SCHI Lecture 1

Definition of Disease

Clinical diagnosis of a condition is rarely simple or clear

Huge variability in disease manifestations, severity and persistence
Variability in diagnostic styles and techniques
Diseases are not necessarily unique pathophysiological entities
Diseases rarely exist in isolation
Definitions of health and illness differ cross-culturally, within a population, over
time, between doctor and patient, and sometimes even between doctors

Biomedical Model

Stresses health in the absence of biological disturbance (historical view)

WHO Definition

Health as a state of complete physical, mental and social well-being

Key Question: If there is no single clear-cut definition of health, what exactly is the
role of medicine?

The Sick Role (Parsons, 1951)

Places both the patient and medical practitioner within a set of hidden social
rules than maintain a smooth running society
A social contract consisting of:
o Exemption from normal social roles
o Not to be responsible for their condition
o To try to get well
o To seek help and cooperate with the medical profession
The doctor is also bound by this contract, serving the patient by providing care
and guidance, but also society by regulating when someone can be considered
ill, for how long, and what the consequences of this might be
Doctors have a much broader role as the gatekeepers, providing social
legitimacy for a patients perceived illness- e.g. sick notes, claiming benefits,
legal matters

Adapting the Sick Role

Sick role model is based on an ideal episode of sickness- acute, short-term,

easily diagnosed and treated with full recovery
Presents medical intervention as an entirely positive process that ensures
people can and will regain their health
Sick role is far less clear when person has chronic or mental illness or if there are
no visible signs to acknowledge
Social contract is potentially undermined with patient in limbo between not
well and not legitimately ill

Overall Point: being sanctioned sick rather than simply feeling sick is the result of
a social set of rules- e.g. the cold/flu distinction (Helman 1978)

Jaffer (Patient Experience)

Jaffer has type 2 diabetes and manages his blood sugar levels via diet & exercise,
tablets (gliclazide and metformin), insulin injections and regular blood testing. Before

diagnosis, he considered it abnormal to pass urine and feel thirsty regularly at night.
Jaffer understands that he has a condition and is able to manage it comfortable and
independently, but he does not like being labelled as a diabetic because it changes
peoples perception of him and also puts him in a negative frame of mind.

SCHI Lecture 2
Diseases as entities

During 16th-17th century, medicine focused on observation, dissection & postmortem

Emphasis on classification, identification and location of disease
Rejection of non-physical ideas
Led to germ theory of disease, emphasising single causal agent, contagion &
specificity
There was no scope to include patients subjective experience
This has been updated into the modern medical gaze in which there is a split
between the patient as a person and the body as a site of disease
Diagnosis is regarded as a process of gradually replacing patient descriptions
with more objective reasoning

Illness

A persons subjective experience and feelings, not only of the physical effects,
but also emotional, psychological and social aspects

Disease

The medical conception of pathological abnormality, indicated by a set of signs

and symptoms

The illness/disease distinction

Disease can be cured whereas illness can be healed

The distinction is frequently unclear and often not stable
The modern doctor needs to be constantly vigilant to the different ways in which
people suffer and express their illness
Who determines what actually constitutes the disease, as a distinct entity from
the illness?

Complementary & Alternative Medicine (CAM)

Many people use alternative methods alongside biomedicine

Therapies claim to be: more natural, more holistic, less invasive, focus on the
patient as a person & adopt notions of energy, balance and vitality
Popularity due to increased consultation time, individualised attention and
placebo effect
Users often feel that their problems do not match biomedical interventions

SCHI Lecture 3
The Doctor-Patient Relationship
Chronic Disease

Diseases that are persistence or recurrent, usually beyond one year

They tend to be incurable, have complex causation, involve multiple risk
factors, have long latency, prolonged course & associated with functional
impairment
Chronic diseases do not manifest themselves from one year to the next
Therefore, difficult to relate to the ideal sick role, germ theory of disease or the
accompanying golden bullet notion of cure
Particularly difficult to distinguish between them as diseases or illnesses
Chronic diseases are the growing causes of morbidity and mortality, the majority
being lifestyle diseases attributed to diet, obesity, lack of exercise, alcohol and
smoking, including T2 diabetes, CHD, stroke, depression, COPD & cancer
Individual behaviour is now focus of medicine due to this shift from acute
communicable to chronic lifestyle conditions
Patients are now considered to be in control and responsible- a duty to be
healthy
People are now more likely to die from chronic rather than acute conditions

