Social Science & Medicine 54 (2002) 161–164

Book reviews

Community care, ideology and social policy

Harry Cowen; Prentice-Hall Europe, London, 1999, 246pp., Price £ 15.99 (paper)

This book is part of the series on contemporarysocial policy and as such addresses the current interna-tional shift in policy from institutional to community

care for persons with multiple and complex healthand social care needs. The author, Harry Cowen,develops the argument that the return to community

care is a reflection of a more conservative, market-supporting, anti-welfare state shift in governmentpolicy that continues to marginalize those in needand to diminish state responsibility for redistribution

of resources. He argues that this change transcendsparty politics and reflects a change in the ideology of thecivil state. In Part I of the text, Cowen traces the history

of this change and describes the current state ofcommunity care in the British context. In Part II, hepays special attention to the inadequacy of current

community care for the elderly, those with physicaland mental health disabilities, women, and minorityethnic groups.

Cowen points to communitarianism (Etzioni, 1995),

which relies on the voluntary sector and citizen participa-tion for the provision of responsive, user-accountableservices as a potential response to the demands and

deficits in the community care sector. He juxtaposes thismodel against the managerial approach that he argueshas captured the current delivery organizations.

The strength of this book, a major reason forrecommending it to anyone concerned with health andsocial service provision, is that Cowen challenges

traditional policy notions of community as a geographicentity and demands that the reader understand theimplications of this narrow, technical interpretation.The broader concept of community as a collection of

interests, needs, talents, and challenges has escapedpolicy makers who want to simplify and quantify theextraordinary complex process of service into tasks,

costs, and technical accountabilities. Cowen calls uponhis readers to imagine a different notion of caring inwhich service is not a commodity but rather a

commitment } a social contract in a civilized society} provided in a community that is more than ‘anythingbut an institution’.

Cowen highlights the dependence of current market

approaches on the availability of an unpaid or

inexpensive (some might even say cheap) female

workforce to provide community care. Others suchas Neysmith and Aronson (1997) Baines, Evans, andNeysmith (1998) have pointed out, in more detail, the

discriminatory and marginalizing effect of these work-force changes on women. From child care providers tocommunity care providers } perhaps little has really

changed when women once again bear the costs ofcaring that sustain but are not valued or supported bythe market.

In addition to clear arguments about the nature andimpact of community care as an expression of changes inthe ideology of social provision, Cowen provides readerswith relevant and useful references which are decidedly,

although not exclusively, British in origin. For readerswith a special interest in British health and social servicepolicy, this book will become an essential reading. For

others, especially those comparing approaches to socialpolicy provision, the book is a beginning point but lacksin-depth comparative analysis. In each application

chapter there is some attention to comparisons betweenthe services in Britain and other countries. However, thereader is left to make the links to underlying ideologicaldifferences and policy approaches that might account

for differences or similarities in services. Internationalcomparison was not a primary purpose of this book andthe reader would be disappointed if they were looking

for a sophisticated presentation of these issues. Forundergraduates, the book makes it clear that there areother approaches to community care that should be

considered and this, in itself, is a worthwhile aspect ofthe book in considering its usefulness for instructionalpurposes.

One major driver of changes in health policy thatis not addressed in this book is technology. This would bean interesting addition to Cowen’s discussion of factorsthat are shaping not only the ways in which we might be

able to deliver community care but also the ways in whichwe view the inherent value of community care.

In short, this highly readable book achieves its

objective of providing a solid analysis of the often-perplexing move from institutional to community carewithout oversimplifying or demonizing the economic

and political forces that are at play. It is suitable forstudents of social policy but serious policy scholarsseeking a more advanced understanding of thesechanges will be less satisfied with the lack of detailed

evidence behind the arguments.

References

Baines, C., Evans, P.M., & Neysmith, S.M. (Eds.) (1998).

Women’s caring: Feminist perspectives on social welfare.

Toronto: Oxford University Press.

