2 HEALTH CARE

Bill Lange's early contacts with undergraduate sociology were not particularly impressive. Bill was even unsure, at least early on, just what sociology was. Nonetheless, the classes he took held his interest. The issues addressed were wide–ranging and the interpretations of society began to have some meaning for him. He was especially intrigued by computer applications, research methods, and statistics. He therefore decided to complete his B.A. in sociology and pursue an M.A. as well. Bill admits, however, that while he was reasonably certain about his education he was not to sure about his post– graduate options. Even more, according to Bill, "My in–laws were not so sure that a degree in sociology was such a good thing for their daughter!"

In his studies Bill had focused his attention on statistical applications and had worked on several projects within the department of sociology. In fact, his experience with research while still in college proved most valuable in his later job search. In addition, Bill became aware of the real need for intelligent national data collection and analyses in a wide array of contexts. In other words, Bill found that the unique skills of the sociologist really are in wide demand, and that there are many professional opportunities if one is properly prepared.

Ultimately Bill answered an advertisement for a "research position" with the Veteran's Administration. One of the primary issues within health care is cost control. How much does health care cost and what does it really produce? The research position Bill applied for required statistical and computer skills for application and analysis of a major study on cancer patient follow–up care. The medical condition being researched was lung cancer, and other studies would soon be targeting colo–rectal cancer and esophageal cancer. In all cases the patients had either surgery or chemo–therapy or both, to the point that the cancer had at least been contained. After such procedures/treatments, there is then a protocol for follow–up care. From the research the federal government wanted to find out if different kinds of follow–up care would be productive of different rates of patient survival. Specifically, should a patient who had been treated for lung cancer be required to submit to a CAT scan every six months, in order to detect new cancerous developments, or would a CAT scan every three years be sufficient to ensure the same survival rates? Or, should patients simply have an office visit with a doctor every six months and have a CAT scan only if the doctor believes one is indicated?

On the surface of the issue it would seem that being checked every six months would result in greater patient survival than being checked every three years. But as those acquainted with research have discovered, there is often a significant difference between how things seem to be, and what the facts really are. In fact, according to Bill, "Our findings so far indicate no significant difference." Now, you must understand that the federal government has paid approximately $200,000–$300,000 to have this research done. With a finding of "no significant difference" this study may seem to some as a waste of time and money. However, as Bill suggested, his sociological perspective prepares him to see the "larger picture." In this case the larger picture could work out in the following way.

A typical CAT scan costs approximately $1000; $750 for the procedure and $250 for reading or interpreting the results. For one lung cancer patient with a survival rate of 10 years, follow–up care programs of six months to three years would produce the following cost differences. CAT scans every six months for ten years would cost a minimum of $20,000 (20 visits times $1,000 per visit). CAT scans every three years would cost $3,333 (3.3 visits times $1,000 per visit). In other words, for follow–up care programs which produce essentially the same results one program is 600% to 700% more expensive than the other. Now consider the implications of these differences on a larger scale. Let's say you have 1000 lung cancer patients in need of follow–up care over a ten year period. If your follow–up care program called for CAT scans every six months then the total cost would be approximately $20 million. However, with CAT scans conducted every three years the cost drops to $3.3 million; a difference of $16.7 million. Such a difference is pretty astonishing, but as with all findings further analysis must be done in order to fully understand the implications.

If you are a lung cancer survivor you, of course, are not interested in aggregate data. You are interested in good health. Therefore, health care decisions on the individual level are never so black and white. What does seem evident is that the quality of the relationship between the patient and his/her primary care doctor is significant to good health and post–cancer survival. So, rather than automatic CAT scans, more frequent primary care exams could substitute. And an exam protocol would indicate when CAT scans would be warranted. Obviously this means that responsibility for ordering CAT scans falls to the primary care doctor. Yet, paradoxically, it has been primary care physicians who have pushed for more frequent special exams and procedures, such as CAT scans. The reason for this is that primary care physicians have been the target of an increasing number of malpractice lawsuits. As this line of reasoning is followed then we find that the significance extends even to medical law, the rights of patients and the responsibilities of practitioners.

Bill's contributions to this research are several, all of which are based in sociological methods and theory. As the only sociologist on the research team Bill is able to bring a societal or social structural perspective to bear on issues as varied as contextualizing the research problem to evaluating data collection tools, such as surveys, for reliability and validity. As the only staff sociologist Bill finds that others within the VA search him out for advice. According to Bill, "Some doctors once came to me with a survey they had constructed to assess some aspect of their work. As with most non–sociologists the technical aspects of a survey are simply beyond them. Asking a meaningful question is more difficult than they often think. Further, how do they know if the questions they ask are at all related to the issue they are interested in?"

In addition to this Bill has primary responsibility for data management, including statistical manipulations using SPSS (Statistical Package for the Social Sciences). Here his background in methods and statistics has been most valuable. According to Bill, "My entree to this work was based more on my sociological skills in research rather than my ability to sociologically conceptualize. But now I feel as though I am able to begin introducing the kinds of questions and conceptualizations which can influence future research."

In terms of his future Bill says that he "looks forward to the next grant." His work, while within the context of the VA, is not routine or repetitious. It is project driven. In future projects Bill expects to be participating more at the front–end of the research, the proposal and grant–writing stage. Here is where he feels his more uniquely sociological perspective will have a real impact. His work is not with other sociologists, it is interdisciplinary; and that makes the work quite challenging. It is the opportunity to do medical sociology, and thereby influence the delivery of health care for good that gives Bill a real sense of satisfaction. "If we believe that sociology really is applicable to a broad array of problems then we must be in those contexts where we can put that perceived contribution to the test." Toward this end, Bill's next project is to pursue a multi–million dollar grant for research into the way anesthesia is used and delivered to patients. This long term study has, according to Bill, "real implications for health care delivery. Further, it is an exciting project."

For those considering sociology as a major Bill advises that, "there is life after school." Special attention should be given to the basic skills and insights, such as research methods and statistics. Given that research findings are not self–evident, it is imperative that writing and speaking skills be cultivated. "If possible, do an internship or practicum. These are great ways to see just how sociology can contribute."

Finally, Bill wants it understood that he has answered his in–laws' worries. His annual income ranges in the low $20,000's for thirty hours of work per week, for now. He fully expects that to increase, though for now the work, both schedule and content, suits him just fine.



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