Compliance

Defined as the extent to which the patients behaviour matches the

prescribers recommendations
Up to 50% of medical provisions are estimated to be wasted with direct costs,
e.g. due to medications not taken or not taken correctly and non-attendance
No clear correlation between non-compliance and different types of patients or
aspects of the medical condition
Education was traditionally seen as the key to improve patient adherence
An alterative approach to increasing compliance revolves around recognising the
patient as an active person, in which their subjective experience of a condition
provides a unique and valuable perspective.
Balints work helped to drive expulsion of the paternalistic approach to
patient care (1957)
If patients are more involved in the consultation then they are more likely to
agree with the outcome and thus would be more inclined to adhere with the
treatment plan offered
Shift to expert patient model, which is more appropriate in lifestyle/chronic
conditions
However, the free availability of information comes at a cost since the accuracy
of such information is variable and this has lead to controversies (1998
Wakefield publication on MMR triple vaccine)

Work Placement Case Study 1

During work experience placement in an endocrine clinic, doctor had a routine
consultation with a patient who was diagnosed with T2 diabetes 1 year ago but up to
this point, had refused to make considerable changes to his lifestyle choices (i.e. noncompliance). As a result, his blood glucose control was not stable. This was interesting
because it illustrates the lack of desire from the patients perspective to take
responsibility for his own condition as well as highlighting that medicalised treatment
is not effective unless the patient understands that in order to be healthy, he needs to

be willing and committed to makes the necessary changes to his lifestyle, despite the
hassle and hardship associated with that change.

SCHI Lecture 4
Labelling
Positives

Response to a distinct difference from the norm

Legitimises a new definition of disease
Can provide reassurance and meaning
E.g. distinguishing autism as a medical category from the broader notion of
subnormals

Negatives

Sometimes a cause of distress

Stereotyping of such abnormal states shapes the behaviour of the individual
and others
Known as secondary deviance the difference is exaggerated due to the
assumption that one must strictly adhere to the label designated to them
Labels are sticky so peoples status as outsiders is further reproduced and
maintained
The person becomes the condition- they do not simply have an illness, they
are the illness
Choices by the individual are severely restricted, serving to exaggerate their role
further
Goffman argued that our common experience is to desire a normal identity
whereas the stigma associated with a label produces a spoiled identity
He suggested that anyone who is stigmatised can only hope for a phantom
normality, such that they are stigmatised by others as well as confirming the
status themselves

Ethnicity and mental health

Potential cultural bias of standard medical practice:

o Correlation between being Black & Ethnic minority (BEM) and diagnosed
with mental health problems
o Rates of hospital admission are three or more times higher for black and
white-black mixed groups compared with the average
o Black groups are up to 44% more likely to be detained under the Mental
Health Act compared to the average
Are there actual cultural differences in the forms and rates of mental illness?
Are there problems in identifying universal characteristics for applying labels
and the treatment consequences that follow? Need to reconsider process of
diagnosis

Key Point: Mental illness serves as an amplified example that diagnostic labels
form part of the experience of illness. They can sometimes alleviate the symptoms
but other times they can be damaging and result in stigmatisation of themselves
and within themselves

Medicalisation

The most appropriate domain to address abnormality or suffering is within

medicine

Concern is that medicine comes to oversee what is socially acceptable or

culturally normal
E.g. the increasing set of behaviours associated with lifestyle diseases
Should medication be applied to addiction or infertility or even pregnancy?

Pre-Menstrual Syndrome (PMS)

Relatively new category with a set of physical, psychological and emotional

symptoms
Legitimacy of condition traced to a convergence of views from doctors, media
and women
Some people argue that it has converted yet another aspect of womens bodies
and normal biological function into strictly medical terms

ADHD- childhood behavioural disorder

The rise in ADHD charts how ideas of an unruly or disobedient child are
increasingly being framed by a new medical label
The controversy extends to the solution - introduction of drug therapies
Consequently, medicalisation of the behaviour frames the problem, cause and
the solution in very specific ways
The dispute is not whether the experiences of a person are real but whether
biomedicine is the most appropriate way of conceptualising the condition and
delivering some kind of care