Etzioni, A. (Ed.) (1995). New communitarian thinking: Persons,

virtues, institutions, and communities. Charlottesville, VA:

University of Virginia Press.

Neysmith, S. M., & Aronson, J. (1997). Working conditions in

home care: Negotiating race and class boundaries in

gendered work. International Journal of Health Services,

27(3), 479–499.

Susan Watt

School of Social Work, McMaster University, KennethTaylor Hall, Room 309, 1280 Main Street West,

Hamilton,

Ontario, Canada L8S404E-mail address: socwork@mcmaster.ca

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The medical interview: gateway to the doctor–patient

relationship (2nd Edition)

C. Knight Aldrich; The Parthenon Publishing Group,

New York, 1999. 164pp., Price £ 14.95 (paper)

C. Knight Aldrich, Professor Emeritus of Psychiatryand Family Medicine, has written an excellent practical

text designed for new medical students (and, as he notes,experienced physicians) about the doctor–patient rela-tionship, which emphasizes the patient interview. The

goal of the book is to show students how to interviewpatients so that it is easy for them to discuss theirillnesses. Aldrich argues that over half of the doctor’s

time is spent talking with patients, but that medicalschools often de-emphasize communication skills andinstead focus on the biological aspects of the patient’sdisease (‘‘the pathology’’). The book provides many

useful vignettes that illustrate successful and unsuccess-ful interviewing. The author describes all aspects ofmedical interviewing, including the introduction, non-

verbal communication, and ending the interview, as wellas how to manage interviews with ‘‘special’’ patients(e.g. children, the elderly).

The book takes an empathic view of the patient’sexperience in the doctor–patient relationship. Aldrichargues that physicians must try to establish rapport

and to develop trust between themselves and theirpatients. He differentiates between the illness } whatpatients subjectively think and feel is wrong with them} versus the disease } the doctor’s diagnosis or

identification of the pathology. According to the text,some students and practicing physicians emphasize thedisease during their interviews with patients rather than

the illness. In fact, some new practitioners attempt toremove their ‘‘social responsiveness’’ in order to seemobjective. For example, students will often try to avoid

using sympathetic words or facial expressions duringinteractions with patients. Aldrich argues that the questfor objectively focusing on the disease is problematic:practitioners should respond empathetically, allowing

the patient to discuss his or her illness, emotions, or

fears before moving to the specific questions containedin the medical history.

The text discusses general issues related to the doctor–

patient relationship, including the uniqueness of therelationship, power issues between doctors and patients,the importance of respecting patient’s perspectives abouttheir illnesses, and the importance of being non-

judgmental of patient’s lifestyles and their explanationsfor their health problems. Aldrich argues that thedoctor–patient relationship is special in that the com-

munication patterns are different than most otherrelationships, except for the parent–child relationship.Because physicians are more powerful than their

patients and have more authority (as with parents andchildren) then they must be vigilant about not abusingtheir power. Practitioners must respect patients, andprotect their confidentiality, privacy, and dignity. For

example, he states that practitioners should refer topatients by their last name (unless they request other-wise), and respect their different views of their illness

compared to the medical view of their disease. Finally,Aldrich argues that practitioners should remain non-judgmental or else risk losing the trust of the patient.

Judging a patient’s explanation of the causes of theirhealth problems only serves to decrease rapport, and thepatient is likely to stop giving information that might be

needed for the diagnosis.As a sociologist, I appreciated Aldrich’s attention to

the power differences in the doctor–patient relationship,the assumptions contained in the doctor–patient inter-

action, and the attention paid to context, particularlythe information about different cultural backgroundsand social class variations among patients. The text

notes that doctors should consider the background ofpatients during medical interviews, including theirculture and social class, in order to be empathic.

Practitioners will likely need to alter their interviewquestions and their non-verbal communication withpatients from different cultural backgrounds. Peoplefrom some cultures are shy about discussing certain

health issues (e.g. those related to sexuality) compared

Book reviews/ Social Science & Medicine 54 (2002) 161–164162