Do diseases have a prestige hierarchy? A survey among physicians and medical students

Abstract

Surveys have shown that the prestige of medical specialities is ordered hierarchically. We investigate whether similar tacit agreement in the medical community also applies to diseases, since such rankings can affect priority settings in medical practice.

A cross-sectional survey was performed in three samples of physicians and medical students in Norway in 2002. A questionnaire was sent to 305 senior doctors (response rate, 79%), 500 general practitioners (response rate, 65%) and 490 final-year medical students (response rate, 64%). Outcome measures were ratings on a 1–9 scale of the prestige these respondents believed most health personnel would accord to a sample set of 38 different diseases as well as 23 medical specialities.

Both diseases and specialities were clearly and consistently ranked according to prestige. Myocardial infarction, leukaemia and brain tumour were among the highest ranked, and fibromyalgia and anxiety neurosis were among the lowest. Among specialities, neurosurgery and thoracic surgery were accorded the highest rank, and geriatrics and dermatovenerology the lowest.

Our interpretation of the data is that diseases and specialities associated with technologically sophisticated, immediate and invasive procedures in vital organs located in the upper parts of the body are given high prestige scores, especially where the typical patient is young or middle-aged. At the other end, low prestige scores are given to diseases and specialities associated with chronic conditions located in the lower parts of the body or having no specific bodily location, with less visible treatment procedures, and with elderly patients.

Introduction

Research on the prestige ordering of medical specialities conducted over many years has shown that medical specialities are informally ordered in a hierarchy (Hinze, 1999; Rosoff & Leone, 1991; Shortell, 1974). Explanations of the differences in prestige between specialities include the part of the body they relate to (Album, 1991), the typical relations between practitioners and patients (Shortell, 1974), their social value (Rosoff & Leone, 1991), and their action orientation and use of sophisticated technology (Hinze, 1999). Results are fairly consistent. “Generally surgery and internal medicine are ascribed the highest status while paediatrics, psychiatry and family medicine hover near the bottom”, wrote Hinze (1999). In studies where respondents are asked to rank several specialities, neurosurgery and thoracic surgery are at the top together with cardiology (Rosoff & Leone, 1991).

However, it is not known whether the medical community also places actual diseases in some sort of rank order. Disease is a basic category of medical knowledge and practice, and together with its typical treatment, disease is also the basic unit in the standards for priority setting. Among lay people, and in the medical community as well, diseases are commonly seen as discrete biomedical entities, reflected in elaborate diagnostic systems. However, seasoned clinicians will acknowledge that diseases are really theoretical constructs developed in order to explain something about the patient's illness (McWhinney, 1997). Thus, diagnoses are useful conceptual tools that enable physicians to make certain inferences and predictions, based on current medical thinking. Increasingly these categories are being used for administrative and economic purposes as well, suggesting that their social meaning is important (Hart, 2006). If diseases are proven to be prestige ranked, it is likely that considerations other than strictly medical ones tacitly influence medical decisions (Martin & Singer, 2003; Polanyi, 1967).

Studies on the social standing of medical conditions are not new to the social sciences. The concept of stigma (Goffman, 1963) has been used to analyse how people with certain diseases are socially evaluated in their interaction with doctors and others. Stigma may even reduce the quality of the medical treatment given. The stigma concept is concerned with medical conditions of low rank. This article, on the other hand, addresses the full spectrum of conditions. Stigma concerns characteristics of people with an illness, as well as their experiences with being stigmatised. We investigate opinions shared by medical practitioners regarding diseases as institutional categories.

In his classic analysis of the medical profession and the concept of disease, Eliot Freidson (1970) introduced a typology of diseases. Building on Parsons’ (1951) analysis of the sick role, Freidson (1970) suggested that the imputed legitimacy and seriousness of the diseases denote the basic characteristics of their social meaning. His typology may be seen as a precursor to the main points of this paper, not only in relation to considering disease a central category in an analysis of medical culture and organization, but also by suggesting that disease categories are loaded with values and emotions.

The main aim of this study was to determine whether physicians rank diseases, as well as specialities, according to prestige. If they do, this may have an impact on priority settings in medical practice. A broader aim of the study was to contribute to the understanding of disease as a sociological concept.