STATEMENT CONCERNING PUBLICATIONS OF RUSSELL SAGE FOUNDATION Russell Sage Foundation was established in igoj by Mrs. Russell Sage “for the improvement of social and living conditions in the United States of AmericaWhile the general responsibility for management of the Foundation is vested in the Board of Trustees, the responsibility for facts, conclusions, and interpretations in its publications rests with the authors and not upon the Foundation, its Trustees, or its staff. Publication under the imprint of the Foundation does not imply agreement by the organization with all opinions or interpretations expressed. It does imply that care has been taken that the work on which a manu¬ script is based has been thoroughly done. SOCIAL SCIENCE IN MEDICINE By LEO W. SIMMONS Professor of Sociology, Yale University HAROLD G. WOLFF Professor of Medicine (Neurology) Cornell University Medical College RUSSELL SAGE l <> I N 1) A I'lON New York ■— ~ 1954 Foreword In 1949 russell sage foundation announced its current program for the improvement of the utilization of research in the social sciences in professional practice. It was intended that this program would be carried on in collabora¬ tion with many of the professions, particularly those most directly concerned with social welfare. The immediate re¬ sponse of the medical profession, which has resulted in the ini¬ tiation of a greater number of Foundation projects in the field of the health services than in any other, was not anticipated but it was welcomed. Medical leaders concerned about social and psychological aspects of health were unexpectedly eager for increased collaboration with social scientists. Yet medical science generally is regarded, at least by or¬ dinary laymen, as having to do almost exclusively with re¬ search of a physical or biological nature. Every schoolboy who thinks of becoming a physician has it quickly impressed on him that he must be proficient in chemistry and biology, and perhaps in other branches of natural science as well. Patients know that the medicines administered to them are chemicals and that the technical equipment of hospital and private office has been made possible by advances in physics, chemis¬ try, and biology. They take for granted that the skills of the physician are largely the product of knowledge gained from the natural sciences. This popular view of modern medicine as predominantly biophysical accurately reflects the over¬ whelming dependence of current practice on the natural sciences; it leaves out of account or minimizes the psycho¬ social factors in illness and health. The medical profession never has been unmindful of social environment and personal traits as elements in sickness. Even 3 4 SOCIAL SCIENCE IN MEDICINE the word “psychosomatic” is well over a century in age, and the approach to the problems of health which it represents is as old as medical practice itself. Until recently, however, the related disciplines of sociology, social psychology, and social anthropology have been inadequate in concept, research method, and substantive content for purposes of medical re¬ search and practice. As Dr. Leo W. Simmons and Dr. Harold G. Wolff so ably demonstrate in the following pages, these disciplines now have advanced to a point where fruitful col¬ laboration between medical and social scientists is feasible and well in process of development. The success of such collaboration is dependent on a degree of interprofessional understanding which so far has been achieved by few individuals in either social research or medi¬ cine. One problem has been the difficulty of bringing into orderly relationship within an eclectic theoretical structure the numerous and complicated separate pieces of medically useful social science knowledge and the even vaster number of medical questions to which social research may be expected to make a contribution. A second problem has been the scarcity of persons well trained in the social sciences and also sufficiently familiar with some segment of the medical field to be able to use their research knowledge and skills effectively. The col¬ laborating social scientist must know the substantive area of collaboration, not merely his own discipline. It is understand¬ able that few people have prepared themselves for careers in a nebulous interprofessional field that requires detailed and easy familiarity with two professional ways of working and living. Dr. Simmons and Dr. Wolff offer a framework for collabora¬ tion between social science and medicine that will aid in re¬ lating to each other many seemingly fragmentary and inde¬ pendent studies of medical significance. Their work will also be an encouragement and guide to others in the frontier area of medicine and social research. Donald Young General Director May io, 1954 Russell Sage Foundation Preface During the past half-century in our clinics and laboratories the medical arts have been integrated with the biological and physical sciences to the great benefit of mankind.1 This fusion of art and science has pushed medical