughly paralleling the prestige, independence, and imputed responsibility of the work (see Wardwell 1963). Patterns of training range from the one extreme of professional schools associated with universities, requiring a full higher education before several years of training, to the other extreme of brief, informal, on-thejob training. Between these extremes are many types of training, varied according to the length of study, the formality and abstractness of the curriculum, and the type of institutional arrangement, such as attendance at hospital training schools or proprietary technical schools, apprenticeships in various institutions, and the like. In the United States, where the university is a considerably less clearly defined institution than elsewhere, more paramedical education with professional trappings is to be found. In Europe technical training schools quite separate from the university are more likely to exist, for the education of even the high-prestige, more independent paramedical occupations.

The paramedical ranks tend to be ordered by the length and type of training required by the occupation: the longer the training and the more formal and the closer to the university it is, the higher is the occupation’s position in the division of labor. It follows from this that the higher the position, the greater must be the investment of time and energy in training, the less casual can be the recruitment, and the greater must be the commitment to the occupation. Recruitment to the many low-skill positions in the paramedical division of labor seems, by and large, to be a simple function of the demand for unskilled service workers willing to do unpleasant work. Recruitment to the higher-skill positions, however, is considerably more problematic, especially in those occupations traditionally filled by women.

The position of women

Nursing is a fairly well-documented example of problems of recruitment and training in the paramedical occupations (see Corwin & Taves 1963). The problem in nursing is not that of attracting people to undergo training as such, for quite a few women begin training; it lies in recruiting women who will stay in training and subsequently pursue a lifetime career in the occupation. The essential difficulty here is that women are likely to be torn between the commitment to work and the commitment to marriage and family. This conflict has been discerned in nursing students and seems to be closely related to school dropouts and subsequent job turnover.

Leaders of nursing in the United States have attempted to contend with the problem by emphasizing the professional qualities of the occupation, presumably hoping to create a stronger “professional” commitment to work that might out-weigh family considerations (Strauss 1966). The problem, however, seems to be inherent in the position of women in the labor force and does not seem soluble by professionalization. Even in the case of that most professional of professions, namely medicine, only a modest proportion of women in the United States who are qualified to practice medicine actually do so. One might therefore suspect that a more likely solution for a social system such as that of the United States would be found in changing the organization of the job so as to accommodate it to the demands of marriage and family.

In European countries the position of women in the medical and paramedical labor force is quite different, apparently because of national differences in the occupational roles of women that make a professional career highly desirable among women of the haute bourgeoisie, small but significant differences in the class system, and, finally, the level of industrialization and the general standard of living. The last consideration brings up another aspect of recruitment and training in the paramedical division of labor. Clear evidence is lacking, but general opinion seems to be that it is becoming more and more difficult to recruit people to the paramedical jobs that require considerable investment of time and money in technical training. If this is so, it might be understood as a symptom of a larger process of advanced industrialization.

Emphasis on professionalism

In the earlier stages of industrialization, the health services constituted a major and conspicuous source of social and economic mobility to which those willing and able to invest in specialized training could aspire. However, in later stages the demand for skilled technical services has developed markedly in other segments of the economy, thereby providing a considerably wider universe of opportunity than that which existed earlier. As older, fairly closely organized systems, requiring relatively extensive investment in training but offering relatively inflexible career lines, the health services, medical as well as paramedical, seem handicapped in competing for a limited pool of potential workers. Part of the pervasive emphasis on professionalism within the paramedical division of labor in the United States seems to be an attempt to increase the attractiveness of the work and thereby aid in recruiting the best possible workers.

However, the emphasis on professionalism is likely to be strong only during the course of training, which is where the leaders of the occupation are most likely to be influential. Inasmuch as professionalism tends to emphasize intellectual and technical skill, there is the danger of dissatisfying students whose motives for entering the occupation are not so much intellectual as humanitarian—a danger that has been observed in nursing schools. Furthermore, inasmuch as professionalism tends to emphasize the dignity and autonomy of the worker, it is likely that upon leaving school and entering the everyday institutions of work, which are generally not controlled by the leaders of the occupation, the erstwhile student, who has been imbued with professionalism, is in for what has been called “reality shock.” If the student’s indoctrination has been thorough, his relations with other occupations in the paramedical hierarchy are likely to be somewhat difficult and personally disillusioning.

Paramedical personnel in the hospital

It has been implied that the greatest opportunity for developing functional autonomy seems to exist for those occupations that can operate out-side the walls of such medically organized institutions as clinics and hospitals. The nursing profession, whose leaders in the United States have with great energy sought to establish unique skills and fully professional status, seems fated nonetheless to remain subject to the doctor’s orders, in part because a nurse’s work is largely carried out in the hospital. In this, however, the nurse is not unique: the largest part of the paramedical division of labor grew up within such organizations and may be expected to persist and proliferate within them in the future. It is for this reason that once we leave the broad societal level of analysis of the paramedical division of labor to undertake the analysis of everyday work, we find ourselves in the community agency, the clinic, and, most extensively studied of all, the hospital.