Medical Imperialism

Perhaps one of the most damaging developments in contemporary society:

o The tendency to assign social problems to biomedicine
o That biomedicine seeks to expand into the social world
o That biomedicine tends to focus on individual causation and treatment
thereby ignoring a social/ecological framework
o That patients become dependent on seeking this service, encouraging the
worried well
Illich calls it an epidemic of medicalisation and argues that it is guilty of
iatrogenesis (preventable harm resulting from medical treatment or advice
given to patients)
His claim is that medical practice breeds its own clients, such that when
vulnerable we rely on experts to decide things for us.
For Illich, individuals should take control and seize power for themselves and
that health care should be removed from the bureaucratic/professional
institutions that cause dependency

SCHI Lecture 5
The Social Determinants of Health Inequalities
Income

The Marmot Review, published in February 2010 as Fair Society, Healthy

Lives highlights many aspects of health inequalities:
In England, people living in the poorest neighbourhoods will, on average, die 7
years earlier than people living in the richest neighbourhoods.
This suggests that neighbourhood income deprivation is associated with lower
life expectancy
Even more disturbing, average difference in disability-free life expectancy
(DFLE) is 17 years. This suggests that people in poorer areas not only die
sooner, but they will also spend more of their shorter lives with a disability
Key Point: there is a finely graded relationship between the socioeconomic
characteristics of neighbourhoods and both life expectancy and DFLE i.e. a
social gradient in health

Occupation

As part of the 2011 census analysis, the ONS released the Health Gaps by
Socio-economic Positions of Occupation Report
The data demonstrated a clear correlation between the age-standardised rates
of Not Good health of men by NS-SEC class. For example, men within the
7.Routine class were approximately 15% more likely to list their health as Not
Good compared with men within the 1.Higher managerial and professional
class

Education & Gender

Ross & Mirowsky published a paper on Sex differences in the effect of

education on depression
Higher levels of education correlate with low levels of depression
The differences in well-being associated with the disadvantaged economic
status will diminish at higher levels of education
There are gender differences however, with depressions negative slope with
respect to education is steeper for women than for men
This supports the resource substitution theory, that education improves wellbeing more for women, because socioeconomic disadvantage makes them
depend more on education to achieve a well-being
However, sex differences in depression become insignificant among persons
with degrees or higher. The gender gap in depression could attenuate or vanish
in future generations due to the increasing number of women earning degrees

Material Factors

Low Income
o Poorer communities
o Residential crowding
o Violence
o Environmental pollution
o Lower quality healthcare & food
o Fewer holidays
Routine Occupation
o No health services through work poor pension

Low Education
o Lack of knowledge on being healthy/accessing healthcare

Psychosocial/orientation to life

Little control & autonomy in job

o Unrewarding & unfulfilling
o Not using creative energy
Feel exploited in job
o The senior managers earn greater salaries but are less productive
Lower earnings than most people
o Feel less valuable
o Feel lower down the social hierarchy
o A feeling of inferiority (low status)

The Status Syndrome

Richard Wilkinson, The Impact of Inequality, 2006

The important effects of not having adequate power and resources to control
ones circumstance, being made to feel inferior, depression, hostility and lack of
support from a friendly social network
Helps to explain why the quality of social life in modern societies has not kept
pace with improvements in material life

Social Causes of Depression

Brown and Harris (1978)- 4 key factors for women:

o Loss of mother before age 11
o Lack of intimate relationship
o Lack of employment
o Three or more children under 14 living in home
Horwitz and Wakefield (2007)
o Loss of loved ones
o Loss of job/status
Holmes and Rahe (1967)- people listed main stressors of illness:
o Death of spouse
o Divorce/marital separation
o Imprisonment
o Death of close family member
o Personal injury

Why might one lead an unhealthy lifestyle?

