£;‘(:f; ABSTRACT DOCTORS AND FAMILY PLANNING: ANALYSIS OF THE RESPONSES OF PHYSICIANS TO FAMILY PLANNING IN THE CONTEXT (:> OF PRIVATE MEDICAL PRACTICE (/5 By Paul David Tschetter This study focuses on the description and analysis of physicians' responses to the provision of family planning services in private medi- cal practice. Specific questions are: (l) for whom will physicians recommend family planning, (2) under what conditions will physicians recommend family planning, and (3) what method or methods of family planning will physicians recommend. Since the provision of family planning occurs in the context of ongoing medical practice, the environment of medical practice is investigated. The focus is on the relationships between the structure of medical practice and physicians' perceptions of technical and social dimensions of medical practice as they affect medical responses to family planning. The intent is to discover and explain substantive differences between physicians in the structure of their medical practices, their conceptions of clinical and social aspects of medical practice, and their conceptions of medical concerns in the area of family planning. The study examined primary care physicians in private practice who could be expected to provide patients with family planning infor— mation and technology. The population studied included all allopathic and osteopathic general and family practitioners, obstetrician- gynecologists, and internists in a three county area in Michigan. Paul David Tschetter Questionnaires were mailed to all members of the population, and using telephone followups, a return rate of 65 percent was secured. The sample for subsequent analysis included seventy-three general practi— tioners, twenty-two obstetrician-gynecologists, and seventeen internists. The general conceptual framework employed in the analysis is Lewin's field theory. This framework is suggested by Freidson's approach to the sociology of medical practice. A graphic model of the doctor-patient relationship as a social system is used to indicate the "vectors" affecting physicians' perceptions of medical practice and responses to family planning. Examination of the structure of medical practices among the three medical specialty fields revealed that practice specialty field is related to type of practice arrangement. Obstetrician-gynecologists and internists were likely to be in group practice while general practitioners were likely to be in solo practice. Patients seen per week was also related to practice specialty. General practitioners reported seeing an average of 200 patients per week and obstetrician- gynecologists and internists reported seeing an average of 100 patients per week. A second area of interest is physicians' perception of clinical or technical and social dimensions of medical practice. Separate ordinal scales were developed to measure physicians' technical orien- tation and social orientation to medical practice. Practice specialty was related to distribution on technical orientation score. Internists scored highest on technical orientation, while obstetrician-gynecologists scored slightly higher than general practitioners on technical orientation. Obstetrician—gynecologists and internists in group practice scored higher than their counterparts Paul David Tschetter in solo practice on technical orientation. General practitioners in group practice had the largest proportion of all respondents scoring low on technical orientation. Although there was no relationship between patient load and technical score for obstetrician-gynecologists and internists, general practitioners with large patient loads were lowest on technical orientation. Practice specialty was related to social orientation score. Obstetrician-gynecologists scored significantly lower than general practitioners and internists on social orientation. Solo practi- tioners tended to have slightly higher social orientations than group practitioners. General practitioners and obstetrician-gynecologists with small patient loads scored significantly higher on social orien- tation than their counterparts with larger patient loads. Internists with large patient loads scored higher on social orientation than their counterparts with smaller patient loads. Examination of physicians’ responses to family planning indi- cated that all respondents exhibit the same rank order in recommending specific methods of contraception. The pill was the overwhelming first choice; the IUD was a distant second choice. Involvement in obstetri- cal work rather than practice specialty explained more of the variance in matters dealing with family planning. All obstetrician-gynecologists and 4h percent of the general practitioners did obstetrical work. Involvement in obstetrical work was related to family planning attitudes and activity. Obstetrician-gynecologists and general practi- tioners doing obstetrical work were more likely than other general practitioners and internists to initiate family planning discussions with patients and to report having discussed family planning with their female patients. Paul David Tschetter Further evaluation of physicians' responses to family planning involved analysis of responses to six hypothetical family planning case histories. Responses to the case histories were evaluated on two dimensions: (1) refusal of family planning and recommending a steril- ization, and (2) method of contraception recommended. Recommendation of a sterilization for one or more case histories was directly related to involvement in obstetrical work and (high scores on) family planning attitudes and activity. There was no association between technical or social orientation and recommendation of a sterili- zation. Low scores on family planning attitudes and activity were pre- dictors for refusal of any contraception. Involvement in obstetrical work was not a predictor of refusal of contraception among general practitioners. There was no association between refusal of contracep- tion and technical or social orientation score. Using the number of cases for which respondents recommended the pill as a measure of standardization of recommended patterns, there was an inverse relationship between technical orientation score and fre- quency of usage of the pill. Involvement in obstetrical work among general practitioners was inversely related to recommendation of the pill. There was no relationship between recommendation of the pill and social orientation and family planning attitudes and activity. The conclusion from analysis of the case histories is that higher technical orientation physicians, regardless of practice specialty, are most likely to recognize contraindications to the pill and recommend alternative methods of contraception. An additional conclusion is that efficacy in preventing pregnancy is of primary importance in physicians' responses to family planning. DOCTORS AND FAMILY PLANNING: ANALYSIS OF THE RESPONSES OF PHYSICIANS TO FAMILY PLANNING IN THE CONTEXT OF PRIVATE MEDICAL PRACTICE By Paul David Tschetter A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Sociology 1975 Copyright by Paul David Tschetter 1975 ACKNOWLEDGMENTS The author gratefully acknowledges the efforts of Dr. David Kallen as thesis director. His critical evaluation and encouragement were invaluable throughout this research effort. Financial assistance made available through the Social Science Research Bureau and Dr. Charles Hanley made execution of the project possible. Also, the sponsorship of Myron S. Magen, D.0., College of Osteopathic Medicine, and W. Donald Weston, M.D., College of Human Medicine, were invaluable in securing cooperation from physicians in the study . The author wishes to express gratitude to Dr. J. Allen Beegle, Dr. Philip Marcus, and Dr. Harry Perlstadt for having worked on the author's guidance committee. The author is also grateful for the assistance provided by Department of Sociology at Michigan State University throughout his graduate career. The support offered by Dr. Baljit Singh, College of Social Science, during the research pro- ject provided a most congenial atmosphere for the work. Last but not least, the author is forever grateful to his family for providing the support and encouragement to pursue his goals, and to Elaine, Marty and Aaron who make it all worthwhile. ii TABLE OF CONTENTS LI ST 0F TAB IE S I I I I I I I I I I LI ST OF FIGURES I I I I I I I I I CHAPTER I. II. III. INTRODUCTION . . . . . . . Review of the Literature . Conceptual Framework . . . Summary . . . . . . . . . . METHODOLOGY . . . . . . . . The Population and Sample . Data Collection Process . . . . Operationalization of Variables Analysis of Data . . . . . GENERAL PRACTICE . . . . . Introduction . . . . . . . . The General Practitioners' Background and Practice . Technical and Social Orientation to Medical Practice Obstetrics and Family Planning 8mm I I I I I I I I I I I I I I I I I I I I I I I OBSTETRICS-GYNECOLOGY . . . Introduction . . . . . . . The Obstetrician-Gynecologists Background and Practice iii PAGE xix 10 25 31 31 32 65 71 71 71 76 101+ 130 133 133 133 iv CHAPTER Technical & Social Orientation to Medical Practice . Obstetrics & Family Planning . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . V. INTERNISTS . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . Technical and Social Orientation to Medical Practice Obstetrics & Family Planning . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . VI. PRACTICE SPECIALTY, PRACTICE STRUCTURE AND FAMILY PLANNING . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . Physicians' Background and Practice . . . . . . . . . Technical and Social Orientation to Medical Practice Obstetrics and Family Planning . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . VII. PHYSICIANS.AND FAMILY PLANNING . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . Case Histories . . . . . . . . . . . . . . . . . . . Contraception in the Context of Medical Practice . . Summary . . . . . . . . . . . . . . . . . . . . . . . VIII. SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . Overview and Conclusions . . . . . . . . . . . . . . Limitations of the Study . . . . . . . . . . . . . . Suggestions for Further Research . . . . . . . . . . APPENDIX A--COVER LETTER AND QUESTIONNAIRE . . . . . . . . . B ELIOGRAPM I I I I I I I I I I I I I I I I I I I I I I I I PAGE 136 145 154 156 156 158 165 171 173 173 174 180 189 197 201 201 203 213 263 266 266 282 283 286 299 TABLE 10. LIST OF TABLES Doctors in the Sample Ruled Ineligible, Eligible, Returned Completed Questionnaires, Percentage Eligible Returning Completed Questionnaires, and Mean Days to Return by Field of Practice and Total Sample . . . . . . Breakdown by Age of DOs, MD:GPs, Md:OBGs, and MD:IMs for Respondents and Total Population . . . . . . . . . Breakdown of Year of Graduation for DOs, MD:GPs, MD:OBGs, MD:IMs Respondents and Total Population . . . . Age by Year of Graduation from Medical School for DO and MD General Practitioners . . . . . . . . . . . . . . Technical Orientation Scale Items by Practice Specialty Technical Orientation Score by Practice Specialty . . . Social Orientation Scale Items by Practice Specialty . . Social Orientation Score by Practice Specialty . . . . . Discussion of Family Planning in Different Circumstances--Female . . . . . . . . . . . . . . . . . Discussion of Family Planning in Different Circumstances--Male . . . . . . . . . . . . . . . . . . Willingness to Initiate Family Planning by Practice Spec ialty I I I I I I I I I I I I I I I I I I I I I I I PAGE 35 37 38 41 5o 53 55 57 61 63 65 vi TABLE PAGE 12. Solo Versus Group Practice by Age for General Practi- tioners . . . . . . . . . . . . . . . . . . . . . . . . . 73 l3. Patients Seen Per Week by General Practitioners . . . . . 74 14. Patients Seen Per Week by Age for General Practitioners . 74 15. Patients Seen Per Week by Solo Versus Group Practice-- General Practice . . . . . . . . . . . . . . . . . . . . . 76 16. Technical Orientation Score by Age for General Practi- tioners . . . . . . . . . . . . . . . . . . . . . . . . . 77 17. Technical Orientation Score by Whether General Practi- tioner Had Residency Training . . . . . . . . . . . . . . 78 18. Technical Orientation Score by Solo Versus Group Practice by General Practitioners . . . . . . . . . . . . 79 19. Technical Orientation Score by Patients Seen Per Week for General Practitioners . . . . . . . . . . . . . . . . 80 20. Technical Orientation Score by Patients Seen Per Week Controlling for Age--General Practitioners . . . . . . . . 81 21. Social Orientation Score by Age for General Practi- tioners . . . . . . . . . . . . . . . . . . . . . . . . . 82 22. Social Orientation Score by Whether General Practitioner Had a Residency . . . . . . . . . . . . . . . . . . . . . 83 23. Social.Orientation Score by 8010 Versus Group Practice for General Practitioners . . . . . . . . . . . . . . . . 83 24. Social Orientation Score by Patients Seen Per Week for General Practitioners . . . . . . . . . . . . . . . . 85 25. Social Orientation Score by Patients Seen Per Week, Controlling for Solo Versus Group Practice for General Practitioners I I I I I I I I I I I I I I I I I I I I I I 86 TABLE 26. 27. 28. 29. 30. 31. 32. 33- vii Social Orientation Score by Patients Seen Per Week Controlling for Age--General Practitioners . . . . . . . . Trend in Medical Practice to Bring Less Serious Dis- orders to Physicians by Social Orientation Score for General Practitioners . . . . . . Percentage of General Practitioners Responding that Trend in Medical Practice to bring Less Serious Disorders to Physicians Is Very Good by Social Orientation Score and Patients Seen Per Week . . . . Total Percentage Matrix for Social by Technical Orientation Score for tioners . . . . . . . . . . . . . Technical-Social Orientation Types Practitioners . . . . . . . . . . Technical-Social Orientation Types Practice for General Practitioners Technical-Social Orientation Types Per Week for General Practitioners Orientation Score General Practi- by Age for General by Solo Versus Group by Patients Seen Frequencies for Technical—Social Orientation Types by Patients Seen Per Week Controlling Practitioners . . . . . . . . . . for Age-~General Trend in Medical Practice for Patients to Seek Help in Personal Problems and Less Serious Disorders by Technical—Social Orientation Types t ioners I I I I I I I I I I I I I for General Practi- PAGE 87 89 89 91 94 95 97 98 10# TABLE 35- 37. 38. 39- 40. 41. 42. “'30 45. viii Proportion of Patients' Visits which Are Trivial by Technical-Social Orientation Types for General Practi- tioners . . . . . . . . . . . . . . . . . . . . . . . Proportion of Patients Who Are Women within Childbear- ing Years for General Practitioners . . . . . . . . . Obstetrical Work by Proportion of Practice Females in Childbearing Years . . . . . . . . . . . . . . . . . . General Practitioners Obstetrical Work by Age . . . . Obstetrical Work by Technical-Social Orientation Types for General Practitioners . . . . . . . . . . . . . . Frequencies for Obstetrical Work by Technical-Social Orientation Types Controlling for Age--General Practi- tioners . . . . . . . . . . . . . . . . . . . . . . . Percentage of General Practitioners Reporting Recom- mending Methods of Contraception to Any Patient . . . Mean Percentage of Patients General Practitioners Advise to Use Each Method of Contraception . . . . . . Number of Sterilizations Recommended by General Practi- tioners to Males and Females During the Past Year . . Proportion of Female Patients in their Childbearing Years with which General Practitioners Report Having Discussed Family Planning . . . . . . . . . . . . . . Proportion of Female Patients in Childbearing Years Have Discussed Family Planning with by Initiation of Family Planning with Patients for General Practi- tioners I I I I I I I I I I I I I I I I I I I I I I I PAGE 105 105 106 107 108 109 110 111 113 113 115 TABLE 47. 49. 50. 51. 52. 53- 55- PAGE Percent of Women Patients in Childbearing Years with whom General Practitioners Have Discussed Family Plan- ning by Obstetrical Work . . . . . . . . . . . . . . . . . 116 Willingness to Initiate Discussion of Family Planning by Obstetrical Work for General Practitioners . . . . . . 117 Percent Female Patients in their Childbearing Years with whom General Practitioners Have Discussed Family Planning with by Age . . . . . . . . . . . . . . . . . . . 117 Willingness to Initiate Family Planning Discussion by Age for General Practitioners . . . . . . . . . . . . . . 118 Percent Female Patients in Childbearing Years Discussed Family Planning with and Willingness to Initiate Family Planning Discussion by Obstetrical Work Controlling for Age--General Practitioners . . . . . . . . . . . . . . 120 Percent Female Patients in Childbearing Years Discussed Family Planning with by Technical Orientation Score Controlling for Obstetrical Work--General Practitioners . 122 Percent Female Patients in Childbearing Years Discussed Family Planning with by Social Orientation Score Con- trolling for Obstetrical Work--General Practitioners . . . 124 Importance of Religion by Age for General Practi- tioners . . . . . . . . . . . . . . . . . . . . . . . . . 126 Willingness to Initiate Discussion of Family Planning by Religious Importance for General Practitioners . . . . 127 Willingness to Initiate Family Planning Discussion by Religious Importance Controlling for Age—-General Practi- tioners I I I I I I I I I I I I I I I I I I I I I I I I I 128 TABLE PAGE 56. Solo Versus Group Practice by Age for Obstetricain- Gynecologists . . . . . . . . . . . . . . . . . . . . . . 135 57. Number of Patients Seen Per Week by Obstetrician- Gynecologists . . . . . . . . . . . . . . . . . . . . . . 135 58. Patients Seen Per Week by Solo Versus Group Practice for Obstetrician-Gynecologists . . . . . . . . . . . . . . 136 59. Technical Orientation Score by Age for Obstetrician— Gynecologists . . . . . . . . . . . . . . . . . . . . . . 137 60. Technical Orientation Score by Solo Versus Group Prac— tice for Obstetrician—Gynecologists . . . . . . . . . . . 137 61. Technical Orientation Score by Patients Seen Per Week for Obstetrician—GynecolOgists . . . . . . . . . . . . . . 138 62. Trend in Medical Practice by Social Orientation for Obstetrician-Gynecologists . . . . . . . . . . . . . . . . 139 63. Social Orientation Score by Age for Obstetrician— Gynecologists . . . . . . . . . . . . . . . . . . . . . . 140 64. Social Orientation Score by Patients Seen Per Week for Obstetrician-Gynecologists . . . . . . . . . . . . . . 141 65. Social Orientation Score by Solo Versus Group Practice for Obstetrician-Gynecologists . . . . . . . . . . . . . . 141 66. Total Percentage Matrix for Social Orientation Score by Technical Orientation Score for Obstetrician- Gynecologists . . . . . . . . . . . . . . . . . . . . . . 142 67. Distribution of Obstetricians on Technical-Social Orientation TypolOgy . . . . . . . . . . . . . . . . . . . 144 xi TABLE PAGE 68. Proportion of Female Patients who Are in their Child- bearing Years for Obstetrician-Gynecologists . . . . . . . 146 69. Methods of Contraception Obstetrician-Gynecologists Ever Recommend to Patients Percentage Doctors Recom- mending Method to at least One Percent of Patients . . . . 147 70. Mean Percentage of Patients Doctors Advise to Use Each Method of Contraception . . . . . . . . . . . . . . . . . 148 71. Number of Sterilizations Recommended by Obstetrician- Gynecologists to Male and Female Patients During Past Year . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 72. Proportion of Female Patients in their Childbearing Years with which Obstetrician-Gynecologists Report Having Discussed Family Planning . . . . . . . . . . . . . 149 73. Proportion of Female Patients in Childbearing Years Have Discussed Family Planning with by Initiation of Family Planning Discussion with Patients for Obstetrician-Gynecologists . . . . . . . . . . . . . . . . 151 74. Willingness to Initiate Family Planning Discussion by Age for Obstetrician-Gynecologists . . . . . . . . . . . . 153 75. Willingness to Initiate Family Planning Discussion by Ever Having Worked at a Family Planning Clinic . . . . . . 153 76. Patients Seen Per Week by Internists . . . . . . . . . . . 