Health and Illness

Health Care Providers

Social and Cultural Identities of Doctors and Patients

Social and cultural factors influence doctor-patient relationships, communication, and treatment.
Doctors, nurses, and other health care providers perform social roles that are defined by the surrounding society and culture. A social role is a socially defined expectation of an individual in a given status or social position. Health care providers occupy a particular status in society, often a fairly elevated status. However, the social and cultural identities of individual health care providers also impact understanding of these roles and of the concepts of health and illness in general. According to a 2017 report by the federal Bureau of Labor Statistics, 72 percent of U.S. physicians are white, while 61 percent of the U.S. population is white. A 2008 analysis found that most medical school students come from families whose incomes are in the highest quintile (the highest 20 percent) of the population. Sociologists look at how this can influence various issues such as doctor-patient interactions, the perceptions of doctors and patients, and approaches to treatment. For example, a study of Cherokee patients treated by white physicians revealed a gap in how the doctors and the patients perceived the patients' overall health. The doctors often rated the patients as healthier than the patients rated themselves. Gaps in perception can create lack of trust between patients and doctors, making patients less likely to seek medical care. Doctors can also miss problems in patients who have low levels of trust or who have culturally different ways of communicating information than their doctors have. Subconscious beliefs about race and ethnicity can impact how physicians choose to treat patients. Studies show that white patients are much more likely than black or Hispanic patients to be prescribed opioids—a class of medicines that are highly effective for pain but are also addictive. This can lead to undertreatment of pain for black and Hispanic patients and to overprescription of opioids for white patients. Because of persistent racial and ethnic disparities in health and health outcomes in the United States, some medical schools provide training in cultural competence to medical students. Cultural competence—possessing skills, knowledge, and attitudes that facilitate communication with people from other cultures—allows health care providers to better understand and support a diverse population of patients. Also called cross-cultural competence, this set of skills requires ongoing, continuing education. Many hospitals, insurance companies, and doctors' offices provide this ongoing training, but lack of cultural competence among physicians remains an issue in the U.S. health care system.

Social Factors in Health Care Education

The medical workforce is less diverse than the U.S. general population, in part because of the levels of education and debt associated with these professions.

Physicians

Physicians, or doctors, spend many years completing their education and training. This is one of the reasons why doctors have relatively high social status and occupational prestige in most societies. Their training also puts them at the top of a hierarchical doctor-nurse-patient relationship. Patients—and other members of society—are often deferential to doctors on medical matters. Sociologists analyze the social roles doctors play, but they also look at the social factors that influence who becomes a doctor. In the United States, medical school is expensive, and many medical schools are competitive. Successful applicants to good medical schools have years of preparation behind them, including success at the college level. This preparation might include private tutors, test-preparation services, or additional time in college beyond the minimum for graduation. This can present obstacles for individuals from low socioeconomic backgrounds. Racial and ethnic stratification also plays a role. Due to structural disadvantages faced by African Americans, Native Americans, and Hispanic Americans, members of these groups are less likely than Asian Americans and white Americans to receive a high quality education or supplemental educational resources. All these factors contribute to the overall makeup of medical school populations. People from more privileged racial and economic groups are more likely to attend medical school and thus are more likely to become doctors. In the past, gender inequality in society at large and in educational settings discouraged women from applying to medical school. This began to change at the end of the 20th century, as more women began to attend college and specialize in science-related fields. In 2017, for the first time more women than men enrolled in medical school in the United States. Medical schools have also become somewhat more racially and culturally diverse, but a 2017 report by the Association of American Medical Colleges showed that the overwhelming majority of students are white or Asian. Since 1980 the percentage of medical students of Asian heritage has risen significantly, from 4 percent in 1980 to 21.3 percent in 2016. However, the percentage of students who identify as Native American, African American or black, and Hispanic or Latino has changed very little. Black students were 6 percent of the medical school population in 1980 and 7.1 percent in 2016. Hispanic students accounted for 4.9 percent of medical students in 1980 and 6.3 percent in 2016. Native American students are a very small portion of medical students, making up 0.3 percent of students in 1980 and 0.2 percent in 2016. White students made up 48.2 percent of medical students in 2016. In order to serve a racially, ethnically, and culturally diverse society, some medical schools are seeking ways to recruit a more diverse student body. Numerous studies note the need for greater racial and ethnic diversity among physicians. Researchers argue that a more racially and ethnically diverse physician workforce has increased cultural competence, the ability to understand and meet the needs of a diverse range of patients. Physicians of color are also more likely to practice in underserved areas, including rural communities. This increases access to health care for many marginalized groups, including people of color and those who have low incomes or low socioeconomic status.

