British Journal of Medical Education, 1973, 7 , 103-108

A sociology programme for medical students

DEAN HARPER' Institute of Psychiatry, University of London

There has been continuing concern about the place of the social and behavioural sciences in the medical school curriculum. Should medical students be taught sociology? If so, how much and when? How should it be taught? What should be taught? These are some of the ques- tions confronting sociologists and physicians concerned with this issue.

This paper, directed to these questions, is a programmatic statement rather than a report of an actual course in sociology for medical students. It is based on several years of ex- perience of teaching sociology to university students, premedical students, medical students, postgraduate physicians, and even to medical school faculty. This experience has been both in the United States and Great Britain. In this paper I will outline a course in sociology for medical students and discuss some of the issues underlying such a course.2

Before discussing the content of a programme in sociology, we must consider three other matters: When should sociology be taught? Who should teach i t? Who should take it?

In my opinion a programme in sociology will be more effective if it is taught in the clinical rather than the preclinical years. Whatever impact sociology will have on medical students, it will be greater once they have had some experiences with patients, and can relate sociological teachings to their own experiences.

'Present address: Department of' Psychiatry, University of Rochester, 260 Crittenden Boulevard, Rochester, New York 14642, USA. ?For other discussions see Stainbrook and Wexler (1956); Bloom (1959); West (1959); Bloom. Wessex. Strauss. Reader, and Myers (1960); Samora(l960): Badgley(l961): Robertson (1961): Martin, McPherson, and Mayo (1967): Butler (1969): Hayes and Jackson (1969); leffreys (1969): Knopp. Johnson, Derbyshire, and Saltis (1970); Ward, Clark. Levine. and Owen (1970); Black (I97 I); Bock and Egger( 1971); McKinlay( I971 ).

If sociology cannot be related to other elements in the students' education, it will have little impact; it can only be related when the student begins to see real live patients.

Ideally, sociology should be taught by a team of two - a sociologist and a physician who can complement each other, one providing sociologi- cal ideas and expertise and the other medical experience and examples. If such a course is to be taught by one individual, then it should be done by a sociologist. Sociology has much to offer to both medical research and practice; medical students and physicians should be informed about this. An individual who is committed to medical sociology will be more likely to transmit this message.

As medical training is moving away from the single track programme, with a course of study followed by every student, to the multiple track system with electives and options, it may seem that sociology should be one of the electives. This would have the advantage that those who chose to study sociology would have a genuine interest in it and thereby make teaching it easier. In my judgement, however, a course in sociology should be required of every medical student. Sociology has a useful perspective to offer the clinician and the research physician; the pro- gramme to be outlined below will not be exces- sive in the demands on the medical student's time.

Before considering the content of a programme in sociology for medical students, we must review what sociology is. Sociology has been described and defined in many ways. However, two charac- teristics of sociology should be emphasized. The major sociological principle, which guides a variety of sociological investigations, and which could also be called a general finding, is that:

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‘An individual’s place in the social structure of his group, be it family, club, community or society, is important in influencing or deter- mining his behaviour in different contexts; it is important in affecting what he believes and thinks and how he behaves.’

Sociology is the elaboration of the above proposition - describing, in detail, instances of it and attempting to explicate the dynamics by which ‘place in the social structure’ works its effects. How the individual votes, how much schooling he obtains, who he marries, his opinions and attitudes about a variety of matters, how he raises his children, are all behavi- ours to which this general proposition applies.

By ‘place in the social structure’ is meant the various positions or statuses which individuals occupy. These are statuses in society (such as occupation, age, sex, race, religion, ethnicity), family statuses (such as father, mother, husband, wife), and statuses within groups (such as chief administrator of a hospital, president of a club, chairman of a committee).

The importance of this proposition for medical students is that ‘place in the social structure’ is related to illness and its treatment. Rates of ill- ness and frequency of each type of treatment vary by age, sex, race, occupation, social class, ethnicity; these are all important positions in the structure of society.

It should be noted that the sociologist is not interested in how the social position of a particular single individual affects that in- dividual’s behaviour. Unlike the physician, the sociologist is not interested in why a particular 35-year-old married male factory worker be- comes ill. Rather, the concern is with a set of individuals - all of whom occupy the same social position within a society or social group. Thus, the sociologist investigates the frequency of different types of mental disorders among men versus women, or among different racial groups, the frequency of cardiac disease among different occupational groups, the frequency of alcoholism among different ethnic groups. Social position increases (or decreases) the likelihood that its occupant will become ill. However, this increased or decreased likelihood is not observed in the single individual; rather it is seen in larger or smaller rates of illness among those occupying the same status.