157 77. Distribution of Technical Orientation Scores for Internists . . . . . . . . . . . . . . . . . . . . . . . . 159 78. Distribution of Social Orientation Scores for mtemiSts I I I I I I I I I I I I I I I I I I I I I I I I 161 xii TABLE PAGE 79. Social Orientation Score by Age for Internists . . . . . . 161 80. Social Orientation by Solo Versus Group Practice for Internists . . . . . . . . . . . . . . . . . . . . . . . . 161 81. Trend in Medical Practice by Social Orientation Score for Internists . . . . . . . . . . . . . . . . . . . . . . 162 82. Total Percentage Matrix for Technical and Social Orien- tations Scores-Internists . . . . . . . . . . . . . . . . 163 83. Technical-Social Orientation Types for Internists . . . . 164 84. Technical-Social Orientation Types by Solo Versus Group Practice for Internists . . . . . . . . . . . . . . 164 85. Percent of Patients' Visits for Trivial or Inappropri- ate Reasons by Technical Orientation Score for Internists . . . . . . . . . . . . . . . . . . . . . . . . 165 86. Methods of Contraception Reported as Ever Recommended by Internists . . . . . . . . . . . . . . . . . . . . . . 166 87. Mean Percentage of Patients’ Doctors Advise to Use Each Method of Contraception-Internists . . . . . . . . . 167 88. Number of Sterilizations Recommended to Male and Female Patients in the Past Year by Internists . . . . . . . . . 168 89. Proportion of Female Patients in their Childbearing Years with whom Internists Have Discussed Family Plan- ning . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 90. Proportion of Female Patients in their Childbearing Years with whom Have Discussed Family Planning by Will- ingness to Initiate Family Planning Discussion with Patients for Internists . . . . . . . . . . . . . . . . . 169 TABLE 910 92. 93- 940 95- 96. 98. 99. 100. 101. 102. 103. 104. xiii Willingness to Initiate Family Planning Discussion by Age for Internists . . . . . . . . . . . . . . . . Percentage in Group Practice by Age and Practice Specialty . . . . . . . . . . . . . . . . . . . . . . Percentage Seeing above the Mean Number of Patients Per Week for Practice by Age and Practice Specialty . Percentage Seeing above the Mean Number of Patients Per Week for Practice by Solo Versus Group Practice and Practice Specialty . . . . . . . . . . . . . . . . . . Percentage Seeing above the Mean Number of Patients Per Week for Practice by Solo Versus Group Practice, Age, and Practice Specialty . . . . . . . . . . . . . Technical Orientation Score by Practice Specialty . . Technical Orientation Score by Age and Practice Specialty . . . . . . . . . . . . . . . . . . . . . . Technical Orientation Score by Solo Versus Group Prac- tice and Practice Specialty . . . . . . . . . . . . . Technical Orientation Score by Patients Seen Per Week and Practice Specialty . . . . . . . . . . . . . . . . Social Orientation Score by Practice Specialty . . . . Social Orientation Score by Age and Practice Specialty Social Orientation Score by Solo Versus Group Practice and Practice Specialty . . . . . . . . . . . . . . . . Social Orientation Score by Patients Seen Per Week and Practice Specialty . . . . . . . . . . . . . . . . . . Technical-Social Orientation Typology by Practice Specmlty‘ I I I I I I I I I I I I I I I I I I I I I I PAGE . . 171 . . 175 . . 178 . . 178 . . 179 . . 181 . . 181 . . 182 . . 182 . . 184 . . 184 . . 185 . . 186 . . 188 TABLE 105. 106 . 107. 108. 109. 110. 111. 112. 113. xiv Percentage Reporting 51%>Or More of Patients.Are Females in their Childbearing Years by Obstetrical Work and Practice Specialty . . . . . . . . . . . . . . . . . . . Percentage of Physicians Reporting Recommending Methods of Contraception to Any Patient by Obstetrical Work and Practice Specialty . . . . . . . . . . . . . . . . . . . Mean Percentage of Patients Physicians Advise to Use Each Method of Family Planning by Obstetrical Work and Practice Specialty . . . . . . . . . . . . . . . . . . . Percent Scoring High on Willingness to Initiate Family Planning Discussion with Patients by Obstetrical Work and Practice Specialty . . . . . . . . . . . . . . . . . Percent Reporting Having Discussed Family Planning with ‘5E% or More of their Female Patients in their Childbear- ing Years by Obstetrical Work and Practice Specialty . . Willingness to Initiate Family Planning Discussing with Patients by Age and Obstetrical Work and Practice Specialty . . . . . . . . . . . . . . . . . . . . . . . Case History I: "Married Female, Twenty-one Years Old, Nulligravid, Good Physical Health, Desires to Postpone First Pregnancy." (Question 2-A) . . . . . . . . . . . Case History II: "Unmarried Female, Sixteen Years Old, Nulligravid, Good Health, Desires Contraception." (Question 2-C) . . . . . . . . . . . . . . . . . . . . . Case History III: "Separated Female, Thirty-three Years Old, Four Children, Good Health, Receiving Welfare Assistance, Desires Family Planning." (Question 2-E) . PAGE 190 191 193 194 194 196 205 205 207 TABLE PAGE 114. Case History IV: "Married Female, Twenty-six Years Old, Three Children, Two Contraceptive Failures Using Dia- phragm, Good Physical Health, Desires No More Children." (Question 2-B) . . . . . . . . . . . . . . . . . . . . . . 207 115. Case History V: "Unmarried Female, Twenty-three Years Old, Nulligravid, History of Diabetes Mellitus Desires Contraception." (Question 2-F) . . . . . . . . . . . . . 210 116. Case History VI: "Married Female, Twenty-five Years Old, One Child, History of Dysmenorrhea and Hyperten— sion, Desires to Postpone Next Pregnancy." (Question 2-D) . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 117. Recommending a Sterilization in One or More Case His- tories by Involvement in Obstetrical Work and Practice Specialty . . . . . . . . . . . . . . . . . . . . . . . . 215 118. Percent Recommending a Sterilization in One or More Case Histories by Willingness to Initiate Discussion of Family Planning . . . . . . . . . . . . . . . . . . . . 216 119. Percent Recommending a Sterilization in One or More Case Histories by Proportion Female Patients in Child- bearing Years Have Discussed Family Planning with . . . . 217 120. Distribution of Family Planning Index Scores by Obste- trical Work and Practice Specialty . . . . . . . . . . . . 218 121. Percentage of Physicians Recommending a Sterilization for One or More Case Histories by Family Planning Index Score and Obstetrical Work and Practice Specialty . . . . 220 122. Percent Recommending Sterilization in One or More Case Histories by Importance of Religion . . . . . . . . . . . 221 TABLE 123. 124. 125. 126 . 127. 128. 129. xvi PAGE Percent Recommending a Sterilization for One or More Case Histories by Technical Orientation Score, Control- ling for Obstetrical Work and Practice Specialty . . . . . 222 Percent Recommending a Sterilization for One or More Case Histories by Social Orientation Score, Control- ling for Obstetrical Work and Practice Specialty . . . . . 223 Percent Recommending a Sterilization for a Married Female, Three Children, Two Contraceptive Failures Using Diaphragm, Good Physical Health, Desires No More Children (Case IV) by Technical-Social Orientation Type and Family Planning Index Score, Controlling for Obste- trical Work and Practice Specialty . . . . . .‘. . . . . . 225 Percent Recommending a Sterilization for a Separated Female, Thirty-three Years Old, Four Children, Good Health, Receiving Welfare Assistance, Desires Family Planning (Case III) by Technical-Social Orientation Type and Family Planning Index Score, Controlling for Obstetrical Work and Practice Specialty . . . . . . . . . 229 Refusing Family Planning Services for One or More Case Histories by Involvement in Obstetrical Work and Prac- tice Specialty . . . . . . . . . . . . . . . . . . . . . . 231 Percentage of Physicians Refusing Family Planning for One or More Case Histories by Family Planning Index Score and Obstetrical Work and Practice Specialty . . . . 233 Percent Refusing Family Planning Services in One or More Case Histories by Importance of Religion—-Tota1 Sample . . 234 TABLE 130. 131. 132. 133. 134. 135. 136. 137. xvii PAGE Percent Refusing Family Planning Services in One or More Case Histories by Technical Orientation Score, Controlling for Obstetrical Work and Practice Specialty . 236 Percent Refusing Family Planning Services for One or More Case Histories by Social Orientation Score, Con— trolling for Obstetrical Work and Practice Specialty . . . 237 Percent Refusing Family Planning Services for an Unmarried Female, Sixteen Years Old, Good Health, Nulli- gravid, Desires Contraception (Case 11) by Technical- Social Orientation Type and Family Planning Index Score, Controlling for Obstetrical Work and Practice Specialty . 238 Number of Case Histories Recommended the Pill by Prac- tice Specialty--Total Sample . . . . . . . . . . . . . . . 243 Number of Case Histories Recommended the Pill by Family Planning Index, Controlling for Obstetrical Work and Practice Specialty . . . . . . . . . . . . . . . . . . . . 244 Number of Case Histories Recommended the Pill by Tech- nical Orientation Controlling for Obstetrical Work and Practice Specialty . . . . . . . . . . . . . . . . . . . . 247 Number of Case Histories Recommended the Pill by Social Orientation Controlling for Obstetrical Work and Practice Specialty . . . . . . . . . . . . . . . . . . . . 249 Number of Case Histories Recommended Pill by Technical- Social Orientation Type by Obstetrical Work and Prac— tice SPeCialty I I I I I I I I I I I I I I I I I I I I I I 250 TABLE 138. 139. 140. 141. 142. xviii PAGE Methods of Contraception Recommended for an Unmarried Female, Twenty—three Years Old, Nulligravid, History of Diabetes Mellitus, Desires Contraception (Case V) by Technical Orientation Score, Controlling for Obstetri- cal Work and Practice Specialty . . . . . . . . . . . . . 253 Methods of Contraception Recommended for a Married Female, Twenty-six Years Old, One Child, History of Dysmenorrhea and Hypertension and Desires to Postpone Next Pregnancy (Case VI) by Technical Orientation Score, Controlling for Obstetrical Work and Practice Specialty . 255 Percentage Recommending Pill and/or IUD for a Married Female, Twenty-five Years Old, One Child, History of Dysmenorrhea and Hypertension, Desires to Postpone Next Pregnancy (Case VI) by Technical Orientation Score, Controlling for Obstetrical Work and Practice Specialty . 259 Percentage Recommending Diaphragm, Foam, or Condom as an Alternative Method of Contraception for a Married Female, Twenty-five Years Old, One Child, History of Dysmenorrhea and Hypertension, Desires to Postpone Next Pregnancy (Case VI) by Technical Orientation Score, Controlling for Obstetrical Work and Practice Specialty . 260 Methods of Contraception Recommended for a Separated Female, Thirty—three Years Old, Four Children, Good Health, Receiving Welfare Assistance, Desires Family Planning (Case III) by Technical Orientation, Control- ling for Obstetrical Work and Practice Specialty . . . . . 262 LIST OF FIGURES FIGURE PAGE 1. The Doctor-Patient Relationship as a Social System . . . . 14 20 TechiCal-SOCial orientation mes o o o o o o o o o o c o 92 xix CHAPTER I INTRODUCTION In conjunction with the remarkable advances in medical knowledge, there has been the development of what can be described as an ”ethical crisis" in the application of medical science. The success of medicine in drastically lowering mortality rates has given rise to growth rates of unprecedented magnitude. There are two immediate questions raised by this success in controlling mortality. First, does the doctor have an obligation to match his efforts in death control with equally stren- uous efforts in the pursuit of birth control? Second, does the doctor have an obligation to provide for a population which is optimal in vigour and potential as well as size?1 The preceding are restated as empirical questions to guide development of one area of study. ‘These questions are: (1) for whom will physicians recommend family planning, (2) under what conditions will physicians recommend family planning, and (3) what method or methods of family planning will physicians recommend. Since physicians' delivery of family planning services occurs in the context of medical practice, investigation of the environment of medical practice is a second area of study. Specifically, the focus is on the relationships between the structure of medical practice and physicians' perceptions of various dimensions of medical practice as they affect medical concerns in the area of family planning. The study is restricted to primary care physicians in private 2 practice who can be expected to provide patients with family planning information and technology. This includes general and family practi- tioners, obstetricians and gynecologists, and internists. Both osteopathic and allopathic physicians are included in the population. The unit of analysis is the primary care physician in private practice whose field of medicine is general or family practice, obstetrics and gynecology, or internal medicine. The intent is to discover and explain substantive differences between physicians in the structure of their medical practices, their conceptions of various dimensions of medical practice, and their con- ceptions of medical concerns in the area of family planning. The purpose is to add to the understanding of medical practice in general, and the understanding of the delivery of family planning services in particular. Although available resources limit the study to an exploratory analysis, the findings add substantively to the sociology of medicine. Review 9f the Literature The organization of this section is guided by a brief review of the literature concerning family planning as a medical problem and the sociology of medical practice. Family Planning as a Medical Problem The consideration of family planning as a medical problem usually focuses on patients' decisions to prevent unwanted pregnancies since it is such decisions that create the potential for patients to seek services from physicians. Herein, the concept of family planning is defined as physicians‘ responsibility to provide for the optimum 3 health of patients and their families by all means at their disposal.2 Decisions concerning how many children and when to have children are considered important factors in the maintenance of the health of patients and families. Technologies of fertility control are a crucial element in the provision of medical services in the area of family planning. Possible means of fertility control include contraception, sterilization, and abortion. Due to the political sensitivity of the issue of abortion at the time of the study, only contraception and sterilization are included in the Study. Methods of contraception are classified as tra- ditional and modern. Traditional methods of contraception include condoms, vaginal diaphragms, spermicides, and rhythmn method; modern methods include oral contraceptives and intrauterine devices. Sterili- zation is viewed as an additional, permanent form of contraception.3 The distinction between traditional and modern means of fertility control coincides with the developing concern for family planning within the general population and the medical profession. Guttmacher's study of physicians' attitudes and practicies in family planning reveals concern for family planning in 1947, but available methods of contraception were traditional means, and the diaphragm was the method most frequently recommended.“ Chronologically, the next major study of physicians and family planning was conducted in 1957.5 Available means of contraception were traditional, with the diaphragm most frequently recommended. Surveys of physicians conducted after the commercial introduction of oral contraceptives and IUDs in the early 1960's reveal a shift in physicians' recommendation patterns. Chien's research indicates that L, by 1966, 92 percent of a national sample of allopathic and osteopathic general practitioners, obstetrician-gynocologists, and internists recommended some brand of oral contraceptives.6 Cartwright7 andWard8 indicate similar recommendation patterns among national samples of British general practitioners. Research conducted on regional and local medical populations in the United States supports the findings from national samples--the pill is the method of first choice for physicians.9 Development of new methods of fertility control, and their adoption by physicians, and patients, have greatly increased the efficacy of attempts to control fertility. As with many new advances in medical science there remain certain questions as to their appropri— ate use. The possibility exists that there are a wide range of medical and social indications for the use or non-use of these technologies in maintaining the optimum health of patients and their families. The side effects and complications of oral contraceptives are well documented,10 and Hellman argues that the physician has a respon- sibility to explain potential side effects to a patient in deciding which method of contraception is to be used.11 Davis adopts a similar approach in his discussion of the IUD, arguing that IUD devices are not efficiently used by the medical profession.12 Bakker and Dightman discuss patients' psychiatric responses to sterilization which may contraindicate the procedure.13 Research on the delivery of family planning services to patients calls into question whether physicians do provide for the optimum health of their patients. Wolf and Ferguson conducted an intensive observation of physicians' activities in a prenatal clinic.14 Although 5 subjective, their findings are instructive. They find: (1) some physicians tend to be overenthusiastic and somewhat authoritarian in urging specific methods of contraception on clinic patients; (2) phy- sicians state concerns for birth control to patients in broad social terms rather than relating contraception to patients' personal lives; (3) misunderstanding arises because physicians assume that clinic patients' failure to ask questions means patients understand birth control; and (4) physicians tend to recommend "sophisticated" con- traceptives when traditional means such as the condom are entirely appropriate.l5 Cartwright's study reveals general practitioners vary in their willingness to discuss family planning.16 Measham, Hatcher, and Arnold's research reports that physicians view the pill as method of first choice for private patients and the IUD as method of first choice for public aid patients.17 They report physicians indicating the IUD as especially suited in cases involving the medically indigent, the illiterate, and the unreliable or poorly motivated.18 This research is descriptive with little effort to explain substantive differences between physicians. Although the methods of birth control physicians recommend are well established, initial investigations indicate a lack of research on the relationship between the organization of medical practice and the delivery of family planning services. The preceding discussion substantiates the validity of the empirical questions stated in the introduction. The context of medical practice in which family planning services are provided remains to be discussed. 