Registered Nurses, Nurse Practitioners, and Physician Assistants

In the United States there are many paths to becoming a nurse. To become a registered nurse (RN), students can complete a four-year bachelor of nursing degree or complete either a two-year or a three-year RN program. Nurse practitioners (NPs) are RNs who attain a bachelor's degree and complete a master's program. Physician assistants (PAs) also complete master's-degree–level training. Nurse practitioners and physician assistants can perform many of the same tasks that doctors can, including physical exams, diagnosing illness, and prescribing medication. Nurse practitioners and physician assistants can often see more patients and charge lower fees than doctors. One reason that doctors' fees are higher is that most medical students must be willing to take on high levels of student debt in order to go to medical school. In 2017 the median debt of an American medical student was $195,000. Debt levels for RNs, NPs, and PAs are similar to those for college students as a whole. Many community colleges offer RN, NP, and PA programs or some courses toward these certifications, for relatively low tuition. These factors can make these professions more accessible to individuals and groups with lower incomes. This also makes these professions somewhat more racially, ethnically, and culturally diverse, although the majority of PAs, NPs, and RNs are white. The vast majority are also women. Some evidence exists that nonwhite patients prefer to see physician assistants or nurse practitioners over physicians. For example, in a 2012 survey of patients, black, Hispanic, and Asian patients expressed a greater preference for NPs and PAs, while white patients preferred physicians. These differences might be, in part, because of greater cultural competence among PAs and NPs and factors related to gender norms.
Education Requirements for Health Care Providers in the United States
Physician Undergraduate degree (BA or BS) 4 years
Medical school (MD) 4 years
Residency (supervised practice and ongoing training) 3–7 years
Physician Assistant Undergraduate degree (BA or BS) 4 years
Experience working in health care field (such as nurse, medical assistant, paramedic, surgical tech) 3+ years
Physician assistant program (MA) 3 years
Nurse Practitioner Undergraduate degree (BA or BS) and/or completed RN program 4 years
Work as an RN Variable
Master of science in nursing (MSN) or Doctor of nursing practice (DNP) 2–4 years
Registered Nurse Associate degree in nursing (ADN) or Bachelor degree in nursing (BSN) 2–4 years

Alternative and Complementary Medicine

Alternative and complementary medicine include treatments provided outside of mainstream medicine and the medical model.

Doctors, physician assistants, nurse practitioners, and nurses are trained in the scientific method. They take a scientific approach to medicine, sometimes called the medical model or evidence-based medicine. This scientific approach to health and illness is sometimes criticized as leading to overmedicalization—treating normal conditions of living as medical problems and prescribing medicine unnecessarily. Alternative medicine includes approaches to health and illness that fall outside the medical model and treatments that occur outside of traditional institutions such as clinics, doctors' offices, and hospitals. Chiropractors, acupuncturists, massage therapists, traditional healers, and others are considered practitioners of alternative medicine. Some mainstream medical professionals regard alternative medicine as unorthodox or ineffective. They might argue that alternative medicine involves approaches and treatments that have not been shown to be effective using scientific methods and definitions. Other medical providers view alternative medicine as an effective, or potentially effective, complement to the medical model. Some doctors, hospitals, and insurance companies incorporate what they term complementary medicine, treatments and therapies that fall outside the evidenced-based, medical model. For example, chiropractic care and acupuncture are sometimes used in conjunction with treatment by a physician or prescription medication.

Sociologists study the social phenomenon of alternative medicine to understand social and cultural trends related to what medicine and medical treatment mean in a particular society or community, or why particular patterns of behavior occur. Some researchers investigate how race, ethnicity, age, gender, or other factors influence people to use or avoid alternative medicine. For example, a 2012 study found that African Americans who felt they had experienced discrimination in any arena were more likely to see a practitioner of alternative medicine. Numerous studies show that women are much more likely than men to pursue alternative medical treatment. Sociologists analyze these findings and try to understand how they impact health outcomes for different social groups. They note that most people tend to attempt to self-medicate before visiting a doctor, by using over-the-counter medication or by taking illegal drugs. The growth of alternative medicine may reduce barriers for some people, prompting them to seek treatment of some kind. However, it may also cause some individuals or groups to avoid consulting medical doctors for conditions that are best treated by mainstream, science-based medicine.