knowledge to the point where persons doing research are aware that human beings should be studied in their day-to- day environments as well as in the laboratory and the clinic, and in psychosocial as well as biophysical perspective, if we are to understand fully the conditions and processes of both health and disease. Medical leadership is thus turning inquiringly to the social sciences for help in solving some of its problems. The social scientists are responding to the best of their ability, but their training has been so different from that of the medical special¬ ists that comprehension of the issues under investigation has been impeded by lack of communication between the two groups. This inability to communicate in common professional language has often been aggravated by differences in concepts, methods, and techniques.2 In spite of such handicaps, social scientists are being called upon in increasing numbers to fill positions on interdisciplinary research teams.3 For the purpose of studying opportunities for closer partici¬ pation between personnel in the social science and medical fields, an exploratory project, sponsored by Russell Sage Foundation, was initiated two years ago at the New York 1 See Shryock, R. H., “The Historian Looks at Medicine,” 1937; Idem, The Development of Modern Medicine, 1947; Sigerist, H. E., Man and Medicine, 1932. The reader will find in the Bibliography of this volume full information concerning names of publishers, place of publication, and so on, for all writings cited in the footnotes. 2 Caudill, William, and B. H. Roberts, “Pitfalls in the Organization of Inter¬ disciplinary Research,” 1951. 3 Statement formulated in collaboration with members of Committee on Social Science and Medicine at Yale University. 5 6 SOCIAL SCIENCE IN MEDICINE Hospital-Cornell Medical Center under the leadership of the senior author of this volume. There have been two results of this undertaking in medical-social collaboration. In the first place, four special studies were launched: (i) an examination of the physician-patient relationship over extended periods of therapy; (2) the analysis of interpersonal relationships in an experimental program of nursing consultation service; (3) a survey study of problems and procedures in night nursing; and (4) a case study of fifty families who have made very extensive use of the medical services of the New York Hospital and its clinics. Reports of these studies are in preparation. The second result is the present volume, which explores some of the major areas of interest shared by medicine and social science. Particular reference is made to those concepts and formulations that bear directly upon the problems of health and that may forward collaborative research. The book is addressed primarily to students in medicine and the social sciences interested in training for research in these related areas. It is the hope of the authors that the report may also interest public-spirited citizens who share responsibility for health and welfare programs, and that it may be of some value to the members of several professional groups, such as medical administrators, educators, public health officials, social workers, and nurses who are closely allied with our medical specialists in the prevention and treatment of disease. We are deeply indebted to Carolyn Zeleny and Edmund H. Volkart for their part in making possible the present publica¬ tion. Dr. Zeleny collaborated in the initial analysis of data and in preparing the early drafts of the manuscript. Professor Volkart assisted in the final revision of the book. Dr. Stanhope Bayne-Jones has been a constant source of inspiration and sup¬ port for the exploratory project. Thanks are due to David P. Barr for encouragement and help throughout the study and to Virginia Dunbar and Joseph C. Hinsey for their reading of the manuscript. Leo W. Simmons, Ph.D. May 10, 1954 Harold G. Wolff, M.D. Social Science in Medicine CHAPTER 1 Medicine and Social Science During the greater part of the twentieth century, “scientific medicine,” as outlined more than forty years ago by the Flexner Report,1 has been the chief medical goal and specialization its dominant pattern. This same period has seen the development of the hospital as the chief treatment and research institution, exemplifying in its depersonalized and fractionated services, as well as its refined procedures, the ideals and principles of the scientific approach to the problem of disease. Although these emphases still largely prevail, there are signs that a new era is opening in which medical care will be conceived in broader terms.2 Advances made in public health, psychiatry, psychoanalysis, social work, and social science have given rise to a new concept of comprehensive (in contrast to specialized) medical care, which is modifying the former definitions and objectives of scientific medicine. Comprehensive care has become a popular slogan, both as applied to preventive medicine, on a community or wider basis, and to patient care within the hospital.