6 Sociology of Medical Practice As ongoing medical practice is the locus for the delivery of family planning services in this study, the following offers a brief outline of basic approaches to the sociology of medical practice. One approach to the sociology of medicine traces the process of occupational professionalization. At the core of the professionaliza- tion process are the primary characteristics of acquisition of a specialized body of abstract knowledge and a service orientation.19 Among derived characteristics presumably caused by these core charac- teristics are: (l) the profession determines its own standards of education and training; (2) the student professional goes through a more extensive adult socialization experience than members of other occupations; (3) professional practice is often legally reCOgnized by some form of licensure; and (4) the practitioner is relatively free from lay evaluation.20 Application of the professionalization framework to the sociology of medical practice, and its emphasis on the acquisition of the know- ledge and skills necessary to meet criteria for licensure, tends to result in an individualistic approach in the study of physicians. Socialization of the physician is a key concept within this framework, and the identification of distinctively "professional qualities" of doctors is a specific form the socialization framework takes.21 The argument in the professionalization approach is that a set of "professional qualities" are inculcated in the process of medical education. Deficient behavior of physicians is explained in terms of inadequate or inappropriate socialization in medical school. Correction of deficiencies in professional behavior is usually related to revision of professional curriculums. .Medical education is important as an absolute source of doctOrs' performance as physicians--it is what separates them from laymen. How- ever, medical practice is an ongoing process and questions exist concerning the influence of the structure of medical practice on pro- fessional behavior. Freidson argues that in explaining professional performance, education is a less important variable than work environ— ment.22 At the core of Freidson's argument is the assumption that a significant amount of physicians' behavior is situational in character. Physicians respond to the pressures of the situation they are presently in, and that what physicians are is not completely but mgrg their pre- sent than their past, and that what physicians do is mgrg an outcome of the situation they are in than what they have earlier "internalized."23 The assumption that physicians' behavior is "rational," that physicians choose from their pool of medical knowledge and skills those best suited to their patients, is questionable. Freidson defines the situations in which physicians practice medicine in terms of variations in practice organization. Solo practice arrangements and group practice arrangements constitute the range of empirical types of practice organization. Practice arrangements vary in the relationships between physicians and their clients (patients) and colleagues. Competition is the explanatory mechanism in Freidson's analysis.21+ In solo fee—for-service practice arrangements competition is greatest since physicians cannot count on the loyalty of their patients or their colleagues in the community. In group practice arrangements Tm 8 access to patients and cooperation of colleagues is better controlled. The relative isolation of the solo practitioner, and the necessity of "keeping" patients, leads to a low level of communication between colleagues and less chance to "keep up—to-date" with developments in the field of medicine.25 The type of patient referral system on which physicians' prac- tices are based is related to variations in practice organization. Freidson describes independent and dependent practices based on "lay referral" and "colleague referral" systems respectively. Independent practices are more conducive to solo practice and dependent practices are more conducive to group practice arrangements.26 Broad medical specialty fields such.as general medicine should exist in a lay referral system. Limited medical specialty fields by virtue of their specialized training deal with a restricted set of medical problems, and should be the recipients of medical referrals. Doctors in obstetrics-gynecology and internal medicine should be more likely to be in group practice arrangements and general practitioners in solo practice. Related to the description of independent and dependent practices is the effect of competition. In solo practice physicians are particu- larly vulnerable to client control, and competition is an especially relevant concept.27 One effect of competition on solo practitioners is that they may have to give patients what they desire, for if they do not, some other doctor will. This notion is relevant to family planning and the provision of contraception and sterilization. A second effect of competition is that solo practitioners may hesitate to refer patients on the fear that another doctor may "steal" their patient—-assume primary medical care for the patient. u . 1 .a a. I... ..~ . 9 Although Freidson discusses competition in terms of solo versus group practice arrangements, the concept is also relevant to competi- tion between medical specialties. Composition of the patient population is relevant to sheer numbers and the types of medical problems patients present. Within the area of family planning there is overlap in professional services, examples being general practitioners and obste- tricians perform deliveries, and general practitioners, obstetrician- gynecologists, and internists provide contraception. The overlap in services offered in the area of family planning makes medical specialty field a relevant variable in describing the environment of medical practice. Although medical specialization directly relates to physicians' original training, specialty field affects the structure of ongoing medical practice. The influence of medical specialty is directly related to the types of medical problems physicians see in their current practices. Ford gt 91. find that various medical specialty fields place differential emphasis on the professional traits necessary for medical practice.28 Mechanic finds differential emphasis on techni- cal and social aspects of medical practice by specialty field.29 The foregoing indicates that the professionalization approach to medical practice must be expanded to include a definition of the environment of ongoing medical practice. Medical practice is an ongoing social process, and understanding of that process involves both the training and present social situation in which medical practitioners operate. 10 Conceptual Framework An immediate need is to establish a conceptual framework of medical practice which is relevant to the development of the present study. The doctor-patient relationship is the focus of the research design, and the conceptualization must adequately describe the context of that relationship. Field Theory Field theory is the general theoretical orientation used to analyze the physicians in this study. Lewin argues that (a) behavior must be derived from a totality of coexisting facts, and (b) these coexisting facts have the character of a "dynamic field" in that the state of any part of the field depends on every other part of the field.30 In the Lewinian usage of the concept of "dynamic field," coexisting facts constitute a set of forces which serve to explain behavior. Lewin defines these forces as "vectors" using a meaning similar to that employed in physics.31 According to field theory, behavior depends neither on the past nor the future but on the present field of vectors.32 Freidson's argu- ment that medical performance is situational in character, depending more on the present than the past, is strikingly similar to Lewin's explanation of behavior.33 The assumptions underlying field theory have been developed by Shepherd and include: (1) the phenomena to be studied are what the individual perceives in his environment and refers to the concept of life space of the individual; (2) that an individual occupies a posi- tion in this life space which is related to the objects of which it is 11 composed; (3) that an individual is oriented toward goals, which ordi— narily involve a change in the relative positions of the individual and the objects in the life space; (4) the individual responds in certain ways to achieve these goals; and (5) that in the process of responding toward goals the individual may encounter barriers which have to be surmounted or circumvented, or which result in a change in goals or in life space or both.31+ Adaption of field theory to a group level of analysis has been developed in group dynamics. Relevant concepts added in this conceptu- alization of the field theory framework are: norms, referring to the rules governing behavior; roles, referring to relative position of an individual and the rights and obligations of position incumbents; valence, indicating the potency of goals or objects in the life space; interaction, referring to the type and degree of communication between group members; and consensus, referring to the degree of agreement regarding goals, norms, roles, and other aspects.35 Basic elements in most definitions of the concept of role are social location, expectations, and behavior.36 Social location derives from the fact that an individual exists in a system of social relationships, and describes the location of an actor in a system of social relationships. The term doctor defines a position in a set of relationships with other doctors, hospital administration and staff, and patients. A particular relationship with one of these other positions in the total set is referred to as a sector of the total role. Particular emphasis is placed on the doctor's relationship to his patient, but other relationships are considered relevant as they influence the physician's perception of his 12 relationship with a patient. The relational aspect of role refers to the fact that no position has meaning apart from the other positions to which it is related.37 The total set of relationships helps to describe the development of the field from which the physician perceives the doctor-patient relationship. Inherent in a social position is some specification of expecta- tions appropriate to that position which are distinct from the individual occupying a position. Expectations express the normative element of social position.38 Expectations involve the specification of behaviors which are "appropriate" to a social position. In role analysis, the concept of expectations usually refers to evaluation of behaviors, but usage of "evaluation" raises the question of evaluation by whom. Problems in dealing with the concept of evaluation will be discussed later in this chapter. At present the assumption is that there are right§_and gbliga- tiggg associated with the position of doctor, while specification of those expectations will be discussed later. What is important in the present study is gaining insight into the factors which influence the physician's perception of his role. The importance of perceptions is justified by the phenomenologi- cal approach taken in field theory and is based on the assumption that the researcher should be concerned with what the individual perceives as objective reality.39 External stimuli are important as they are perceived by the individual. Such a position is counter to the assumption of many social scientists that a given stimulus is perceived in the same way by different individuals. The argument is that objective stimuli are always perceived in 13 time context of individual experience and predispositions. Objective Irxility does not completely determine the individual's interpretation. Speuzification of the objective environment of the physician and his intrarpretation of that environment as reflected in his response to patients constitutes the objective in this research. Field of the Doctor—Patient Relationship Sigerist effectively argues that the practice of medicine is dependent on available scientific knowledge and the values of the Scxziety in which it exists.1+0 The organization of medicine exists in the context of ongoing society. Bloom's graphic model of the doctor—patient relationship as a Scncial system serves to identify the various elements of the doctor- Ifiltient relationship in social space. Relevant elements are the ESociocultural matrix, the doctor, the medical profession, the patient, ‘the patient's family, the interaction between doctor and patient, and 'tke application of medical science by the doctor.)+1 Using Freidson's Elrguments, the additional factor of the organization of medical IPIactice should be added to Bloom's model.)+2 (See Figure l on page 14.) From the field theory perspective the specific concerns with Iregards to physicians are: the individual predispositions of physi— Cians; the standards of professional behavior internalized by physicians; and the specific stimulus complex provided by patients which may be perceived as medical problems.43 The approach is to examine the social environment and social forces which influence the perceptions of physicians in medical practice. Adopting Freidson's approach, the position taken is that physicians' work environment will be the most important vector in explaining physicians' perceptions 14 ZMHmwm A_i_t_. 65. Ford, pig” pp. 9313. 66. Clute, pp. p_i_t_. 30 67. David Mechanic, "Practice Orientations Among General Practi- tioners in England and Wales," Medical Care, Volume 8, 1970, pp. 15-25. 68. H. Menzel, J. Coleman, and E. Katz, "Dimensions of Being 'Modern' in Medical Practice," Journal pf; Chronic Diseases, Volume 9, 1959, PP. 20-400 69. Cartwright, 1968, o . p_i_t_.; Wolf and Ferguson, pp. pip. 70. A. Donabedian, "Evaluating the Quality of Medical Care," Mil- bank Memorial Fund Qparterly, Volume 44, July 1966 , part 2, pp. 166—206. 71. Ibid., PP. 167‘1690 72. Segal and Tietze, pp. c_:i_p. 73. J. F. Hulka, "A Mathematical Model Study of Contraceptive Efficiency and Unplanned Pregnancies," American Journal _o_f Obstetrics and Gynecology, Volume 104, June 1969, pp. 443-447. 74. Donabedian, pp. p_i_t_., p. 169. 7 5. Wolf and Ferguson, p_p. p_i_p. 76. Donabedian, pp. p_i_t_. 77. Ibid., PP. 177’l78. 78. Of particular help was Thomas Kirschbaum, Chairman, Depart- ment of Obstetrics and Gynecology, College of Human Medicine, Michigan State University. 79. Donabedian, pp. p_i_t_.., p. 177. CHAPTER II METHODOLOGY This chapter focuses on the methodology employed in the study. Implementation of any research project depends on practical problems that constitute reconciliation of what is "desirable" with what is "possible" in terms of resources available. Discussion is divided into four sections: (1) popuLation and sample, (2) data collection tech- niques, (3) operationalization of variables, and (4) analysis of the data. Thp_Population.§pd Sample The population was defined by type of medical specialty and geographical location of practice. Identification of physicians to be included in the study focused on selecting doctors who could be expected to provide fertility control information and technology within their regular practice, with the condition that such doctors be involved in primary medical care. Whether doctors do provide family planning ser- vices is an empirical question for the study. Allopathic and osteopathic physicians were included in the population if they met all of the following criteria: (1) they were in private practice; (2) their specialty field was general or family practice, obstetrics and gynecology, or internal medicine: (3) their practice was in Ingham, Jackson or Eaton County, Michigan. Listing of the population was accomplished using national medical and osteopathic association directories and telephone 31 32 directories.1 Physicians identified as meeting all three criteria were included in the population. If search of directories produced a physi- cian who could not be identified as to type of practice, the doctor was included in the population on the assumption that eligibility would be determined in the data collection process. The listing of the population produced a total of 217 physicians. There were fifty-two osteopaths, one hundred and one allopathic general or family practitioners, thirty-one allopathic obstetrician-gynecologists and thirty-three allopathic internists. The sample was defined as identical to the population so that all physicians who were listed were mailed questionnaires. A total of 217 questionnaires were mailed out.2 Data Collection Process Data collection accomplished two purposes. First, completed questionnaires were secured for subsequent analysis. Second, eligibility of physicians for inclusion in the study was established. The following will serve to describe how these purposes were accomplished. Important to the execution of the study was securing apprOpriate sponsorship encouraging physicians to c00perate. Since the sample included both osteopathic and allopathic physicians, the cooperation of representatives from both the College of Osteopathic Medicine and the College of Human Medicine at Michigan State University was secured.3 A cover letter over the signature of the Associate Dean for Community Affairs of the College of Human Medicine was prepared and enclosed with questionnaires mailed to allopathic physicians in the sample. A cover letter over the signature of the Dean of the College of Osteopathic Medicine was enclosed with questionnaires mailed to all osteopathic 33 physicians in the sample. The data collection process started in November, 1972, and was continued through January, 1973. Cover letters and self-administered questionnaires were sent to 217 physicians. Followup of all doctors who had not returned questionnaires was begun ten days later using telephone interviews. Telephone followups were made by professional interviewers. Interviewers were instructed to ask to speak directly to the physician if possible, but if access was denied to solicit the physician's secretary's help in having the respondent complete the questionnaire. Calls were made to 85 percent of the respondents. As described, tele- phone calls were used to encourage response, and also served to confirm eligibility of respondents. Additional followups on nonresponding doctors using a letter and postcard to encourage participation were subsequently mailed. Duplicate questionnaires were mailed when requested by physicians. A final telephone followup was used for non- responding osteopaths because of their lower response rate. Examination of returned questionnaires and followup by telephone interviewers introduced several criteria for dropping physicians from the sample. Retirement, departure from private practice in the defined geographical area, and death were criteria used to drop a physician from eligibility in the study. The other determinant for eligibility was the expectation a physician's practice included the provision of family planning services. Obstetrician-gynecolOgists presented no problem in this regard, but this distinction for general practitioners and internists became difficult. Examples of the types of practices that did not meet this last 34 criteria were those limited to gerontology, urology, general surgery, cardiology, gastroenterlogy, and manipulative specialties. Physicians most likely to fall into these categories were internists whose practices were limited to subspecialties such as cardiology and gastroenterology, and those physicians whose practice specialty could not be determined from directory information. Using the eligibility criteria, forty-four doctors were dropped from the sample—-seven osteopaths, twenty—one allopathic general practitioners, and sixteen allopathic internists. The total population of eligible respondents was 173 doctors in the three counties. One hundred and nineteen respondents returned questionnaires. Due to incom- plete answers to key items, seven respondents were dropped from the data analysis. The number of respondents for subsequent analysis is 112. The return rate for eligible respondents was 64.7 percent with Md:IMs having the highest return rate and osteopaths the lowest return rate. There was some indication during the telephone followups that osteOpaths were less willing to Complete the form. Specific reasons for this are difficult to give, but the impression was that items at the end of the questionnaire generated hostility among local osteopaths. The specific items were sociometric questions and one item for a self- rating of practice effectiveness. These questions were dropped from the analysis because of the large proportion of missing data. The mean number of days to return completed questionnaires was fifteen days. Variation in time to return questionnaires seems related to practice specialty, or more directly to the size of doctor's prac- tices as measured by patients seen per week. MD:OBGs' and MD:IMs' 35 s.ma m6 NHH mas as sea acres m.r rm ma AH ca mm zHumz a.ma no am am :- Hm among: s.sa mm mm or am Hos more: s.ca an mm we a mm on Spam 9H. gpom moficsoogmogu mama and: saoosom coeoaasoo censuses capamaaosa cease: seesaw gases mza acHecara so cqua am ampere oa mean zamz nae .mamHazonemasa amsmamzoc oszmssmm sachHam acaezmomem .mmrHazzOHammea massacres seamsamm .machqu .aancHQHZH cream seesaw are 2H mmoacos H @993. 