The second characteristic of sociology emerges

from a feature of the behaviour studied by sociologists. Much of this behaviour consists of relationships between people who are unequal - either socially or politically or economically or unequal in all three respects. This is conveyed in the concept of social class. A social class is a collection of people who are more or less equal in prestige, power, and wealth; to say that social classes exist is to say that within a society not all individuals are equal. Some have more prestige or power or wealth or opportunities than others. Sociologists and others do not will it; rather, inequality emerges in human relations regardless of what sociologists want or do.

The social class system of an industrial society is not the only instance of inequality. Inequality is found in nearly all settings: in the family where the parent is superior to the child and the hus- band may be superior to the wife; in the school where teachers are superior to the pupils and some teachers are superior to others; in the playground where some children dominate others; in the factory or the work place where there is an explicit hierarchy which codifies the patterns of inequality; and on and on.

It might be said, then, that people are socially, politically, and economically unequal and that human relations consist of petty feuds whereby individuals attempt to become superior to each other. Among individuals there exist pecking relations which differ from that of chickens or chimpanzees only in that humans embellish their pecking relations with a rich cultural overlay. Thus, sociology is the study of the social patterns of inequality: the human pecking order and its varied cultural forms. The fact of inequality is particularly significant because in most modern industrial societies there is an egalitarian ideo- logy (most people in Great Britain, in the United States, and other western societies would pro- fess a belief that there should at least be equality of opportunity) and those who are in an inferior position may frequently experience a sense of personal failure which, in turn, may generate psychological stresses and strains.

The notions that ‘place in the social structure is an important factor which influences be- haviour’ and that ‘the social structure consists of an articulated hierarchy of unequal social positions’ are two unifying themes in nearly all sociological investigations; they are perspec- tives which must be conveyed in any sociological

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course of study, and therefore they should be manifest in a programme of sociology for medi- cal students.

the video tapes of patients be prepared by some central body and distributed to each medical school; this would be particularly attractive in

Now we turn to the content and the format of England where there has been considerable a course in sociology for medical students. What is proposed below is obviously only one of a number of alternatives. The proposed program- me may seem to have some arbitrary features. However, these features are based on a variety of teaching experiences.

The proposed sociology course is an 18-hour programme given during the clinical years of medical school training and organized into six three-hour sessions given of a morning or an afternoon once a week or in alternate weeks. The final session is an examination. Each of the first five sessions is devoted to a single topic or theme and has a three-part structure. The first third to half of the session consists of a lecture given by a sociologist and would summarize the theories and findings of the topic of that day.

In the middle third of the session a ‘patient’ is presented. Ideally, this would be in the form of a film or a video tape. In the best of all worlds it would consist of a scenario prepared by a socio- logist and by those skilled in creating dramatic presentations; using trained actors it would attempt to illustrate, but not too bluntly, the ideas of the day’s session. For example, one session indicated below focuses on organiza- tional and administrative problems which emerge in medical settings. The scenario might focus on the conflict over patient care between a medical director and a registrar and how this conflict affected nursing staff, administrators, and patients.

What is possible in different medical settings may fall short of the ideal; i t may not be possible to create a taped film even of amateurs in the parts. In this instance, the teacher would have to depend upon a protocol of a patient or a script of the sdenario which students have read beforehand or which some of them present to the class. The protocol or scenario should be made as specific as possible, and realistic in respect to the experiences of the medical student. For example, the protocol should not be a discussion about social class and its effects on illness and patient care; rather it should be a concrete example of how a particular individual’s class position relates to his illness and care.

The reader may be tempted to propose that

experience and great success in the use of educa- tional television. While this has some advantages, there are some reasons for not doing this, at least for the present. If several different medical schools did follow the programme suggested here, each developing their own protocols and scenarios based on experiences in their own setting, then the diversity of experiences and attempts could be collectively brought together at some later time into a programme that should be better than that prepared at any one institu- tion.‘

The final third of each three-hour session would be directed to a discussion of the ‘patient’, with an attempt to illustrate the notions and ideas presented at the lecture. Ideally, medical students would derive these in their own think- ing and discussion, but ii not, the sociologist would need to point them out. Some individuals might suggest that small discussion groups of, say, 10 students be created, but in my experience i t is not impossible to hold a discussion with 100 students.