All hospitals are complex organizations coordinating a number of tasks and forming the focus for a number of distinct, usually overlapping goals. Given the fact that hospitals are fairly stable and spatially fixed, it is no accident that the para-medical occupations working within them have been studied far more than those working outside in the community at large, where the bulk of health services are actually provided. Thus, we have a severely limited view of paramedical as well as medical work. Among studies of hospital personnel, the nurse in the general hospital is the most frequent subject, and the attendant or aide in the mental hospital ranks second. We have little systematic empirical information about virtually all other paramedical workers. Handicapped as we are, the nurse and attendant between them do present us with a view of the range of workers, from the most professional to the least. By reviewing their respective positions, we can obtain some hints about the kinds of analytical problems posed by the work of paramedical personnel.

The nursing profession

It is difficult to speak of nursing as a single occupation, because the training and work situations of nursing are so variable. Training in the United States can vary from a three-year hospital-nursing-school program to a four-year college program and even to programs leading to the doctorate (Davis et al. 1966). On the job, nurses in some American and European hospitals are preoccupied with bedside patient care and virtually all housekeeping tasks; however, in larger American teaching hospitals nurses are characteristically engaged in supervising the lesser personnel who give bedside care and do the housekeeping. Furthermore, there are major differences in the organization of hospitals in which nurses work: in most hospitals throughout the world the medical staff constitutes the only significant hierarchy, but in some of the larger American hospitals the medical hierarchy is paralleled by that of a nonmedical administrative staff. In the latter case the nurse’s traditional subordination to the physician becomes complicated by subordination to another hierarchy. The two lines of authority may make quite different, even opposing, demands on her, thereby introducing into her work more strain than has existed traditionally ( see Croog 1963).

However, the problem of two lines of authority in hospitals has been overemphasized, particularly in light of the fact that the development of an administrative hierarchy provides the nurse with a better opportunity for mobility than exists when a medical hierarchy alone is present. The possibility of moving up into an administrative hierarchy is common for many occupations, including medicine, but it seems particularly significant for para-professional occupations. By their nature such occupations are technically subordinate: success within the occupation does not remove that subordination, and movement into the superordinate occupation is not usually possible. Only by forsaking the particularistic skills of the occupation and moving into administrative positions can that subordination be escaped. While administrative positions may in fact not be superordinate to professional staff positions, they may at least run parallel to the professional positions and attain equality with them.

We can therefore understand why it is that nurses who are preoccupied with attaining a fully independent status attempt to pass over as “dirty work” the skills of bedside care (i.e., what was once called nursing) to lesser workers and to specialize in administrative work (see Hughes 1958). Recalling the problems involved in recruiting students who can become committed to nursing as a career and the attempt to create such commitment by emphasizing professionalism, we are led into an interesting dilemma: if women become committed to nursing by becoming “professionalizers,” their commitment makes them prone to forsake the work for which they were recruited in the first place.

That dilemma, however, is more characteristic of nursing in the United States than elsewhere, reflecting a national emphasis on social mobility and professionalization. Furthermore, it refers to one of the better-established paramedical occupations and more particularly to those members of the occupation in the United States who have been trained in and work in the high-prestige, academically oriented institutions. As such, it is hardly representative of the total range of paramedical occupations and their dilemmas. The cross-national comparison presented by William Glaser (1963) suggests that the more common problems of para-medical occupations are not really represented by American nursing studies. What is needed most is insight into the less trained, less mobile occupations. Unfortunately, about all we have to provide us with this insight are studies of attendants and aides in American mental hospitals.

The attendant

The essential problem posed by the hospital attendant, and presumably by other relatively untrained personnel in similar positions in the division of labor, is his failure to satisfy the expectations of his professional supervisors. This difficulty may be the more important because the attendant is in the most continuous and intimate contact with the patient and therefore may in fact have greater influence on the patient than the supervising professionals. Thus, his “custodial” orientation to his patients is deplored, and a more “therapeutic” orientation is expected.

The cause of the attendant’s deficiencies seems to stem from at least two sources. First, his job is, in the most immediate sense, one of keeping order—minimizing dirt, destruction or waste of property, and personal injury and allowing house-keeping, therapeutic, and other services to be carried out on a predictable and efficient schedule. In the nature of the case this is a custodial responsibility, requiring something of a custodial attitude. If health institutions are to be run relatively economically, such an attitude on the part of those responsible for the hour-by-hour care of resident patients seems necessary and inevitable.

It is the second element that is more variable—the way in which the attendant perceives his patients, their illness, and his relationship to them. Almost by definition, as a paramedical worker without formal training, the attendant is likely to adopt a view similar to that of the layman. The problem is not lay attitudes as such but which lay attitudes the attendant adopts. A great many studies of American state mental hospitals suggest that attendants adopt an attitude of punitiveness and contempt toward patients and of antagonism toward the expectations of the professional staff. Part of this attitude, as noted already, stems from the job the attendant has to do, as well as from the feeling that the more remote professional staff does not really understand how difficult it is to keep order or even how to keep order. Another part, however, seems to reflect more than anything else the average “unenlightened” American layman’s conception of the mentally ill (see Strauss et al. 1964).