36 mean number of patients seen per week is considerably lower than that for all general practitioners. On this assumption, general practitioners probably found it more difficult to find time to complete a questionnaire. Since the population and sample are defined as identical it is possible to examine how representative the actual respondents are of doctors practicing in the three county area. Two variables for which comparable data are available for respondents and nonrespondents are age and year of graduation from medical school. Such data are available for all respondents and ninety-four percent of the total population. For those nonrespondents where the data are missing the following fact was established. Nonrespondents for whom data on age and year of grad- uation from medical school are missing are the more recent arrivals to the three county area. Based on this fact it is assumed that non- respondents are younger than the mean age of the total population and are later graduates from medical school than those for whom data are available. Table 2 presents the age breakdown for both the total population and respondents. For each group of physicians, the age breakdown looks fairly representative. Differences that exist probably reflect missing data discussed in the preceding paragraph. Assuming missing data are for younger doctors, the overrepresentation of younger physicians would diminish. Osteopathic physicians are slightly younger than the total population. In looking at comparisons for the total sample and respondents, respondents are representative of the total population of eligible doctors practicing in the three county area for age. Data on year of graduation from medical school reveal a similar 37 TABLE 2 BREAKDOWN BY AGE OF DOS, MD:GPS, MD:GBGS, AND MD:IMs FOR RESPONDENTS AND TOTAL POPULATION Age Percent of Percent of Total Population Respondents DO 60 + 14 4 50-59 21 17 40-49 38 44 30-39 21 22 20—29 14 13 Total 993 100 (42) (23) MD:GP 60 + 24 21 50-59 20 24 40-49 41 36 30-39 15 19 20-29 -- -- Total 100 100 (74) (53) MD:GBG 60 + l7 19 50-59 30 24 40-49 33 38 30-39 20 19 20-29 -- -- Total 100 100 (30) (21) MD:IM 60 + 12 13 50-59 38 40 40-49 38 33 30-39 12 13 20-29 -- -- Total 100 99a (16) (15) Total 60 + 19 18 50-59 24 25 40—49 38 38 30-39 18 18 20-29 1 1 Total 100 100 (42) (112) aRounding Error 38 TABLE 3 BREAKDOWN OF YEAR OF GRADUATION FOR DOs, MD:GPs, MD:GBGS, MD:IMS RESPONDENTS AND TOTAL POPULATION Year of Graduation Percent of Percent of Total Population Respondents DO Before 1940 12 4 1940—1949 10 9 1950-1959 36 44 1960 + 43 44 Total 101a 1018 (42) (23) MD:GP Before 1940 24 23 1940—1949 20 23 1950-1959 38 34 1960 + 18 21 Total 100 101a (74) (53) MD:GBG Before 1940 17 19 1940—1949 27 29 1950-1959 37 33 1960 + 20 19 Total 101a 100 (30) (21) MD:IM Before 1940 12 13 1940-1949 38 40 1950-1959 25 20 1960 + 25 26 Total 100 99a (16) (15) Total Before 1940 20 19 1940-1949 20 22 1950-1959 36 33 1960 + 25 25 101a 99a (162) (112) aRounding'Error 39 pattern. Due to greater variation in year of graduation, it is diffi- cult to make definitive statements on the representativeness of respondents for the total population. Osteopaths are likely to have completed their training later than other physicians with the mean year of graduation for osteopaths being 1955 and for other respondents 1949. It is difficult to predict year of graduation from medical school from a physician's age since completion of training is related to other variables in addition to age. This fact is probably reflected in the differences between the total population and respondents. However, distribution of respondents for year of graduation from medical school is representative of the total population. Classification of respondents has included whether respondents are osteopathic or allopathic physicians, and whether respondents are in general/family practice, obstetrics and gynecology, or internal medicine. The distinctions allow for a large number of classifications for subse- quent analysis. Since the focus is on primary care physicians, respondents will be classified as general/family practitioners (GP), obstetrician-gynecologists (OBG), and internists (TM). The decision to classify respondents by practice specialty is based on analysis of osteopathic respondents. Of twenty-three osteo- pathic respondents, twenty indicated general/family practice as specialty field, one indicated obstetrics—gynecology, and two indicated internal medicine. Due to the small number of osteopaths, generalizations con- cerning differences between osteopathic and allopathic physicians would be tenuous, and the consideration of osteopaths in terms of their specialty field rather than as osteopathic general practitioners seems a logical alternative. 4O Justification for the combination of osteopathic and allopathic physicians in a single category rests on the assumption that there are no significant differences in the practices of osteopathic and allopathic general practitioners due to their medical training. Since this study focuses on private medical practice, direct examination of experiences in the socialization process of osteopathic and allopathic medical stu- dents is not possible. Inferences concerning differences in medical education for osteopathic and allopathic physicians must come from analysis of respondents' answers to questions concerning medical prac- tice. The following discussion is limited to all general practitioner respondents. An important area where osteopathic and allopathic general practitioners differ is age. Osteopathic physicians who responded tend to be younger (mean age of forty-seven) than allopathic general practitioner respondents (mean age of fifty-one). Also, osteopathic general practitioners are more likely to have graduated from medical school later (mean year = 1955) than allopathic general practitioners (mean year = 1948). Examination of Table 4 illustrates these differences of age and year of graduation from medical school; two conclusions for the present sample are that osteopaths' age structure is markedly younger than that for allopathic general practitioners, and osteopathic general practi- tioners are more likely to have completed their medical education later than their allopathic counterparts. The possibility that osteopaths' age structure is due to selective response rates is refuted by the fact that age is available for all osteopaths practicing in the three county area (see Table 2). 41 Hanna msavnsomd mm mace am an mm mm ashes OH ooa ooa -- -- :: as case mmoH ma ooa n er Ha -: as-os ma ooa .. we as r amuom Ha ooa :- u: -- ooa + or om ooa m: on m .: acres a ooa or is -- -- or case made a ooa am as u: :- sauce 6 maoa AH , an AH :: amuom .i I... I: .i II II + or some area odes + oped -omaa -osaa daemon #Gmofimm Pcmounmm 9G0 OHmm Pgmofimm Psooaom z chem asses coasmscnso mo snow era mmHZOHBHBU ON mm mm psoouom oseneaoom enssosom HO OH an no 3O ecoonom oHPmHHmom hHo> sumo» a mono pmmoH pm hence? Ho>o mvsoapmm onsom HHm How madman mo meccaemm onsom HHs Mom mnmosm mc coco pmnoH pm apnom Ho>o mPsovam so Hmoamhnm oponeoo m 0U 09: mmHZOHHHBO :Hmoh a mono PmmoH 9w hvsozp Ho>o mvcoHpmm HHw Mom madman mo mono pmmoH pm anom Mo>o mesofipmm so Hmc lawman meonEoo m ow OB: enesoeeod so: HHm Mom NHopman HMOHOme oponsoo m ow OB: HZHOHOHS Ho coco pmmoH pm Npsom Hm>o meccavmm so Hmoamhnm opmHmeoo m 06 08: :mvmop capmosmmdd mo mm: one an momonmmfid HHm EHHmsoo ca: =nesoeeom so: HHd MOM hhopmHs Hmoados opmHmsoo m ow oB: MBH¢HOmmm mOHBO pdnzosom pmnzosom NHo> NBHon 09: .< pscomom psmoymm asmonom psmonmm pcoonmm OHpmHHcoHcO OvaHHmchO oapmHHdcm OHPmHHmom z omdm Hmpoa NHo> panamaom Panzoeom NHo> MBH¢HOmmm HOHBO Icoo Hm: OnHHdO moHpSO OCHmooxomdon Mom mesoaomcmahm oxms map Iprmon mm: mmHz mmonz Oceans: o dHos o9: .O NHH OOH N ON a: mm Hneoe OH OOH NH O mm a: osHOHOoz HnsnoesH mm OOH O on HO OH OOOHooossOInOHseoeneO ms OOH O OH NO Om OOHeonhm Honosou :.:HOHHo :H OHHOEOmononm mH 30H£3 :Hmm H60H>Hoo mo mmohdom HOGOHv nose dew HmHoom esp OcH>HomoH pcoHpmm a 39H: osHe Osman 09: .O pcmoamm pcconom psmouom pnoonom pqoohmm OHpmHHmonnb OHpmHHmchO OHpmHHdom oavaHmmm z onnm Hneoe sno> enssoeom enssosom shes Ae.esooO N mHmHHOO HoO noon mamww NH HOV NO HOV OO NH HOHO OO ONO NH HO>HHOO moon NO . OO NN u HOHoO NN n O N n «O no OH AOO OO ANHO NO OH HOV OO ANHO NO HO>HHOO HoO OOOO 2 .HwOHO .Ho 1. O ANO OO ANO OO N AHO OO AHV OO HosHHOO nooO OHOOO OO pcwomwm pcwonwm who: .3 33 Ho O OOHO soH O HsOoHOO HO HOOOHOO OO OOHmmHOomHQ OeHssta NHHsOO OOH: OOHOOOHO OHHsOO waHHHnH on. mmwOHOHOHHHHs memdome wHwOOwh pnwofiwm wO< Mmos HHHOO HoO OOOO OH OOH ON NN OOHO NO n HOHOO N n OO OO n O O OOH AOOO HoOO soH OH OOH OO HO esHOOO namsHHOO NH OOH NO OO OOHO wHo: Ho mme no pcwonwm HO quonm OO pswonwm OOHGOOHm OHHOOE wHoom OOHHOpOwHHO z wmwm HOPoB mewsomHO wpstpwm wHwewO pcwonwm HOOHOSOOB x903 HOOHHHmepO OOHZOHBHBOOON HOmmszIIMm03.HOOHmamHmmo mom UZHHHOOHZOO mmoom ZOHBOHZHHmO H oqom Mm mmmwe ZOHBOHzmHmO H¢m 20m: :EH3 mm¢m mBmHzmmBZH 20m; mHHz mmOHM OZHmQ< mzOn has mesousommon oosHm psoouom OOH Hmeoe Ho: 06 momwpsoonom onem NHH OH H O O OO Haeoe OH ON I: O 1: OO osHoHOOz HOsHopsH NN O I: O O HO ONOHoomsaulmoHHpopmnO OO OH H H O OO OOHeoONm HOHcsoo psooyom vsoonmm psooncm psoonom psooumm OmOm osoz sovsoo Ho scom stHsmOHO OOH HHHm OAOIN ZOHOOOOOO :.2OHOOOOOn are mesmosommou mosHm Homonmm OOH op HOpop poo 0O mmmmpsmonmm OSBO NHH O H H O NO HOpoB OH NH In In NH NO msHOHOmz HOsHopsH NN -- n- u- -- OOH OOoHoocsaO-onNHcOnOO MO 3 H H O NO ooHpoOHm HOHosmO psoonmm esconm psconom Psmoymm esooaom z mmOm Osoz ssnphm sovsoo Ho sOoh OOH HHHm cAarN ZOHOOOOOO =.HOzmO has mpnodcommmn oonHm acoonO OOH op Hmpov #0: oc mommpaooHoO mafia NHH O OH HO Hm HmHoe OH NH OO OO o msHOHewz HauaneH mm -- OH ow ON OmoHoomaOo-m0Hapopmpo OO O OH OO Om moHpomnm Hammaou vamonO psoonm pnoohom Osmonom z «mam meoz 93H HHHm cOHpmaHHHHmpm aAmrm zOHOOODOO =.zmmgHHmo mmo: oz mmmHmmm .manamm_HHUHmOmm mooo .zUOOOOOHO qum: mamaHHgm OOHBOOUHOOzoo O39 .zmmmHHmo mmmme .mHo mmam» HHmnwezmze .mHOSHO mmHmmm£ Ode mvcovqommmm moch PcmoHoO OOH op Hmpop 90: 06 monpnooHoO oOBm NHH O H OO Ow OH Hapoa OH .. .. OO OO .. mcHoHemz HangchH NN 1: I: OH ow OH OmOHoooOOO|moHHpopwpo OO O H Nm NO OH ooHpomHO HmHonoO vcoonom ecoonom psooHoO pcoonO pcoouom z ome @202 EMOHOOOHO OOH HHHO :opruHHHHopm aAmrm ZOHOOODOO =.UZszaHm HHHzam mmmHmmn .mozHmUmm .maHamm mooo .zmmgHHmo mpom .aHo OOOOH mamme-HOmHme .mHazmm amOOmOmmmz "HHH HmoemHm mmau MHH OHOOH 208 choices expressed in the first two case histories, this may also be regarded as a "routine" case indicating the pill. The results do not reflect the same pattern, only 63 percent choosing the pill. Although the presence of four living children is a new factor, other factors probably offer a stronger basis for explaining the methods recommended. Separation and welfare assistance seem to be key stimuli, the interpretation being that such a situation falls into a stereotype for the doctor. Fourteen percent recommended sterilization and 34 percent recommended an IUD. These two methods do not require continued motiva- tion for effective use, and the fact they were chosen for this patient implies that many respondents were concerned about the motivation of this patient.3 An important conclusion is that physicians apparently do react to the described social factors in dealing with patients on family planning, since no other explanation is reasonable from this hypothetical case. Reconciling "best" and "acceptable" care for the patient in Case History III is difficult since there are no medical contraindications for specific methods. Risk of pregnancy using traditional and modern means of contraception indicate that the alternative of sterilization should be presented to the patient. In this case, sterilization may be the best alternative to the hypothetical situation. The important cues in Case IV (see Table 114, page 207) are marital status, three children, twenty-six years old, contraceptive failures using diaphragm, good health, and the desire to have no more children. Stating a desire to terminate reproduction results in a recom- mendation for a sterilization by a relatively large number of respondents, 209 even with the young age of the patient. Again the pill is still the method of first choice. An interesting comparison can be made in com— paring Case IV with Case III regarding the question of physicians' perception of patients' motivation. Even with the fact that the patient in Case IV has had two contraceptive failures, there is a 15 percentage point difference in physicians recommending the IUD for the patient in Case III. This supports the notion that Case III is evoking a stereotype for a relatively large number of physicians. Ninety—five percent of the respondents did choose the three most theoretically effective forms of contraception available to the patient, which is an acknowledgement of the patient's desire for no additional children. In dealing with the question of "acceptable" versus "best" medical care, Case IV (see Table 114, page 207) presents a dilemma for the medical profession. Assuming that the hypothetical patient has reached desired family size, failure to recommend sterilization should be coupled with provision of abortion services for future pregnancies.5 This last alternative or sterilization would constitute "best" medical care. There is no way of evaluating physicians' attitudes toward abortion in the present study. Immediately apparent factors for this hypothetical patient are age, marital status, history of diabetes, and the desire for contracep- tion. (See Table 115, page 210.) Comparison of this case to the sixteen year old reveals a refusal rate considerably less for an unmarried woman in her twenties--9 percentage points. The patient's history of diabetes mellitus is a medical contra- indication for prescription of the pill.6 Given this fact, #4 percent of the doctors still recommended the pill. For other recommended 210 .Oospoa mco gasp mnoa Omucmaaoooh o>mn Ode mpnmvcommon mocHw pamoHoO OOH op Hdpop won 0O mowmpcoonom QSbNI NHH O O 0N OO .OO H HOOOO OH NH O OH ON OO -- mOHOHOoz HOOHOOOH NN -- OH ON ON OO -- OOoHoomOOuum0HnOopmpo OO O O OH NO HO H moHpomnO Hmumqmu anohmm PGmOHmnH Pcmohmm PGmOHmHH Pcm Ohmm Pam ohmm z owmm maoz soOOoo no Odom OOOHOOOHO OOH HHHO coHOOOHHHanO OAO-N ZOHOOOOOO =.OonzOOOm exmz Ozomamom oa OOOHOOO .zOHOzOeOOOOO sz gags mo $95? .938 mzo .So OOOHQ Emufizmfi .OHOOOO OOHOOOE “HO OOoOOHO OOOO QHH Handy .Oonpme mac swap whoa dmucmssoomn m>m£ Ode wycovnommon moch pcoohoO OOH op prov you 00 mowmvcmohom ones NHH O O OH OO OO N HOOoe OH NH O ON ON OO .. OOHOHOOO HOOOOOOH NN .. O OH OO OO O OOoHoomOOo-m0Humemno OO O -- NH oO NO H moHOoOHO Hmamnmo vcoonom paooumm pnmohmm vcmonO puoonom pmooymm z mmmm onoz aoOOoo no Odom OOOHOOOHO OOH HHHO OoHOOOHHHHmOO «HO-N zOHeOOOOO =.z0HOOOOOOOzou OOOHOOO OOOHHHOO OOBOOOHO mo OOonHO .OH>OOOHHHOz .gHo OOOOO OOOOH-OOzO39 .OHOOOO OOHOOOzzO= n> OOOOOHO OOOO mHH mHmsB ’4 O . , . r allll’xl ’VII'VII O r r a” p {I . . _ . .I -. . . . . I . , A . . . . . P». v p../— z ‘ Ott -1-‘-I)‘ u t y t I I‘ t? OI‘III tfllusnl‘. 1 A . . . . . .._.. . . ~ 1 \ I O_ . , ., r . . r I r t .. or}. gill. ‘ 1 9| f O \ I I. It | I . 1 II r. I. l / .. . - n | _. I I.: I. . f X I . v r r f.’ I l .. I . . s u , . n . ,Lru ‘, .l - t a Liv- . .L - - 4. w .. _ . . :_ l— I _.. “a .t..H!-. . .1.r.. . 1.: . \. .2 V V II \ I a . O r . IL 1 .. 1 II a nr \ ‘ OI L ., . ‘ .0 . 211 methods, the IUD is chosen by 39 percent indicating a greater acceptance of the new IUDs for nulligravid women. The important fact is that while respondents still are likely to choose the pill as method of first choice, a majority of the physi- cians rec0gnize diabetes mellitus as medical contraindication to the pill and choose an alternative method of contraception for the woman. There is no way of determining if respondents take into account the possible frequency of intercourse in recommending a given method. The overall concern again seems to be theoretical efficacy in preventing conception. With the clear medical contraindication to the pill, the present population reveals a large proportion defining prescription of the pill as "acceptable" medical care. The circumstances should detine pre- scription of the pill as "unacceptable," with "best" medical care being provision of a suitable means of contraception other than the pill. Case VI presents the respondents with the most complicated set of cues to evaluate in recommending a method of contraception. (See Table 116, page 210.) The woman is young, married, and has one child; she expresses the desire to postpone her next pregnancy; and she has an important medical history for recommending contraception. Dysmenorrhea is considered in the literature as a contraindica- tion to use of the IUD,7 while hypertension is considered a contra- indication to using the pill.8 Existence of these conditions should make physicians consider recommending a method of contraception other than the pill or IUD, but responses show #4 percent recommended the pill and 37 percent recommended the IUD. An important cue in the case is the fact the woman desires to 212 postpone her next pregnancy. Recognition of this cue is indicated by comparing recommendation of sterilization between Case VI and Case IV. There is almost a 21 percentage point difference in the recommendation of sterilization by respondents. Both patients are the same age, and yet the mentioning of desire for additional children makes use of sterilization almost nonexistent. The high percentage of respondents recommending methods which are contraindicated (pill and IUD) allows for several explanations. The immediate concern of respondents seems to be theoretical efficacy in preventing pregnancy. Respondents may feel that the health risk is greater in pregnancy because of her medical history; there should be concern for recommending sterilization since the risk will be continuous throughout her life. If the risk is evaluated as use of specific methods of contraception, then the fact that the woman wants to postpone her next pregnancy calls for the use of methods with no immediate health risk themselves, but with a greater potential for contraceptive failure. For Case VI, "best" medical care should be recommendation of a method other than the pill or IUD. The "acceptable" or "best" means of contraception would be a method of contraception without health risk, but possibly a greater risk for pregnancy. When desired family size is reached then sterilization should be a realistic alternative. Taken cumulatively the case histories do reflect a pattern which indicates that the majority of physicians are concerned with efficacy in the prevention of conception, a conclusion which is also supported by the proportion of patients to whom respondents reported recommending specific methods of contraception. This assumes that in addition to the medical efficacy of individual methods of contraception, 213 the physician perceives patients' concerns with family planning as also involving medical and social factors. Analysis of which respondents will recommend specific methods of contraception follows. Contraception in the Context 9f Medical Practice The purpose of developing the case histories for family planning was to measure physicians' perception of differences between individual patients and their reactions to individual patients. Discussion of the case histories shows that physicians do perceive differences between individual patients and make their recommendations accordingly. Although the individual case histories are important in them- selves, the condensation of the data in some simpler measure of contra- ception recommendation is desirable. The criterion for measuring pattern of physicians' recommendations is normative in that choice involves some evaluation of the "quality" of individual physicians' responses to respective case histories. Stated most broadly, the normative definition of quality used herein is that a physician should not recommend a method of family planning which is contraindicated by the facts of a case. Certainly this definition will be modified by the circumstances of the particular discussion. In reviewing the responses for the case histories, several ques- tions concerning recommendations of contraception were formulated. Responses which raise questions are the recommendation of sterilization, the use of the pill, the use of medically contraindicated methods, and the refusal to recommend any method of contraception to a patient. These questions are analytically separate, making the development of a single overall measure of physicians' responses too complex to be 214 meaningful, and thus impractical. However, the questions can be divided into two areas which subse- quent analysis will show are relevant. First the question of who will recommend sterilization and who will not recommend any form of family planning for a patient are related. Second, the question of who recommends the pill and who will recommend a medically contraindicated method of contraception are related. Subsequent analysis will follow these two areas for purposes of organizing the discussion. Both indi- vidual cases and overall measures of responses will be employed. Sterilization and Not Recommending Family Planning Measurement of who recommends sterilization and who will not recommend family planning at all, at its simplest level involves examining individual case histories. A cumulative measure of responses would be indicating physicians who would recommend sterilization for one or more case histories. The same procedure can be adopted for phy- sicians refusing family planning for any case history. The variables of sterilization recommended and no family planning recommended will be discussed separately. The immediate question is whether these variables are related to the fact a respondent is a general practitioner, obstetrician- gynecologist, or internist. Twenty-five percent of all respondents (N=112) recommended a sterilization in response to one or more of the case histories. One respondent recommended a sterilization as an alternative in three of the cases, while 12 percent (n=13) recommended a sterilization in two of the cases, and 15 percent (n=14) recommended a sterilization in one of the cases. 