Early childhood experiences affect physical and mental health- shaping attitudes
to lifestyle
Stress/depression more inclined to smoke or eat unhealthily
Peer Pressure is a powerful influence- especially if smoking/drinking is the norm
amongst the people you know
Possible rejection of the whole notion of healthcare
Lack of power/resources unhealthy food being much cheaper

Clinical Practice

Being aware of social determinants of heath

In consultations, disadvantaged likely to be less confident, knowledgeable,
forthcoming
When working in deprived communities, need to be aware of characteristics,
typical issues, community figures, patterns of working/living etc

Inverse Care Law

Suggested by Julian Tudor-Hart

Those who most need medical care are least likely to receive it
Conversely, those with least need of healthcare tend to use health services more
(and more effectively) implies greater knowledge about the range of services
on offer to them
Demonstrates that the strength of socio-economic factors in determining health
inequalities is further enhanced by the lack of suitable and equally distributed
provisions by the healthcare services

Examples where Inverse Care Law has been demonstrated:

In areas with high needs, such as inner cities and deprived areas, there tend to
be fewer doctors working with higher caseloads and sicker patients
Although GPs are encouraged to work in 'underdoctored' areas through a system
of incentives, these have not enticed enough GPs to work in the poorest areas
Rates of immunisation and screening for cervical and breast cancer, are
significantly lower in people from more deprived areas - areas where cancer
mortality rates are highest
The quality of treatment in general practice for people with chronic diseases
such as asthma has been shown to be inadequate, with significantly higher
admission rates to hospital for these conditions from deprived areas

Helping sick people in a socially determined world?

Biomedical interventions needed to treat immediate disease pathologies

More importantly, offer advice and information on healthier lifestyles
Refuse to treat those who do not follow the guidelines?
Respect for lives and hardships experienced by some of the people you are
treating
Recognition of systemic weaknesses in healthcare provision
Find better ways to communicate, accommodate and provide support
Challenge prejudices within and outside of the system- gypsies, travellers etc

SCHI Lecture 6
Medical Professionalism

GMC created with the Medical Act of 1858 and 1950 Medical Act increased
regulatory powers

A regulating professional body is important now because:

o There is a huge (and expanding) body of knowledge
o Doctors need an idea of what best practice is
o There is a need for standardisation
o There is a need for trust, both institutional and within the doctor-patient
relationship

Factors which constitute professionalism:

o Autonomy with both self-regulation and external regulation
o Intellectually challenging/creative work
o Specialised set of tasks with fixed points of regulated entry
o High standard of ethics, behaviour and work activities

The Stanford Hospital scandal is an example of institutional abuse, in which

there was a culture of wilful neglect in regards to patient care. It is believed that
100s of unnecessary deaths occurred in a three-year period between 2005 and
2008.

Social factors influencing professionalism:

o Rapid expansion of medical knowledge
o Rapid expansion of medical ability- Chantler 1999 Medicine used to be
simple, ineffective and relatively safe. Now it is complex, effective and
potentially dangerous
o Revolution in IT for both doctors and the wider public
o Increased media attention to health issues
o Changes in philosophy of care for patients favouring a multidisciplinary
approach
o Changes in doctors attitudes (e.g. part-time, outsourcing on-calls)

Professional regulation relevant to & affecting us now:

o Standards expected from new UK graduates are laid down in Tomorrows
Doctors 2009
o Good Medical Practice sets out principles/values on which good practice
is founded

What
o
o
o

makes a good doctor?

Accurate knowledge
Knowing limits of knowledge and ability to ask for help
Treating others the way you would wish to be treated/have your parents
treated

SCHI Lecture 7
Everyday Ethics: Power, Consent and the Doctor-patient
relationship
The doctor-patient relationship
Doctors primary duty is to do best they can for their patient- promoting their
good
Medicine is an inherently moral enterprise
Power Imbalances
Patient needs something
Doctor is the gatekeeper resources, sick note, illness status
Patient is ill
Knowledge is two-way
Medical Paternalism
Traditional approach
Doctor is exercising power
Patient is passive and expected to adhere exactly to doctors recommendation
Patient as Consumer
Patient is exercising power
Doctor is passive
Partnership
Both patient & doctor need to exercise power in order to establish an end result
that satisfies and meets the expectations of both parties
Autonomy
The right to decide for yourself how your life goes
Emphasis on choice and control
Consent
The requirement that doctors obtain their patients consent to treatment is a
way of demonstrating that they respect their patients autonomy
Consent may be implicit or explicit, the latter being written or verbal
Consent relies on capacity to understand, clear information provided and
voluntariness
Why

consent does not answer our problem?

Patients are rarely fully autonomous due to pain, fear or cognitive limitation
Information overload
Lack of knowledge
Perception of risk
The process of consent is not always an answer to a moral problem
Obtaining consent should not be seen in terms of the passage of information,
but as part of a communicative transaction within a relationship of trust