Group discussion frequently converges on the conclusion that sociological truths are nothing but matters of public opinion and that as long as they each discuss it, the sociology of one man-in-the-street is as good as that of another man-in-the-street. This democracy in the inter- pretation and application of sociological prin- ciples is understandable, and though it should not be discouraged, it also should not be en- couraged to proceed to its ultimate. Sociology does have something to offer to the medical student and this does not necessarily emerge out of group discussions. There is a middle ground between the sociologist proclaiming ‘the truth’ and the sociologist suggesting, ‘what ever you think is so’.

Above it was indicated that the programme would consist of six sessions. There is nothing sacred about the number six except that i t constitutes what would appear to be an absolute minimum. Any fewer than six sessions would be

‘For other uses of simulated or artificial patients sce Stoller and Geertsma (1958): Geertsma and Stoller (1960); Langsley and Aycrigg (1970): Harless. Drrnnan, Marxer. Root, and Miller (1971 1.

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little better than no sociology at all. On the other hand, there is also probably an upper limit on the number of useful sessions which could be con- ducted.

The objective of each session would be to illustrate in different contexts the two principles stated above. The topics which could be the basis for these sessions include the following.

Social structure of wards and hospitals Each hospital and medical ward has a formal and explicit structure organized around a hierarchy of unequal social positions. Super- imposed on this is an informal structure which embellishes and, in some instances, contradicts the formal structure. The formal and informal structures influence individual behaviour but within it individuals struggle in the pursuit of their own interests. The structures and the adaptations of staff and patients to those struc- tures affect and may inhibit effective patient care. Example of a ‘patient’. In a hospital ward a new set of patient management procedures was intro- duced by the medical director recently appointed to the ward. The nursing staff strongly and nearly unanimously opposed the new procedures. Some nurses attempted to circulate a petition which, when signed by all nurses, they planned to present to the hospital administrator; how- ever, other nurses opposed the petition; they felt that it was unprofessional. Thus, there is much discontent on the ward which appears to impair patient care.

Social class Just as a hospital is organized around a hierarchy of unequal social positions so also are communities and society itself. However, in the community and in society the social structure is more complex. Social rank depends largely but not solely on occupation which in turn depends on education, and this in turn depends on familial position, sex, and race. i n turn social rank ‘causes’ differences in many behaviours : voting, child rearing practices, social friendships, but most important in rates of illness, responses to illness, and treatment for illness. This is the case regardless of the organization of medical care - whether a National Health Service as in Britain or a private entrepreneurial system as in the United States.

Example of a ‘patient’. One member of a lower class family comes to an outpatient clinic for treatment for a skin infection. He is accompanied by his wife and teenage daughter. There appear to be a number of medical problems in the family. It is clear that family members are less aware of signs of illness, have less salutary health practices, are more resigned to the fate of illness, more dependent on medical personnel but less responsible in following their prescriptions and advice.

Social mobility Within industrial society, whether capitalist, socialist, or quasi-socialist, there is opportunity for mobility between different class levels; and in all industrial societies there is roughly the same amount of social mobility. However, members of society are differentially motivated to achieve mobility and are differentially success- ful. Mobility aspirations generate various social and individual tensions which have consequences for the health and illness of both those who achieve their aspirations and those who are frustrated.

Example of a ‘patient’. A middle class clerk is highly motivated to move upward; this motiva- tion is exemplified in all of the activities of his life. His family, continually influenced and affected by his mobility orientations, is frequently undergoing tension; the tension possibly precipi- tates his wife’s illness. His anger about her illness and her absence from home contributes to be- havioural problems in their two children.

Family dynamics In the family, the most intimate of social groups, many needs are met. One of these is the socializa- tion of the young. In their attempts to mould their children to their own and to society’s image, parents may unintentionally elicit what are to them and to society undesirable be- haviours: aggressive and destructive behaviour, rebelliousness, withdrawn and sullen behaviour. Again, some of this may be problematic for the physician.

Example of a ‘patient’. A ‘typical’ middle class family with three children; the youngest, a boy, was unwanted and is reared very strictly - much more so than his two older sisters; in the boy are

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a number of problems; the physician becomes implicated when the mother brings her son to his office because of frequent stomach pains.

Ethnicity Most industrial societies consist of peoples of a variety of different ethnic backgrounds; each ethnic group may still retain some of the customs, beliefs, and culture and perhaps even the lan- guage of their native land. Many of these jmmi- grants were born and reared in a peasant society; as such they may be poorly equipped to cope with the demands of industrial society or they may develop unique ways of coping. Significant for the physician are their attitudes and beliefs towards health and illness, and their response to death; these attitudes and beliefs are not identi- cal to those of the lower classes discussed in the first session above.