215 Internists were least likely to recommend a sterilization (n=l). Although the proportion of general practitioners and obstetrician- gynecologists recommending a sterilization was relatively even, previous analysis showing involvement in obstetrical work differentiated general practitioners' attitudes and activity in family planning suggests that general practitioners and obstetricians should be dichotmized for involvement in obstetrical work. TABLE 117 RECOMMENDING A STERILIZATION IN ONE OR MORE CASE HISTORIES BY INVOLVEMENT IN OBSTETRICAL WORK AND PRACTICE SPECIALTY Practice Percent Recommending Base N Specialty a Sterilization GP OB 44 32 No CB 17 41 Total 29 73 OBGa 27 22 mb 6 17 aOBGs considered as single group for banalysis IMs are not involved in obstetrical work General practitioners involved in obstetrical work are most likely to recommend a sterilization and obstetrician-gynecologists who do obstetrical work are next most likely to recommend a sterilization. Although the findings support the contention that practice structure affects physicians' behavior, the difference between general practi— tioners and obstetricians involved in obstetrical work is remarkable. Possible sources of explanation for the results in Table 117 are family planning attitudes and activity, and technical and social orientation 216 Examining the relationship between family planning attitudes and recommending a sterilization, a significant correlation was fOund (gamma = .409). Physicians willing to initiate discussion of family planning are more likely to have recommended a sterilization in one or more case histories. TABLE 118 PERCENT RECOMMENDING A STERILIZATION IN ONE OR MORE CASE HISTORIES BY WILLINGNESS TO INITIATE DISCUSSION OF FAMILY PLANNING Willingness to Percent Recommending a Base N Initiate Sterilization High 31.7 63 Total 25.0 112 Yules Q = .409 Examining the relationship between sterilization and family planning activity, the correlation is significant (gamma = .517). The strength of the association may be misleading since internists scored low on family planning activity and obstetrician-gynecologists scored high on family planning activity skewing the results in favor of a higher association. All obstetrician—gynec010gist respondents recom— mending a sterilization were high on family planning activity, and only one internist recommended a sterilization. 217 TABLE 119 PERCENT RECOMMENDING A STERILIZATION IN ONE OR MORE CASE HISTORIES BY PROPORTION FEMALE PATIENTS IN CHILDBEARING YEARS HAVE DISCUSSED FAMILY PLANNING WITH Family Planning Percent Recommending a Base N Activity Sterilization 51 Percent or More 33.9 59 50 Percent or Less 14.0 50 Total 24.8 Yules Q = .517 N = 109 NA = 3 Total = 112 The association between the two family planning measures and recommending a sterilization suggests that the measures of family plan- ning attitudes and family planning activity might form a cumulative index for predicting physicians' responses to the case histories. A Family Planning Index was constructed in the following manner. Physi- cians scoring high on both family planning measures were scored as high on the Family Planning Index; physicians scoring high on one family planning measure and low on the other family planning measure were scored medium on the Family Planning Index; and physicians scoring low on both family planning measures were scored low on the Family Planning Index. Table 120 shows the distribution on the Family Planning Index for the three practice specialties. Since involvement in obstetrical work has been considered an important variable in explaining differences 218 .Hohhm mcqusomH .xnoz HOOHHpovmpo :H O®>Ho>qH you mad OOHm .mHmOHOQO H0O Osonm OchHm mm OonOHmcoo mOOOO .mpcoHvOO OHOEOH mo mOOH Ho pqooHoO on OOH: wancwHO OHHEOH OommsomHO was dam mGOHmwso umHO OGHOGOHO OHHEOM ovdeHnH ov mmocmnHHHHz no :oH OoHoomo .oHOOHHO> wannOHO OHHEOM Honpo map :0 :0H dam .AOOOOOHOPO Ho OPH>HPoOV moHOOHHO> wananO OHHEOH on» mo oco no OOH: Oonoomp .OOGOHPOO OHOeom OH: mo pqooHOO on cmnv onoe OOH; mchanO OHHEOM OommsomHO mm: OOO mconmso ImHO quncOHO OHHEOH opOHpHcH ow mmonmnHHHHz no OOH: moHoomO OH OHOH ON ON OO 02H NN OOH OO OO O OOOO OO u HOOoO O n Oz OO OOH OO OO ON anoe OO OOH ON NO oO OO\oz OO OOH OO OO OH OO OO psooHoO OnooHoO pcoohom OOOHO pssHomz osoH OOHnHooOO z mnmm Hmpoa mesH OsHsanm OHHeOO moHOomnm MBHOHUmmm mUHBOHo>cH pom mud mzHo Mom 36% OHmOHm mm OoHoOHmcoo mud mom .mommpcoouo map How .mHmOHOGO m.z mwmp map mud mmmosvcoHOO OH whopeszd NHH n Hapoe O n «z OOH n z HOV HOV AOO OT- OON O-- ozH ANHO HOO ONO Rmm RmN RII pUmO AONO HONO AONO NO ON OH HOOoO HHHO HOHO HOHO ON ON O mo oz AOHO HHHO HOV OOO OOO OON mo mo OH 5H8: :3 OHHOHoomO mesH OsHssOHO OHHsnO moHOoOnO ONBHOHUmmm HUHBUH MmHBmmUHmomm .meqao>ca pom mam mzHo .mamhamnm How macaw oncam mm uoHovasoo mwmon mowmpsoonom one MOM m.z omen map one monogacoawm ca muonsszm NHH u H38 m n .2 OOH u 2 AsO HOV HOV a... a} so: ozH ANHO LOO ANO NO er. s-- eOmO AONV Ast AONV ON OOH O3 H38. AHHO AOHO AOHO NO is... Own eoz moon AOHO HHHO Asa OON. Rom “Ron moon mu anm 5H8: :3 s83 seHOHooem xoocH madncwam haasmm Havaypopmpo weapomnm NMBQ¢HUmmm MUHBU¢mm Qz< mmoz AOOO oszzOHm :HH:OO ozHOOaOm OszOOO A.O.OsoOv NOH OHOOO 240 First, previous analysis has served to establish the fact that family planning attitudes and activity are related to involvement in obstetrical work. When Catholic physicians involved in obstetrical work or scoring high on the family planning measures are examined, they would provide family services to the hypothetical patients. This would support an argument that nonmedical values can be modified by the structure and experiences of actual medical practice. This presents an involved argument concerning whether Catholics are less likely to be involved in obstetrical work, which raises the second crucial reason for modifying the generalization concerning Catholics. The small number of Catholic respondents (N=l3) raises the possibility that Catholics were less likely to return their question- naires for a variety of reasons. If Catholics were overrepresented among nonrespondents this would present a serious bias in the present discussion. Thus the tentative conclusion with regard to Catholics and refusal of family planning services is that those Catholics not involved in obstetrical work are more likely to possess less positive attitudes with regards to all aspects of family planning than Catholics involved in obstetrical work and family planning. Summarizing the analysis of which physicians would recommend a sterilization or would refuse family planning services indicates that family planning activity and attitudes are important sources of explana- tion. Involvement in obstetrical work (practice structure variable) is also significant, but its influence must be carefully traced. Among general practitioners involvement in obstetrical work is directly related to recommending a sterilization, but it is not related to 241 ‘zrefusal of family planning services. Obstetrician-gynecologists are :leely to recommend a sterilization and least likely to refuse family Jplanning services. The conclusion is that sterilization and refusal of :fhmfily'planning tap different motives in the respondents. This conten- 'tion is supported by the fact that no obstetrician—gynecologists :recommending a sterilization (N=6) refused family planning services; no internists recommending a sterilization (N=2) refused family planning services; and 19 percent of the general practitioners recommending a sterilization (N=21) refused family planning services. One substantive difference between the two groups (recommending and refusing) was religious preference and religious values. Also, there was no signifi- cant relationship between technical or social orientation and recommend- ing a sterilization or refusing family planning services. Evaluation of Methods of Contraception Recommended Apart from the concerns discussed in the previous section, the methods of contraception respondents recommended should be subjected to some form of evaluation. Since physicians responded to hypothetical patients, evaluation cannot involve how the usage of the recommended methods would actually affect the patients'total health. Evaluation must be normative, and the basis for the normative judgments rests in the medical literature and the types of contraception that physicians actually recommend. Description of the methods of contraception that respondents recommend in their practices, and the methods recommended in response to the six case histories indicates the pill is method of first choice. This suggests the number of cases for which physicians recommended the 242 pill would serve as one basis for measuring quality of medical practice. The fact that the pill is medically contraindicated in the presence of hypertension and diabetes mellitus suggests that physicians who recom- mend the pill less frequently should be considered substantively different than those who routinely recommend the pill. This conclusion is based on the assumption that physicians not recommending the pill are likely to recognize hypertension and diabetes as contraindications to the pill and thus recommend an alternative method. An additional assumption is the greater the number of cases for which physicians pre- scribe the pill the more standardized their practice is in response to patients' needs. To avoid an unnecessary bias in this analysis, those five respondents who would refuse family planning services in all case his- tories are considered not applicable to the present analysis. The analysis concerns when family planning services are provided what method of contraception will be recommended. Other appropriate controls will be stated when used. The mean number of case histories for which respondents recom- mended the pill was 4.10 cases (N = 107, Not Applicable - 5). As a gross measure this figure does show that respondents recommend the pill for approximately two-thirds of the cases. This measure will be used, but its interpretation is difficult because it is not amendable to controls for other variables. Another more appropriate measure is the proportion of respondents who recommended the pill for five or six of the case histories. This measure is based on the assumption that physicians recommending the pill for five or six case histories is likely to have recommended the 243 pill for at least one situation where oral contraceptives are contra— indicated. The results using this measure show that 37 percent of the respondents recommended the pill for five or six of the case histories (N = 107, Not Applicable = 5). This measure also dochotomizes respondents at the mean number of cases the pill was recommended. Six- teen percent of the respondents giving family planning services (N=107), recommended the pill for all six cases, and 22 percent recommended the pill for five cases. When the usage of the pill is examined by practice specialty, obstetrician-gynecologists are more likely to have recommended the pill than either general practitioners or internists. The implication that obstetrician-gynecolOgists are most likely to recommend the pill may be the result of the structure of their practice or the effect of some other variable not immediately apparent. TABLE 133 NUMBER OF CASE HISTORIES RECOMMENDED THE PILL BY PRACTICE SPECIALTY--TOTAL SAMPLE Number of Cases Pill Recommendeda Total Base N Percent 5 - 6 (Percent) 0 - 4 (Percent) GP (OB Work) 31 69 100 32 (No 0B Work) 47 53 100 38 OBG 55 45 100 22 IM 40 60 100 15 Total 38 62 100 107 Not Applicable = 5 Total = 112 aFigures adjusted to take into account family planning refusals. 244 TABLE 134 NUMBER OF CASE HISTORIES RECOMMENDED THE PILL BY EAMILN PLANNING INDEX, CONTROLLING FOR OBSTETRICAL WORK AND PRACTICE SPECIALTY Practice Family Planning Number of Cases Pill Total Base N Specialty Index Recommendeda Percent 5—6 0-4 Percent Percent GP OB High 33 67 100 15 Medium 18 82 .100 11 Low 25 75 100 4 Total 27 73 100 30 No 0B High 64 36 100 11 Medium 23 77 100 13 Low 54 46 100 13 Total 54 46 100 37 OBGb High 42 58 100 12 Medium 62 38 100 8 Low 100 -- 100 2 Total 55 45 100 22 IMC High 75 25 100 4 Medium 25 75 100 4 Low 14 86 100 7 Total 33 67 100 15 N = 104 NA = 3 Not Applicable = 5 Total = 112 aFigures are adjusted for refusals of family planning services. BGs are considered as single group for analysis. CIMs do not do obstetrical work. 245 One possibility is that recommendation of the pill is related to the Family Planning Index, but analysis of the total sample shows that there is no overall relationship (gamma = -.l88) between Family Plan- ning Index score and recommendation of the pill, a fact confirmed by inspection of Table 134. There are some interesting differences between specialties. Among general practitioners involved in obstetrical work, all categories of Family Planning Index score are unlikely to recommend the pill for five or more case histories. For each category of Family Planning Index score, general practitioners not involved in obstetrical work are more likely to recommend the pill than general practitioners performing deliveries. There is a negative relationship between Family Planning Index score and recommendation of the pill for obstetricians and a positive relationship between Family Planning Index score and recommendation of the pill for internists. The difference between obstetrician- gynecologists and general practitioners performing deliveries is most striking since the assumption would be that these two groups would be most alike. Explanation of the findings in Table 134 is difficult since the results may be actually a reflection of another variable not taken into account. Since prescription of the pill is based on the concept of contraindication for its usage, the explanation of who will recom- mend the pill for the case histories may be related to technical orientation score. Since technical orientation is considered at least an indirect measure of clinical competence, high technical orientation respondents should be more likely to recognize medical contraindica- tions, or at least feel that the contraindications are important 246 enough to warrant avoiding usage of the pill. Analysis of the total sample revealed a direct relationship between technical orientation and recommending the pill less frequently (gamma = .417). Remembering that some physicians (N=107) refused family planning services, an additional control can be made for the analysis. If a physician recommended the pill for all other cases than the one he refused contraception services for, he is prescribing the pill routinely even in situations where oral contraceptives are contraindicated. If such physicians are included in the group recommending the pill for five or six cases, the correlation with technical orientation is increased (gamma = .507). Another indication of the strength of the association between technical orientation score and prescription of the pill is that when practice specialty and involvement in obstetrical work are controlled, high technical physicians are less likely to have routinely recommended the pill. The additional control for respondents refusing family plan- ning services was used in presenting the data in Table 135 (see page 247). General practitioners involved in obstetrical work are least likely to routinely prescribe the pill for the case histories, but the relationship between technical score and prescription of the pill remains regardless of specialty or involvement in obstetrical work. When social orientation score is examined for a relationship with recommending the pill for the case histories, there was not a signifi- cant correlation for the total sample (gamma = .030). Even when the control on refusal of family planning Services is made for the total sample, the correlation is not significant (gamma = .010). There is no particular reason to expect that prescription of the pill should be 247 .xnoz HOOOHPOPOQO OH OO>HO>OH pom mum mzHo .mamaadsm Mom msohm mamsam mad mumop .mmahovmfis Ommo 02» Ho Ono ca Hmmsmmn map padooom opqfi Oxmp ov OOPOSOOO ohm mmhsmamm NHH u HOOoO O u meOOHHOOO eo: OOH u : OH OOH OO oO Hmeoe H OOH .. 