Attendants from other cultures may have entirely different conceptions of the mentally ill and behave quite differently, as Caudill’s analysis of the tsukisoi in Japan (1961) and Parsons’ discussion of a Neapolitan hospital (1959) suggest. Even in the United States, when the illness involved is not as stigmatized as mental illness, lay attitudes of unskilled aides can be supportive rather than punitive, sympathetic rather than hostile. In this sense, precisely what is “unprofessional” about such lower-order workers can be as much a virtue as a vice.

Indeed, that same less-professional character enables the paramedical worker to accomplish what the professional cannot, that is, the para-medical worker can draw into treatment patients who would otherwise be evasive and hostile to organized health services. Many studies from around the world, particularly those summarized by Simmons (1958), indicate that patients of humbler origins than that of physicians feel more comfortable dealing with such paramedical workers as nurses, feldshers, and midwives, who are closer to their own class and culture. Furthermore, lower-status patients seem more easily “educated” by paramedical personnel than by physicians, not only because they can enter into rapport more easily but also because they are more prone to “speak the same language” and to adjust themselves to the patient’s expectations.

This lesser social distance from patients seems to be particularly critical in circumstances where the contact between patient and health worker is voluntary and casual, rather than forced and desperate, and where status differences are quite marked, linguistically, culturally, and socially. In-deed, it appears that it is the need on the part of lower-status patients for consultants who are more nearly equal to them and who operate in a manner compatible with their culture that modern irregular practitioners have risen to serve. To the extent that paramedical personnel become professionalized, they may lose their advantage in dealing with lower-status patients. However, to the extent that the paramedical worker’s success with those patients is predicated on lay attitudes, his relations with supervising professionals are certain to be problematic. This is one of the major dilemmas of paramedical work.

Eliot Freidson

[See alsoMental Disorders, Treatment of, article On The Therapeutic Community.]

BIBLIOGRAPHY

Caudill, William 1961 Around the Clock Patient Care in Japanese Psychiatric Hospitals: The Role of the tsukisoi. American Sociological Review 26:204-214.

Corwin, Ronald G.; and Taves, Marvin J. 1963 Nursing and Other Health Professions. Pages 187-212 in Howard Freeman et al., Handbook of Medical Sociology. Englewood Cliffs, N.J.: Prentice-Hall. → A review of many American studies of nursing.

Croog, Sidney H. 1963 Interpersonal Relations in Medical Settings. Pages 241-271 in Howard Freeman et al., Handbook of Medical Sociology. Englewood Cliffs, N.J.: Prentice-Hall. → A review of studies of inter-occupational relations in American hospitals.

Davis, Fred et al. 1966 Problems and Issues in Collegiate Nursing Education. Pages 138-175 in Fred Davis (editor), The Nursing Profession: Five Sociological Essays. New York: Wiley.

Freidson, Eliot 1961/1962 The Sociology of Medicine: A Trend Report and Bibliography. Current Sociology 10/11:123-192. → Contains a brief review of the field and a fully annotated and classified international bibliography.

Glaser, William A. 1963 American and Foreign Hospitals: Some Sociological Comparisons. Pages 37-72 in Eliot Freidson (editor), The Hospital in Modern Society. New York: Free Press. → A sketch of the different international settings in which paramedical personnel work.

Glaser, William A. 1966 Nursing Leadership and Policy: Some Cross-national Comparisons. Pages 1-59 in Fred Davis (editor), The Nursing Profession: Five Sociological Essays. New York: Wiley.

Hughes, Everett C. 1958 Men and Their Work. Glen-coe, 111.: Free Press. → Seminal essays on the study of occupations, many referring to paramedical and medical workers.

King, Lester S. 1958 The Medical World of the Eighteenth Century. Univ. of Chicago Press. → Contains a few excellent essays on interoccupational relations in English medicine of the sixteenth through the eighteenth centuries.

Parsons, A. 1959 Some Comparative Observations on Ward Social Structure: Southern Italy, England and the United States. Ospedale psichiatrico 2:3-23.

Sigerist, Henry E. 1935 The History of Medical Licen-sure. Journal of the American Medical Association 104:1057-1060.

Simmons, Ozzie G. 1958 Social Status and Public Health. Pamphlet No. 13. New York: Social Science Research Council.

Strauss, Anselm 1966 The Structure and Ideology of American Nursing: An Interpretation. Pages 60-180 in Fred Davis (editor), The Nursing Profession: Five Sociological Essays. New York: Wiley.

Strauss, Anselm et al. 1964 Psychiatric Ideologies and Institutions. New York: Free Press.

Turner, Ernest S. 1959 Call the Doctor. New York: St. Martins. → A social history of medicine in England, somewhat popular, but containing more data on practice and practitioners than conventional academic studies.

Wardwell, Walter I. 1963 Limited, Marginal and Quasi-practitioners. Pages 213-239 in Howard Freeman et al., Handbook of Medical Sociology. Englewood Cliffs, N.J.: Prentice-Hall. → A review of American materials on pharmacists, dentists, podiatrists, optometrists, clinical psychologists, osteopaths, chiropractors, and others.