Example of a ‘patient’. A member of a family which had emigrated from a peasant society is hospitalized; all of the members of his immediate and of his extended family (not only his wife and children but cousins, aunts, uncles, parents, and other relatives) become emotionally implicated in his illness. By medical criteria he is a ‘bad’ patient; he fails to understand the physician and is unable to follow his instructions. This is further exacerbated by his family, who, though well-intentioned, further interfere with his re- habilitation.

Elderly in society In industrial society the aged are defined and treated as an inferior group, Frequently rejected by their adult children, many live alone, poorly able to attend to their needs, preparing them- selves to die - some welcoming it and others resisting it. Many become helpless and depen- dent, behavingjn some ways like children. Few industrial societies have evolved satisfactory mechanism for meeting the needs of the aged.

Example of a ‘patient’. An elderly couple live alone in a two-room flat. He has a heart con- dition, and she is bedridden with a chronic illness. Of their three children only one occasion- ally visits. Welfare and social services attempt to meet their needs for meals and health care but they are unable to provide all of the care they need. The husband fails to take his prescribed

medicine and probably should be hospitalized for treatment, but if hospitalized, his wife, who is quite dependent upon him, might die. During a previous hospitalization his wife’s condition deteriorated considerably and she became unmanageable.

‘Labelling’ behaviour in society In every group, ranging from the nuclear family to the society, each member deviates at some time from that which is expected of him and which the group defines as appropriate be- haviour. Some individuals, whose deviant be- haviour is either extreme or frequent, become labelled as deviants and are treated as being in some way different from those not so labelled. The label may make it more difficult for the individual to keep from deviating; it additionally poses a problem for the deviant: how to deal with the stigma associated with the label. All individuals engage in labelling each other, but some, viz, policemen, teachers, social workers, physicians, have more crucial roles in the labelling process. This is of especial significance to the physician who must take care in how he perceives, defines and treats patients. The chronically ill, those with some physical impair- ment and the mentally ill may acquire a label which inhibits their rehabilitation or prevents success in coping with their illness.

Example of a ‘patient’. A young housewife with two children of preschool age finds herself increasingly unable to cope with her life. She sleeps badly, awakes feeling tired, has become very inefficient in her household management, is irritable with her children and husband and frequently feels anxious and worried. Her husband calls her ‘neurotic’ and says she needs to see a psychiatrist. Her family physician becomes aware of these problems when she seeks help for a menstrual problem.

These are seven sessions which could be in- corporated into a programme on sociology for medical students. Other topics, such as addiction and the sociology of mental disorder, could be included.

The last session of a programme in sociology for medical students is an examination. This serves two purposes. In the first place, it provides the sociologist a measure of the effectiveness of

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the programme in sociology. Secondly, it is an additional learning experience for the medical student.

To measure the effectiveness of the programme requires that its objectives be specified as precisely as possible. Obviously, this programme is not intended to make medical students into sociolo- gists. Some medical sociologists would judge i t successful if medical students acquire a sensitivity to and sophistication about sociological factors and their bearing for health and illness. This is a desirable objective but it is difficult to assess. To this objective, I would add another: a knowledge and understanding of the two sociological principles mentioned above. By knowledge and understanding is not meant that which comes from merely hearing the principles asserted. Rather, medical students should be aware of the many instances of these principles and attempt to see illness in the context of these principles, even when the operation of these principles is not pointed out to them.

The proposed sociology programme is asses- sed by the use of an additional set of patient protocols similar to those used in the three-hour sessions; in a final session these are presented to students who are asked to write in detail for each case answers to the following:

In what ways, if any, do sociological factors appear to be relevant to the aetiology, course, and treatment of this illness? I n what ways, if any, is your thinking about this case affected by sociological considera- tions? What further sociological data would you want to collect about this patient? In what ways, if any, and how does a know- ledge of sociological principles aid the physician in the treatment of this patient’s illness?

The test should also be designed to provide some satisfaction and edification to students. In thinking about patients - even ‘paper patients’ - and in trying to invoke sociological principles, students should learn something about socio- logical factors and should be gaining even greater sophistication.

All of this is not to suggest that medicine is or should become applied sociology (Henderson,

1936); however, most illnesses have sociological components and the modern physician must be sensitive to these aspects. A programme such as that described above should achieve this goal.

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