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HOHOHOOOO OOHOOOOO O:O_:OO3_H OOOOV :OHOOOOOOezoo OOOHOOO .OOOHHHO: OOOOOOHO OO :OOOOHO .OH> mm¢ov 202¢2Ummm 9x92 m2omfimom OB mHMHmm9 92¢ 20Hmzmemmmwm 92¢ ¢mmmmozmzmw9 ho meBmHm .9HH20 920 .OHO OOOO: :HOIaezmze .OHO:OO OOHOOO: O mom OOO2O::OOOO :OHOOOOOmezoo ao OOOOOO: OOH OHOOO 256 .xHoz 90 OO 90: 0O OZHO .meOHOOO man Hom muonm Ono mm OOHOOHmaoo OHO mumon .Oozvms Ono cane OHos OOOEOEEOOOH O>O£ Owe mpcovcommwh monHm pnmoumm OOH Hmpov Poe 0O mmnswfimm NHH I HOHoH O I O: OOH I : OH O ON ON OO -- HOHoH H I- - OOH OOH . II on O ON ON ON OO -- esHOm: O II NN OO OO II OOHO o:H pcoonmm pqoonm pcOonm PGOoHom pqoohmm HOHHOHEOHHO OOHOHommm z mmOm soOOoOIeOoO sOOHOOOHH OOH HHHm OoHHOOHHHHmHO HOOHsOomH moHeoOHm OMBH¢HU99W 9UHBU<99 92¢ 2903 9 9m¢ov 902<2U999 9292 92098m09 OB m999m99 92¢ 209m29899992 92¢ <99990292m29 90 MmoBmHm .99Hmo 920 .990 mm<92 meI262938 .99<299 99Hmm¢2 ¢ 909 99929220099 209899U<99200 90 m902892 HOO.HOoOv OOH OHOOH 257 Among general practitioners, those involved in obstetrical work are more likely to recommend the IUD with a greater frequency than the pill, while those not involved in obstetrical work recommend the pill with a greater frequency than the IUD. Also, general practitioners performing deliveries are more likely than other GPs to recommend the diaphragm, foam or condom. Obstetricfan—gynecologists recommend the pill with greater fre- quency than the IUD, and are most likely of all groups to recommend the diaphragm, foam or condom. Internists recommend the pill with greater frequency than the IUD, and recommend the diaphragm, foam or condom with a frequency simi- lar to that for general practitioners performing deliveries. As mentioned, Case VI involves contraindications for both the pill and IUD, and there are two approaches that can be taken in analyz- ing the results. One is to dichotomize recommendations into those recommending the pill and/or IUD, and those not recommending those methods. For the total sample there is a weak correlation between technical orientation and recommending the pill and/or IUD (gamma = -.298). General practitioners involved in obstetrical work and high on technical orientation are least likely to recommend the pill and/or IUD. Overall results in Table 140 weakly support the contention that technical orientation score is directly related to perception of contra- indications to recommendation of specific methods of contraception. Adopting the opposite approach by identifying respondents whose alternative recommendations involved methods other than the pill or IUD, the analysis of the total sample shows a weak correlation between technical orientation score and recommending diaphragm, foam or condom 258 (gamma = .274). Giving some credit to physicians who in addition to the pill or IUD, recommend the diaphragm, foam or condom, the data reveals that high technical physicians are more likely to have least given as an alternative a method not medically contraindicated. Although there is little variation in the total percentages for the specialty breakdowns recommending the diaphragm, foam or condom, general practitioners involved in obstetrical work are most likely to recognize medical contraindications. The differences between the two groups of general practitioners is striking, supporting the contention that the structure of medical practice is an important variable. Two conclusions are drawn from analysis of Case VI. First, general practitioners involved in obstetrical work are more likely to perceive medical contraindications in Case VI. Second, technical orientation score is directly related to perception of medical contraindications in Case VI. This conclusion is reached on the basis that the data for Case VI at least does not refute the argument that technical orientation is related to the normative definition of "quality" in medical practice with regards to the prescription of appropriate methods of contraception. However, the data does show that even in Case VI physicians seem to see as a first concern providing patients with methods of contraception that will provide the greatest theoretical efficacy in preventing conception. Explanation of the specific results of Case VI must deal with the concept of "patient management" and physicians' belief that through appropriate monitoring of the patient, undesirable side effects can be controlled. If this is the case, the analysis would seem to give a basis for intuitively arguing that higher technically oriented physicians would do a better job in this respect. 259 TABLE 140 PERCENTAGE RECOIOENDING PILL AND/0R IUD FOR A MARRIED FEMALE, TWENTY-— FIVE YEARS OLD, ONE CHILD, HISTORY OF DYSMENORRHEA AND HYPERTENSION, DESIRES TO POSTPONE NEXT PREGNANCY (CASE VI) BY TECHNICAL ORIENTATION SCORE, CONTROLLING FOR OBSTETRICAL WORK AND PRACTICE SPECIALTY Practice Technical Percent Recommending Total Base N Specialty Orientation Pill and/or IUDa Percent GP OB High 25 100 12 Medium 100 100 13 Low 71 100 7 Total 66 100 32 No 0B High 82 100 11 Medium 81 100 16 LOW 100 100 11 Total 87 100 38 OBGb High 62 100 8 Medium 83 100 12 Low 50 100 2 Total 73 100 22 IMC High 78 100 9 Medium 60 100 5 Low 100 100 1 Total 73 100 15 N = 107 Not Applicable = 5 Total = 112 8’This figure is based on respondents who recommended the pill or IUD as one alternative method, so that each respondent is counted only once. OBGs are considered as single group for analysis. CIMs are considered as single group for analysis. 260 TABLE 141 PERCENTAGE RECOMMENDING DIAPHRAGM, FOAM, OR CONDOM AS AN ALTERNATIVE METHOD OF CONTRACEPTION FOR A MARRIED FEMALE, TWENTY—FIVE YEARS OLD, ONE CHILD, HISTORY OF DYSMENORRHEA AND HYPERTENSION, DESIRES To POST- PONE NEXT PREGNANCY (CASE VI) BY TECHNICAL ORIENTATION SCORE, CONTROLLING FOR OBSTETRICAIIWORK AND PRACTICE SPECIALTY Practice Technical Percent Recommending Total Base N Specialty Orientation Foam, Condom, Diaphragma Percent GP 0B High 50 100 12 Medium -- 100 13 Low 43 100 7 Total 28 100 32 No GB High 27 100 11 Medium -— 100 16 Low 43 100 11 Total 28 100 38 OBGb High 38 100 8 Medium 25 100 12 Low 50 100 2 Total 32 100 22 IMC High 22 100 9 Medium 40 100 5 Low —— 100 1 Total 27 100 15 N = 107 Not Applicable = 5 Total = 112 aBasis for this figure are those recommending diaphragm, foam or condom only, or as alternative to the pill or IUD. Each respondent is counted only once. OBGs are considered as one group for analysis. cIMs are considered as one group for this analysis. 261 Patients with the medical history of the patient in Case VI probably constitute a small proportion of actual family planning cases doctors do see, but was included since it offered an opportunity to observe physicians' responses to a complex medical situation. Examination of Case II (adolescent female) revealed no relation— ship between technical orientation or social orientation score and method of contraception recommended. Ninety-six percent of doctors providing contraception (N=93), recommended the pill. For all techni- cal and social categories, the pill is recommended by more than 90 percent of the respondents. Such a finding supports the notion that doctors are more concerned with the risks of pregnancy, rather than possible medical consequences from usage of the pill by a young female. The only differentiation of respondents in Case III arises from the previous relationship between refusal of services and Family Planning Index score. Case III (welfare recipient) provides another reference point in analyzing the impact of technical orientation score. Using the pill as the point of comparison, high technical orientation respondents are significantly less likely to suggest the pill as an alternative method of contraception. If patient motivation is a legitimate medical concern, then high technical respondents recOgnize this by recommending the IUD more frequently. Previous analysis has shown that recommending a sterilization is related to involvement in obstetrical work and Family Planning Index score. Thus for recommending methods other than sterilization, Table 142 shows that high technical respondents are most likely to recommend the IUD as a nonpermanent method of effective contraception that deals with problems of patient motivation. METHODS OF CONTRACEPTION RECOMMENDED FOR A SEPARATED FEMALE, 262 TABLE 142 THIRTY-THREE YEARS OLD, FOUR CHILDREN, GOOD HEALTH, RECEIVING WELFARE ASSISTANCE, DESIRES FAMILY PLANNING (CASE III) BY TECHNICAL ORIENTATION, CONTROLLING FOR OBSTETRICAL WORK AND PRACTICE SPECIALTY Practice Technical Method Recommendeda Base N Specialty Orientation Sterilization Pill IUD Percent Percent Percent GP--OB Work High -- 58 50 12 Medium 31 62 55 13 Low 43 72 28 7 Total 22 69 47 32 GP-—No OB High 18 55 36 11 Medium 19 62 19 16 Low -— 89 18 11 Total 13 66 24 38 OBGb High 12 88 25 8 Medium 25 92 -- 12 Low -- 50 5O 2 Total 18 86 13 22 IM0 High —- 22 89 9 Medium -- 100 20 5 LOW -- 100 100 1 Total -- 63 67 15 N = 107 Not Applicable = 5 Total = 112 aFigures do not total to 100 percent since respondents may have recommended more than one method. CIMs do not do obstetrical work. OBGs are considered as single group for analysis. 263 In conclusion, method of contraception recommended seems to be related to technical orientation score. Responses to the case histories shows that efficacy of method to the exclusion of possible health risks from usage of the pill. High technical orientation are more likely to perceive health risks in individual cases, but even that difference' is not large. An interesting fact is that there is no relationship between technical orientation score and whether a respondent rated the pill most hazardous for patients' health as compared to the IUD or diaphragm, yet physicians routinely recommend the pill. The conclusion is that high technical respondents are more likely to perceive health risks in prescribing the pill. Summagy The following conclusions were developed in the analysis: 1. In reviewing individual case histories, there is a discrepancy between "best" and "acceptable" medical care in recommending alternative methods of family planning. 2. There are two dimensions to the provision of family planning services, these being (a) refusal of family planning and recommending a sterilization, (b) method of contraception recommended. 3. In recommending sterilization, involvement in obstetrical work and scores on the Family Planning Index were useful predicting variables. There was no association between technical or social orientation and recommending sterilizations. 4. In refusing family planning, the Family Planning Index was the best predictor of such behavior, while involvement in obstetrical work was not a predictor for general practitioners. Religious values 264 influenced refusal of family planning, especially among physicians not involved in obstetrical work especially among Catholic respondents. There was no association between refusal of family planning and techni— cal or social orientation. 5. Using recommendation of the pill as an indicator of standardization of recommendation patterns, there was an inverse relationship between technical score and frequency of usage of pill. Involvement in obstetrical work was inversely related to usage of the pill among general practitioners. 6. There was no association between social orientation or family planning activity and attitudes and recommendation of the pill. 7. For individual case histories efficacy in preventing pregnancy is of primary importance. NOTES 1. Hellman, _p. cit. 2. Sadja Goldsmith, "San Francisco's Teen Clinic: Meeting the Sex Education and Birth Control Needs of the Sexually Active School- girl," Family Planning Perspectives, Volume 1, Number 2, 1969, pp. 23- 26. . Measham, gal” _p. cit. . Davis, _p. cit. 3 LI 5. _I_bid. 6 7. _I_b_ig. 8 . Segal and Tietze, _p. cit. 265 CHAPTER VII SUMMARY AND CONCLUSIONS This chapter focuses on the synthesis of the results of the research. Such a synthesis provides an overview of the study with emphasis on the principle findings intrepreted within the conceptual framework of the study. The intent, herein, is to explore insights on the nature of medical practice and physicians' responses to family planning provided in the research. Within this context suggestions for further research are offered. Overview and Conclusions Analysis dealt with two borad areas: (1) the description and analysis of medical practice for a sample of general practitioners, obstetrician-gynecologists, and internists, and (2) the description and analysis of medical performance in the area of family planning. Inter- pretation of the results of the study will be discussed in the order of the preceding areas. Sociology of Medical Practice From the field theoretical perspective the specific concerns with regards to the physicians studied were: the individual predispo- sitions of physicians, the standards of professional behavior internal- ized by physicians, and the specific stimulus complex provided by patients which may be perceived as medical problems. A graphic model was used to describe the social forces affecting the preceding 266 267 considerations of medical practice. The complexes of variables considered were personal attributes, professional history, practice organization, perceptions of dimensions of medical practice, and per— ceptions of patients. One of the purposes of the study was to examine Freidson's argument that present medical practice and medical performance is explained more by present work environment than by standards of pro— fessional behavior acquired during training. Work environment is defined by the number of patients, types of patients, types of medical problems, and relationships to colleagues. A difficult problem in intrepreting the analysis is sorting out the relative influences of the forces affecting physicians' perceptions of the dimensions of medical practice and the organization of medical practice. While professional socialization is a source of absolute difference between doctors and laymen, the question remains concerning which factors in medical prac- tice and medical orientation differential socialization explains. An illustration of the problem of sorting out the influences of professional socialization on current medical practice was found among osteopathic and allopathic general practitioners. Assuming that pro- fessional socialization (medical training) is a crucial variable in explaining professional behavior and that osteopathic and allopathic socialization processes are significantly different, there should be significant differences between these two types of general practitioners. Data analysis showed (controlling for differences in the age structure of osteopaths and allopaths) there are no significant differences between the two types of general practitioners in organization of medical practice or distribution on technical and social orientation 268 to medical practice. The conclusion is that demands of present work environment for general practitioners, as reflected in types of patients and medical problems, serve to promote similar organization of medical practice and orientation to medical practice. Such a conclusion is consistent with Friedson's argument and the field theoretical framework. While patterns of practice organization and medical orientation are similar within general practice, comparison of the three medical specialty fields included in the study revealed substantive differences between respondents. Differences between medical specialty fields included not only variations in patients seen per week and incidence of solo versus group practice, but also significant differences in tech— nical and social orientation scores and the rank order of items com- prising the respective scales. Discussion will focus on the decision to specialize and the effects of such decisions on medical practice. Decisions to specialize and the effects of such decisions on physicians' present practices are the first consideration. Within the field theoretical framework, the decision to specialize must be examined in terms of the forces present at the timg doctors make deci- sions on practice specialty. One consideration in the decision to specialize is the influence of personal attributes. Do physicians having higher technical orien- tations tend to choose residency training and specialization? Do physicians choose to specialize because they enjoy working with particular types of patients and specific medical problems? Although there is no specific data on these questions, their influence on the context of the decision to specialize directly influences the organi— zation of ongoing medical practice. 269 The effect of opportunity on decisions to specialize can be briefly traced using differences between osteopathic and allopathic physicians. Until recently, osteopathic training has been confined to private schools hard pressed to compete for financial resources neces- sary for expanding training. The lack of resources within osteopathic medicine is shown in the small absolute number of osteopathic physi- cians in private practice. Additionally, the tendency to recruit osteopathic faculties from practitioners in ongoing medical practice (general medicine) reinforces an interest in general medicine. Such restrictions constitute an important influence on osteopathic students' decision to specialize. The resources available to.allopathic institutions, the recruit- ment of faculties from medical schools rather than ongoing medical practice, and the involvement with specialists constitutes the set of forces influencing allopathic students' decision on practice specialty fields. The recent concern for recruiting a larger proportion of allopathic students into general practice, evidenced by emphasis on family medicine at specific institutions, indicates recognition that medical education is an important force in the decision to specialize. If the decision to specialize is influenced by the forces pre— sent at the time of the decision, what differences does the implied differential socialization of various specialty fields have on present practice? Medical education is intended to inculcate standards of professional behavior, and among these standards are the knowledge and skills involved in technical and social aspects of medical practice. The process of medical training, and in turn specialization, describes an environment involving acquaintance with ranges of patients and 270 medical problems. Basic medical education includes a broad range of medical patients and problems, while specialization involves concentra- tion on some subset of such patients and problems. The specialist in his training develops intensive and extensive knowledge and skills in a particular*area of medical practice. Formal professional recognition of this expertise comes through board certification. Student physicians gain technical and social skills necessary to deal with the patients and medical problems they encounter, a process which in an important sense continues throughout their professional lives. The process of training is the first step in developing physi- cians' recognition and perception of the dimensions of medical practice. Without panel data this process of initial internalization of medical standards and subsequent modification and performance is difficult to analyze. An example of the process being described is the fact that all medical students gain some knowledge and skills in the area of obstetrical work. However, obstetrician-gynecologists extend their knowledge and skills in obstetrical work, a fact which subsequently affects their practice structure. A significant proportion of general practitioners also decide to do obstetrical work, and this decision also affects their subsequent practice structure. In their decisions to do obstetrical work GPs and OBGs are setting limits on the publics with which they will deal in actual practice. OBGs, and GPs doing obstetri- cal work, present practices have larger proportions of female patients in their childbearing years than other physicians studied. The translation of medical training to the explanation of on- going medical practice is problematical. Decisions made in training are reflected in the "label" attached to physicians' practices--general 271 practice, obstetrics-gynecology, and internal medicine. Practice labels are a factor in restricting the patients with whom physicians deal. Restrictions on patients and medical problems reinforces the training of doctors--physicians tend to see the medical problems for which they were trained. Training inculcates the standards of professional behavior, and subsequent practice reinforces and possibly modifies those same standards. In this study, the professional standards of interest are tech- nical and social orientation to medical practice. The distribution of technical and social orientation scores for respective specialties revealed substantive differences between the three specialty fields. Do these differences between specialties reflect differential sociali- zation or responses to differences in current practice environments? Although the present study cannot give a definitive answer to this ques- tion, some of the relationships can be traced. Medical training acquaints physicians with the knowledge and skills necessary to diagnose and treat types of patients and their medi- cal problems. The range of patients and medical problems varies with practice specialty, and this range is seen in physicians' work environments. Also a part of the current work environment are doctors' relationships with colleagues. 0f the three specialties, general practitioners deal with the broadest range of patients and medical problems. As generalists they deal with all medical problems, serving as a starting point in the medical system for patients seeking treatment. Because of the incidence rates of the range of medical problems with which they deal, general practitioners have larger patient loads than other practice specialties. 272 Tnifis last finding is supported by the fact that general practitioners' Patients essentially come from the "lay" public, referral being from (“flier members of the public who "know something" about doctors in the area, and that general practitioners are in competition with all other general practitioners. Among general.pmactitioners there was variation in the number of patients seen per week, and this variation in patient loads was related to social orientation score. As patients seen per week increases, general practitioners must make accommodations in procedures, the first accommodation seems to be less concern for social and psychological aspects of medical practice. Although lack of data on changes over time in patients seen per week makes complete analysis of cause and effect relationships between social orientation and patient load diffi- cult, other variables gave some insight. The fact that older GPs had smaller patient loads than younger physicians suggested that physical demands of practice affect patient load. If patient load declines with age, and lower patient load allows more time to be spent with individual patients, general practitioners might become more concerned with social concerns as they grow older. Confirmation of this argument through further research would support Freidson's argument that work environment affects practice orientation and performance. The relationship between practice organization and technical orientation for general practitioners was much less clear. Practice demand in patients seen per week is one area where the influence of work environment on technical orientation might have been expected to be manifested. Responses to large practice loads was accommodated more in 273 social orientation than technical orientation. While general practi- tioners with large practices were almost uniformly low in social orientation, the range on technical score for such GPs was considerable. A conclusion is that differences in technical orientation within a specialty is related to such factors as personal attributes and medical training. This last conclusion is supported by the fact that the relationships between technical orientation, social orientation, and patients seen per week were not affected by incidence of solo versus group practice among general practitioners. Examination of obstetrical-gynecological practitioners revealed relationships between work environment, practice organization and orien- tation to medical practice. There is nothing in obstetrical- gynecological training that directly implies that OBGs should be in group practice. Demand in terms of numbers of patients seen per week does not explain the high incidence of group practice among OBGs, since GPs have larger practices but a lower incidence of group practice arrangements. As previously discussed, the physical demands of exten- sive involvement in obstetrical work are probably a primary factor in explaining preference for group practice among obstetricain—gynecologists. Training limits the medical problems OBGs see, and the physical demands of dealing with this restricted set of medical problems is a primary force in explaining ongoing medical practice. The present work environment also serves to partially explain OBGs' response to social orientation. Obstetrical-gynecological practice is a male dominated field, but OBGs are primarily providing services to women in their childbearing years, and are dealing with these women on an intimate biolOgical basis. Since obstetricians are 274 dealing with sexually related problems, the prescription to remain effectively neutral takes on special meaning. The doctor-patient relationship for the OBG must be viewed in relation to traditional sexual roles in larger society. The doctor is dealing with a patient on an intimate basis, but must remain in control of his emotions and the patient's emotions, so that he reacts by treating patients on an impersonal basis, avoiding involvement in non—physiolOgical problems of the patient. Obstetrician—gynecologists thus avoid situations for potential emotional involvement with patients, maintaining a discreet "social distance" between themselves and patients. Obstetrician-gynecolOgists' response to social orientation is reinforced by the group practice arrangements predominating among OBGs. The conclusion is that group practice does not allow for the doctor- patient interaction necessary in dealing withsocial and psychological problems. Viewing the types of problems obstetrician-gynecologists see as a significant aspect of their work environment is a partial explana- tion of OBGs' score on technical orientation. For example, obstetrical work necessitates a complete medical history, complete physical exams, and use of diagnostic tests to determine possible complication in pregnancy. Recognition of these technical demands of obstetrical prac- tices begins in training and is reinforced by ongoing medical practice. In describing the public with whom internists deal, the fact that specialization defines a narrower range of medical problems is probably more important than the types of patients. Internists' specialization is aimed at the acquisition of expertise in dealing with acute medical problems. First, the incidence of serious medical problems calling for 275 the attention of internists is lower than the incidence of all medical problems. Second, many internists only accept patients on a referral basis. Assuming that physicians only refer difficult medical problems, those patients referred to IMs probably have serious medical problems and dealing with such problems involves a longer duration of internist— patient contact. This last relationship was discussed previously. Restriction of practice to serious medical problems probably accounts for the fact that internists scored high on technical orienta— tion. Dealing with serious medical problems requires attention to diagnostic tests and medical histories. ReCOgnition of these needs begins with training and is reinforced in actual practice. Dealing with three medical specialty fields has allowed for com- parisons within and between general practitioners, obstetrician- gynecologists, and internists. Such comparisons have helped to examine Freidson's arguments within a field theoretical framework. ,Although the examination of medical performance will be discussed in the next section, some tentative conclusions concerning the sociology of medical practice can be made. The first factor to be taken into account in explaining ongoing medical practice are physicians' decisions on the range of medical pro- blems with which they will deal in practice. Choosing a specific specialty field is the common form such decisions take but even within specialty fields the effect such restrictions on medical problems has can be found. For example, general practitioners doing obstetrical work have larger proportions of female patients in their childbearing years than other general practitioners. Restriction of practice serves to define the work environment 276 34:1 terms of relationships to colleagues (referral systems) and publics (:the number and types of potential patients). Demands of dealing with 'these publics in ongoing practices revealed differences within and between specialties in their effects on the structure of medical practice and orientation to medical practice. Work environment influences the proportion of time spent in hospital work and proportion of followup visits between doctor—patient for specific complaints, a conclusion based on differences between prac— tice specialties. Related to this conclusion is the work environment of various specialties is related to group practice arrangements. Group practice arrangements are less conducive to social orientation. Also, demand in terms of numbers of patients forced accommodations in medical practice, lessening of physicians‘ social orientation being one important response to patient load. Differences in medical problems dealt with in current medical practice is related to differences in technical orientation between specialty fields. Differences in technical orientation within practice specialty are attributable to differences in personal attributes and medical training, in addition to the demands of present practice. Another factor in current practice is age of practicing physi- cians. Older general practitioners are likely to have smaller patient loads than younger general practitioners. This difference is attri- buted to physical limitations imposed by age. Although inferences concerning the relationships between the variables described and medical performance will be made in the next section, the analysis of the sociology of medical practice indicates that the demands of the immediate work environment are important 277 explanatory variables in understanding practice organization and medical orientation, and justifies use of the field theoretical frame- work. Family Planning Services Since a major focus was on the delivery of family planning services, the discussion will review the findings in this area. The majority of physicians do provide family planning services to their patients. With regards to specific types of family planning recommended, oral contraceptives were reported as prescribed to an overwhelming majority of patients. Responses indicated a uniformity of behavior that should be explained. The pill has the highest theoretical efficacy in preventing pregnancy among presently available contraceptives. Findings from this study, in previous research on physicians, and findings in previous research on the general public indicate that for both physicians and the general public, the most generic concept of family planning essen- tially means the pill in doctor-patient contact. Although the present analysis showed important exceptions, the conclusion is that there is a standardization in the use of oral contraceptives in the delivery of family planning services. Such standardization was especially preva- lent among physicians with 1ow technical orientations. Existence of standardization in family planning is problematical in that it can lead to depersonalization in the delivery of family planning services. Examination of the hypothetical case histories substantiates this conclusion. The pill is recommended for a majority of the cases, this pattern carrying over to specific situations where the pill is medically contraindicated. Even among high technical orientation 278 physicians, who were more likely to recognize contraindications to the pill, a large proportion recommended the pill. Physicians' perception of family planning as being the pill was further substantiated by the case of the women with contraindications to both the pill and IUD. In such a case traditional means of contraception would be most appropriate. This finding supports the argument that doctors recommend sophisticated means of contraception when traditional means are probably preferable. These findings bring into question the content of physician- patient discussion of alternative family planning methods. The pattern would seem to be that physicians spend little time discussing alternative methods. One exception to this case would be those physicians who responded to the case histories by recommending a sterilization. Recognition of sterilization as a viable alternative form of family planning was found among a small group of physicians. Analysis revealed that physicians recommending sterilization are active in dis- cussing family planning and have positive attitudes toward discussing family planning. These last two variables in combination were most significant in predicting recommendation of sterilization, and the relationship of these variables to obstetrical work was significant. The relationship between family planning attitudes and behavior and obstetrical work reflects the importance previously attributed to the demands of dealing with specific medical problems. Since physi- cians involved in obstetrical work are more likely to have discussed family planning and are more willing to initiate discussion of family planning, the fact these physicians were more likely to recommend a sterilization supports the argument that work environment affects physicians' performance. 279 Involvement in obstetrical work, and all that work entails, makes physicians aware of the personal problems created by unwanted preg- nancies after desired family size is reached. Also, the pressures of large families on financial resources on some families is another part of their experiences. Such physicians probably are more acquainted with the anxieties of patients who are at unnecessary risk for long periods of their reproductive lives. If physicians have a responsibility for providing the best advice possible to their patients, sterilization should be a viable alternative at some stage in a couple's reproductive lives. A conclusion is that physicians not involved in obstetrical work, and less involved in family planning, do not view sterilization as a possible alternative means of family planning except in cases where there is a clear and present dan- ger to a woman's health from pregnancy. Apart from the preceding discussion, the relationship between obstetrical work, the family planning attitudinal variables, and recom- mending a sterilization supports Freidson's argument that work environ- ment affects medical performance. Although majority of physicians studied were at least marginally involved in the provision of family planning services, actual practice experience, in terms of the patients and medical problems with which doctors deal, serves to modify the range of doctors' approaches to the delivery of family planning services. Involvement in obstetrical work is the most important work environment variable in explaining physicians' attitudes concerning family planning. An important conclusion is that patients seeking to discuss family planning problems with a physician should see an obstetricianrgyneCOIOgist or a general practitioner doing obstetrical 280 work. Such physicians are most likely to initiate discussion of family planning with patients. Obstetrical work and family planning attitudes are one aspect of family planning services. Orientation to technical and social aspects of medical practice is the other relevant factor in the delivery of family planning services. Responses to the case histories indicated that physicians higher on technical orientation are less likely to respond in a standardized pattern by recommending the pill. The con- clusion is that physicians high on technical orientation are more likely to recognize contraindications to the pill and recommend alternative methods of contraception. Relating the findings on technical orientation to involvement in obstetrical work and family planning attitudes indicates that physi- cians' doing obstetrical work and high on technical orientation are most likely to discuss family planning and recognize specific means of contraception as contraindicated. A conclusion is that such physicians can be identified by the structure of their practices. Obstetrician- gynecologists in group practice would be one group, and general practi- tioners doing obstetrical work and having small patient loads would be the other group. If "best" physicians can in some sense be identified by analysis of responses to the two dimensions of family planning services studied, physicians at the other extreme can similarly be identified. Physicians least likely to be willing to initiate family planning discussion and to recognize contraindications to the pill are general practitioners not doing obstetrical work and having large patient loads. Such physi- cians had little direct experience with obstetrical work, and the number 281 of patients seen per week necessitates accommodations in technical and social orientation to medicine. Low Technical-Low Social general practitioners are the prime example of this group of physicians. The previous description of Low Technical-Low Social orientation physicians as "processors" seems appropriate in light of their standard response to the case histories and their low scores on willingness to initiate family planning discussions. The conclusion is that the environment of ongoing medical prac- tice is a primary factor in explaining medical performance in the area of family planning. Involvement in obstetrical work is one variable differentiating between and within medical specialty fields in willing- ness to discuss family planning with patients. Types of medical problems and number of patients seen per week are environmental factors differentiating physicians in their technical and social orientation to medicine, and subsequently their recognition of contraindications to specific types of family planning. Analysis and discussion gives significant support to Friedson's argument that the conditions of current practice are of primary con- sideration in explaining medical performance. Physicians respond to their present situation more than their previous training, a conclusion which is consistent with the field theoretical framework. The importance of publics in that present environment has been demonstrated. Another significant finding in the delivery of family planning services is that patients are not receiving the "best" medical care. Whether services rendered, as indicated by the data, are "acceptable" medical care is questionable in view of the responses for patients with' medical contraindications to specific methods of family planning. This 282 finding is related to physicians' equating the pill to family planning services rather than a more generic concept of family planning as a responsibility to maintain the optimum health of the family by all means at his disposal. Such an approach views family planning as taking into account both psychological and social and emotional aspects of family health. It is this last standard that family planning services should try to reach. Limitations g the My To set some limits on the findings of the investigation, the limitations of the research must be taken into account. This is an exploratory study guided by several concerns. Structure of medical practice, orientations to medical practice, attitudes and practices in family planning, and the delivery of family planning services in the context of the preceding variables constituted the framework for the study. Limitations arose from the compromises made in reconciling the research design to available resources. Use of a mailed questionnaire constituted an important compromise. Although use of sponsorship and followup procedures achieved a representative response from the pOpu- lation, limitations inherent in a mailed questionnaire made exploration of certain areas difficult. Clarification of respondents' interpreta- tions of questions and followup questions on topics of interest were outside the scope of the data collection procedures. Findings are restricted to the specific population under study since there is no way to show that the sample is representative of the medical professions. This limitation on generalizability applies to both geographical area and medical specialties studied. The latter 283 limitation is apparent considering the substantive differences found 'between medical specialty fields in the analysis. This restriction is zacceptable since family planning was a central focus, thereby eliminat- ing other types of physicians. Use of perceptual data places limits on the findings, such data representing one perspective on the problems under investigation. Also physicians' perceptions disregards patients' position in the doctor- patient relationship. Conclusions concerning physicians' depersonaliza- tion in providing family planning services are important if they constitute barriers to the delivery of the "best" or "acceptable" medical care. Data from patients could resolve this question. Finally, the criteria used for evaluating medical care were limited by the research format. Although any normative standards are subject to debate, evaluation of medical care is difficult because of the potential consequences of errors in medical judgments for patients. There was no way to measure such consequences in the present research. Suggestions for Further Research Implicit throughout the discussion are several avenues for fur- ther research. The structure of medical practice and the delivery of family planning services represent two areas. Analysis described the complexity of medical practice indicating the necessity for elaborating and modifying the conceptualization employed herein. Substantive differences between specialty fields indicates that the variables used to measure specific aspects of medical practice must be modified. For example, differential ranking of the items used to measure technical orientation to medicine indicates a necessity for future research. Refinement of the measurement of the 284 technical dimension of medical practice is necessary to understand wtuather the "found" differences between specialties are "real." Further Iresearch can establish whether technical orientation varies by Slxecialty fields, and the implications of such differences for medical (aiucation and medical care should be investigated. Study of the structure of medical practice should be expanded to include such variables as number and type of office staff, division of labor among office staff, diagnostic facilities available in office or immediate building, record keeping procedures, time spent with individual patients, followup procedures for patients treated, and hospital admissions. Such information involves alternative data collection procedures such as interviews, access to medical records, and direct observation of physicians' offices. The overall pattern of physicians' practices in family planning is well established—-they are most likely to provide such services and to recommend the pill. A next step is to examine the delivery of such services in the context of medical practice. The barriers to the delivery of family planning services created by the structure of medical practice and physicians' attitudes toward medicine and family planning is a next step. Cost of an office visit, waiting for rather than eliciting questions from a patient, and failure to discuss alterna- tive methods of family planning may constitute barriers to effective medical care. What is truly needed are data from patients and their doctors, a need that could be satisfied by direct observation of doctor-patient contact. A primary research goal should be extending study of the relation- ship between practice specialty, practice structure and dimensions of 285 medical practice to other areas of medical care. Such study could offer important support for the conclusions reached herein. APPENDIX APPENDIX A--COVER LETTER AND QUESTIONNAIRE Dear Dr. : I am writing to ask your participation in a survey of doctors' atti- tudes and practices regarding family planning. .At a time when medical education in the state is rapidly changing we feel it is worthwhile to know in a more formal way how doctors in private practice deal with problems of family planning.. Since this is a statistical survey des- cribing general patterns of doctors' approaches to family planning, it is important for us to have the views of a true cross section of physi- Clans. Questionnaires are being sent to physicians (M.D. & D.0.) in the prac- tice of family medicine, general practice, obstetrics and gynecology, and internal medicine in Ingham, Eaton and Jackson counties. Your questionnaire is identified in the upper right hand corner to make our records complete. All answers are confidential and your own specific answers will not be identified in any manner. The questionnaire takes less than a half hour to complete. Most of the questions just need a check beside the appropriate answer but we welcome your views in more detail if you would like to give them, so we have provided space at the end of the questionnaire. We would be very grateful if you would answer all the questions and return the form to us as soon as possible. If you would like further information about the study or a copy of the final report, please let Mr. Tschetter know so that he can get in touch with you. Thank you for your cooperation. Sincerely, 286 287 FIRST WE WOULD LIKE TO ASK YOU A FEW QUESTIONS ABOUT FAMILY PLANNING. l. The circumstances in which.a doctor will discuss family planning with a patient vary considerably. For each of the following situa- tions would you: a Introduce the subject of family planning yourself. b Discuss family planning only if asked directly. 0 Not discuss family planning if asked, but refer to appropriate person. CHECK ONE BOX ON EACH LINE. Introduce Discuss Not discuss subject only if [233 refer yourself asked I patient A. Wife with two children and who has mitral stenosis .......... ( ) ( ) ( ) Husband with two children and whose wife has mitral stenosis ( ) ( ) ( ) B. Wife of eighteen who has just had her first baby () () () Husband of nineteen whose wife has just had her first baby .. ( ) ( ) ( ) C. Woman who is seeing doctor for a premarital examination ....... ( ) ( ) ( ) Man who is seeing doctor for a premarital examination ....... ( ) ( ) ( ) D. Wife with three children and no social or health problems .... ( ) ( ) ( ) Husband with three children and no social or health problems . ( ) ( ) ( ) E. Wife whose husband earns less than $7000 and has just had her fourth baby .............. ( ) ( ) ( ) Husband who earns less than $7000 and whose wife has just had their fourth baby () () () F. Unmarried woman of nineteen who ms radabaaby OIIOOIOOOOIIIOO Unmarried man of nineteen who ms fathered. 8! why I I I O O O I O I O () () () () () () 2. When a patient sees a doctor concerning family planning, a doctor makes his recommendations based on his knowledge of the patient's medical history and physical health. In each of the following situations: 288 a) For those methods requiring medical prescription--pill, IUD, diaphragm--indicate all those methods you feel are clinically contra-indicated. CHECK METHODS CONTRA-INDICATED FOR EACH PATIENT. b) State the method of family planning you would be most likely to advise each patient to use-—that method need not be the pill, IUD, or diaphragm. If you would not recommend family planning to a patient, write none in the space. WRITE YOUR ANSWER IN THE SPACE PROVIDED FOR EACH PATIENT. Contra-indicated Method most Pill IUD Diaphragm likely Married female, twenty-one years old, nulligravid, good physical health, desires to postpone first pregnancy. Married female, twenty-six years old, three children, two con- traceptive failures using dia- phragm, good physical health, desires no more children. Unmarried female, sixteen years old, nulligravid, good health, desires contraception. Married female, twenty-five years old, one child, history of dysmenorrhea and hyperten- sion, desires to postpone next pregnancy. Separated female, thirty-three years old, four children, good health, receiving welfare assis- tance, desires family planning. Unmarried female, twenty-three years old, nulligravid, history of diabetes mellitus, desires contraception. A. What proportion of your patients are women within their child- bearing years? % B. With what proportion of your female patients in their child- bearing years have you discussed family planning? % 289 C. We are interested in the methods of family planning you advise patients to use. For those methods that you do recommend to patients, please indicate the proportion of patients you advise to use each method. For those methods of family plan- ning you never recommend place a‘Q next to that method. Pill % IUD % Diaphragm % Foam % Condom % Rythmn % Other % SPECIFY lOO % 4. Taking the three types of contraceptives that are medically pre- scribed--pill, IUD, and diaphragm--how would you rate these three methods for: a) Physical health hazards for patients. b) Reliability for the average patient. c) Acceptability for most patients. SCORE EACH DIMENSION BY USING: 1 = MOST, 2 = MIDDLE, 3 = LEAST. Health hazards Reliability for Acceptability for for patients average patient most patients Pill IUD Diaphragm IF; YOU NEVER PRESCRIBE THE PILL 99 _T9 QUESTION £6. 5. A. What is the duration of your initial prescription for oral contraceptives for a patient? months. B. What is the duration of the renewal prescription for oral contraceptives for a patient who is regularly using the pill? months. 6. 290 Does your practice include the fitting of diaphragms? CHECK ONE. Yes ...é No .... Does your practice include the insertion of IUDs? CHECK ONE. Yes ... ( ) No .... ( A. How many premarital exams do you perform in an average month for: IF YOU DO NOT PERFORM PREMARITAL EXAMINATIONS WRITE NONE. Men . Women . B. At the time of a premarital exam, how often do you talk about problems of sexual and emotional adjustment in marriage with: CHECK ONE IN EACH COLUMN. IF YOU DO NOT PERFORM PREMARITAL EXAMS CHECK 99 NOT PERFORM. Men: Women: Do not perform ... ( Do not perform ... Never ............ E Never ............ Occasionally ..... Occasionally ..... Frequently ....... ( ) Frequently ....... Routinely ........ ( Routinely ........ E p_U 13 NOT PERSONALLY PERFORM DELIVERIES go _T_O_ QUESTION # 10. 9. 10. A. How many deliveries do you perform in an average month? B. During the puerperium, do you discuss family planning with a patient: Never ................ ( ) Occasionally ......... 2 Frequently ........... i Routinely ............( C. During postpartum exams, do you discuss family planning with a patient: Never ................ E ) Occasionally ......... Frequently ........... ) Routinely ............ What do you feel is the ideal spacing between births? CHECK ONE. One year .......................... ( ) Two years ......................... Tmee yea-rs cocoons-00000000000000. More than three years ............. Left up to the patient ............ ( 11. 12. 13. 291 We are interested in the conditions under which a doctor will recommend a sterilization to a patient. For each of the following couples would you suggest the possibility of a sterilization: IF YES, would you advise sterilization for the husband 2; the wife No .Ygg Male Female Couple with two children and the wife has had severe toxemia in successive pregnancies ..... ( ) ( ) ( ) ( ) Couple with four children and the husband, a construction worker, earns less than $7000 a year .. ( ) ( ) ( ) ( ) Couple with two children and no social or health problems and do not want any more children . ( ) ( ) ( ) ( ) Couple with no children and the wife carries the trait for‘ hemophilia: IOOIOIIOOOOOIOOIOOOO () () () () Couple with no children and the husband and wife both have extremely low intelligence .... ( ) ( ) ( ) ( ) Couple with five children, and last four have resulted from contraceptive failures . . . . . . . . ( ) ( ) ( ) ( ) A. How many times in the past year have you recommended a sterili— zation to: Male patients . Female patients . B. What proportion of the sterilizations you recommended in the past year were performed: Male patients % Female patients % Physicians must deal with problems of sexuality and family planning in treating patients. Please indicate how comfortable you feel in dealing with the following problems when encountered in your practice: CIRCLE THE APPROPRIATE NUMBER FOR EACH SCALE. A. Discussing problems of general psychosexual development. Very Very comfortable = 5 4 3 2 l = uncomfortable 292 Discussing problems of sexual behavior with adolescents. Very Very comfortable = 5 4 3 2 1 = uncomfortable Discussing sexual and emotional problems in adjustment to marriage. Very Very comfortable = 5 4 3 2 l = uncomfortable Explaining the methods and uses of the techniques of family planning. Very Very comfortable = 5 4 3 2 l = uncomfortable 14. We are interested in the sources of information doctors find most helpful in dealing with the various problems of family planning encountered in practice: a) b) O\OCD\1 O\ U‘PKJONH 3.: In the first column, check all sources of information you have found helpful in dealing with patients' problems with family planning. CHECK.ALL THAT APPLY. In the second column, check the one source that has been most helpful in dealing with family planning. CHECK ONE. All helpful One most sources hel ful Undergraduate medical training ...... 2 Internship and/or residency.......... Discussion with other doctors........ E Medical journals, textbooks.......... Drughouse representatives, literature.....................o..... () () Knowledge & understanding gained through treating patients............ Professional seminars................ Family planning clinics, courses..... 13y PreSSOOIOOOIIOOOOOOOII0.00......O é Other.............................on SPECIFY Have you ever worked at a family planning clinic? CHECK ONE. Yes ... NO ...I Are you presently working at a family planning clinic? CHECK ONE. Yes ... ( ) No .... ( 293 NOW WE WOULD LIKE TO ASK YOU A FEW QUESTIONS ABOUT MEDICAL PRACTICE IN GENERAL. ' l6. l7. l8. 19. Some medical commentators have recently argued that there is a growing tendency for people to bring less serious disorders to doctors and more readily seek help for problems in their family lives. Given present conditions of medical practice, do you feel: CHECK ONE. In general, it is a very good trend .............. ) In general, it is a fairly good trend ............ In general, it is a rather disturbing trend ...... In general, it is a very disturbing trend ........ What proportion of your patients' office visits would you estimate are for reasons you feel to be trivial, unnecessary or inapprOpri- ate? CHECK ONE. 9W0 or more ooooooucoooooooooo () 75% but less than 9% 0.0000.- 5Q% but less than 75% ........ 25% but less than 5% 0.000000 10% but less than 25% ........ ) LGSS'Lhan10% 000.000.000.060. Please indicate the relative importance of the following ways of keeping up-to-date with new developments in medical practice. PUT "l" BESIDE THE MOST IMPORTANT, A "2" BESIDE THE NEXT MOST IMPORTANT, AND SO ON. Professional meetings Informal discussions with doctors Drughouse representatives or literature Journals, books, other publications Refresher courses and seminars One often sees articles that describe what some people believe to be the proper role of the practicing doctor. With an average size patient case load, under present conditions of medical practice, do you believe it is realistic or unrealistic for a doctor to be expected to do each of the following: CHECK ONE BOX ON EACH LINE. Very Somewhat Somewhat Very realistic realistic unrealistic unrealistic To do a complete his- tory for all new Patients 0.0.0.0000... () () () () I. To make sure a patient understands the diagno- sis and treatment of his illness .......... To keep abreast of new developments in medical specialty fields other than his own To routinely discuss diet with overweight mtients .OIOIOOOOOOI To provide counseling for a patient who is having marital diffi— culties ............. To do a complete phy- sical on patients over forty at least once every three years ... To confirm all diagno- ses by the use of diagnostic tests .... To help a husband whose wife has hepatitus make arrangements for house- keeping duties during her convalescence ... To require PAP smears for all female patients over twenty at least once a year ......... To spend time with a patient resolving the social and emotional sources of cervical pain which is psychosomatic in origin OOOOOOIOOOI To use drughouse repre- Very () () () () () () () () () sentatives and literature as a primary source of keeping up—to-date with new developments in drmg therapy 0000000000000 () 294 Somewhat () () () () () () () () () () Somewhat realistic realistic unrealistic unrealistic () () () () () () () () () () Very () () () C) () () () () () () 295 NOW WE WOULD LIKE TO ASK YOU SOME QUESTIONS CONCERNING YOUR PRACTICE. 20. Would you describe your practice as: CHECK ONE. Family practice ......... General practice ........ Obstetrics-gynecology ... Internal medicine ....... Other coo-00000000000000. SPECIFY 21. A. Is your practice: CHECK ONE. 8010 00000000000000.0000000000000.0 ( Group, PartnerShiP 000.00.00.00...- Group, Salaried 0.000....0000000... InStitional, Salaried coco-00000000 Other ococoon.coco-00.000.000.000no SPECIFY B. If group practice, with how many other doctors are you associated? . 22. How many patients, a week, do you see in your office at this time year? . 23. A. How many years have you practiced? . B. How many years have you practiced medicine in this community? 24. A. At which hospital(s) do you have admitting privileges? CHECK ALL THAT APPLY. Ingham Medical ( Eaton Rapids Community ... St. Lawrence ..... Hayes—Green Beach ........ Sparrow oooooooooo LanSing General 00.000000. Foote Memorial ... Jackson Osteopathic ...... Mercy 000000.00... Other 00000000000000.00... Mason General .... E St. RU]- 000000000 SPEcm B. To which hospital do you admit most of your patients? CHECK ONE. Ingham Medical . . . ( Eaton Rapids Community . . St. Lawrence ..... Hayes—Green Beach ....... Sparrow 000000.... LanSing General 00.00000. Foote Memorial ... Jackson Osteopathic ..... Mercy coo-00000.00 Other 9.0000000000000000. Mason General .... St. Pall]. 000.000.. SPECIFY 25. A. How many medical journals do you review reguarly? . 26. 17. 296 B. What medical journal do you read most thoroughly and regularly? NAME ONE. A. How many refresher courses or professional seminars have you attended in the past three years? . B. How many of these courses have dealt either directly or indirectly with family planning? . Compared to other physicians in the community in your medical specialty field, how good a doctor would you say you are: CHECK ONE. Upper 10 percent Of dOCtorS in my SPeCialty 00000000000000. ( Upper 25 percent to 10 percent of doctors in my specialty.. Upper 50 percent to 25 percent of doctors in my specialty.. Lower fifty percent of doctors in my specialty ............ FINALLY A FEW QUESTIONS ABOUT YOUR BACKGROUND. 28. 29- A. What medical or osteopathic school did you attend? B. In what year did you graduate? . A. In what hospital did you intern? (name) (citY) B. On what service(s) or rotation did you serve? __ YOU DID NOT HAVE;A RESIDENCY £9.29 QUESTION #31. 300 31. 32. A. On which service did you serve a residency? B. In which hospital(s) did you serve? (name) (citYI (Fame) (city) (Name (city) What was your age at your last birthday? . Are you: CHECK ONE. male 000000.00 E; Female ....... 33- 35- 36. 297 Are you presently: CHECK ONE. Single 00000000000000000 Married 0000000000000000 Separated 00000000000000 Divorced 000000000000000 Widower (ed) 00000000000 A. What is your religious preference? CHECK ONE. PreteStant 000000000000000 i ; cathOliC 00000000000000000 JeWiSh 0000000000000000000 Other 00000000000000000000 Agnostic/Atheist ......... E SPECIFY None 000000000000000000000 How often do you attend religious services? CHECK ONE. Once a month 00000000000000000000 ( Two or three times a year ....... ( ) Only on special religious , holidays ....................... ( ) Never 0000.00.00.00000000.00000.0( Quite apart from attending religious services, how important would you say religion is to you? CHECK ONE. Once a week 00000000000000.000000 ( 3 Very important 00000000000 Fairly important 000000000 NOt tOO important 00000000 Not important at all ..... If a member of your family needed obstetrical or gynecological help, which obstetrician-gynecologist(s) in this community would you prefer that she see? 1. 2. 3. If a member of your family were moderately ill and you did not want s to treat him yourself, which general practitioner( or internist(s) in this community would you prefer that he see? 298 THANK YOU FOR YOUR COOPERATION IN THIS STUDY. IF YOU WOULD LIKE A COPY OF THE FINAL REPORT OF THE STUDY PLEASE CHECK THE BOX PROVIDED. .I WOULD LIKE IQ REASSURE YOU THAT ALL YOUR ANSWERS WIIl.REMAIN CONFIDENTIAL. IF YOU HAVE COMMENTS ABOUT INDIVIDUAL QUESTIONS OR THE SUBSTANTIVE MATERIAL COVERED IN THE SURVEY, PLEASE MAKE THEM ON THE BACK OF THIS PAGE. PLEASE FORWARD A COPY OF THE FINAL REPORT: ( ) BIBLIOGRAPHY BIBLIOGRAPHY Bakker, Cornelis B. and Cameron Dightman. "Physicians and Family Plan- ning: A Persistent Ambivalence," Obstetrics and Gynec010gy, Volume 25 (1965), pp. 279-284. Barnes, J., L. Johnson, J. Kaufman, W. Nichols and P. Olsson, “Attitudes and Practices of Physicians Concerning Birth Control in Two California Counties." Berkeley, California State Department of Health and Planned Parenthood League of Alameda County, 1965 (mimeograph). Becker, Howard S., Blanche Geer, Everett C. Hughes, and Anselm L. Strauss. Boys in White: Student Culture in Medical School. Chicago: Univ. of Chicago Press, 1961. Biddle, Bruce J., Edwin J. Thomas. Role Theory: Concepts and Research. New York: John Wiley & Sons, Inc., 1966. Bloom, Samuel W. The Doctor and His Patient, A Sbciological Interpre- tation. New York: Russell Sage Foundation, 1963. Cartwright, A. "General Practitioners and Family Planning," Medical Officer (1968), 70, us-ué. 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