Close
About
FAQ
Home
Collections
Login
USC Login
Register
0
Selected
Invert selection
Deselect all
Deselect all
Click here to refresh results
Click here to refresh results
USC
/
Digital Library
/
University of Southern California Dissertations and Theses
/
Role accommodation: A study of optometrists in a prepaid medical group as perspective for viewing relations between two professiosl occupations
(USC Thesis Other)
Role accommodation: A study of optometrists in a prepaid medical group as perspective for viewing relations between two professiosl occupations
PDF
Download
Share
Open document
Flip pages
Contact Us
Contact Us
Copy asset link
Request this asset
Transcript (if available)
Content
ROLE ACCOMMODATION : A STUDY OP OPTOMETRISTS IN A PREPAID MEDICAL GROUP AS PERSPECTIVE PGR VIEWING RELATIONS BETWEEN TWO PROFESSIONAL OCCUPATIONS by Bertram Leon Roberts A Thesis Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OP SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OP ARTS (Anthropology) August 1967 UMI Number: EP54617 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Oiasertation P S iK lis M n g UMI EP54617 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arhor. Ml 48106- 1346 UNIVERSITY OF SOUTHERN CALIFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES, CALIFORNIA 9 0 0 0 7 This thesis, w ritte Bertram Leon Roberts under the direction of hl.B—-Thesis Committee, and approved hy a ll its members, has been p re sented to and accepted by the Dean of The Graduate School, in p a rtia l fu lfillm e n t of the requirements fo r the degree of MASTER OF ARTS ......... Dean THESIS COMMITTEE E . ' S d . . .2 . : .. TABLE OF CONTENTS Page TABLES............................... iv I* THE NATURE OF THE STUDY............ 1 Statement of the Problem Statement of Hypotheses Significance of the Study II. REVIEW OF THE LITERATURE ...... 5 General Analogous Summary III. METHOD, RESEARCH DESim . ........ 16 The Case Study The Questionnaire IV. BACKGROUND OF OPTOMETRIC-OPHTHALMOLOGIC RELATIONS ..... .. .. .. .. 20 V. CASE SETTING . .................... VI. CHANGES WITHIN THE OPTOMETRY DEPARTMENT 44 VII. CASE SETTING RELEVANCE TO FUTURE PATTERNS OF PRACTICE . .... . . . 56 VIII. THE GROUP SITUATION AS AN EXTENSION OF ACADEMIC INTEREST AND PROFESSIONAL ORIENTATION . . . ... . .... . 65 IX. QUESTIONNAIRE . . . . . . . . . . . 68 Ophthalmologists* Comments ii Chapter Page X. RECENT INTERPROFESSIONAL DEVELOPMENTS : FACTORS IN THE EMERGING CHANGING RELATIONSHIPS .......... 84 XI. CONCLUSIONS......................... . 89 Hypotheses Findings in Relation to the Literature Limitations of the Study Suggestions for Future Research APPENDIX................. 95 BIBLIOGRAPHY....................................100 iii LIST OF TABLES Page 1. Composition of Lunch Groups of Optometrists Observed in the Building Cafeteria Over a Four-Week Period (Twenty Working Bays) 4l 2. Classification of the Research Publications in 1964 of Both the Department of Ophthal mology and the School of Optometry of the University of California . . . . . . 67 3. Attitudes of 168 Ophthalmologists toward Working with Optometrists. ....... 72 4. Attitudes of Ophthalmologists toward Working with Optometrists (Nine Equivo cal Responses Deleted) ... .......... 73 5. Attitudes of Diplomates and Nondiplomates in Ophthalmology toward Working with Optometrists 76 6. Attitudes of Diplomates and Nondiplomates in Ophthalmology toward Working with Optometrists (Nine equivocal Responses 76 7# Some Characteristics of Ophthalmologists with Favorable, Unfavorable, and Equivo cal Attitudes toward Working with Optometrists......... ........... 8. Attitudes of Ophthalmologists Who Have Held Office and Ophthalmologists Who Have Not Held Office in Professional Societies toward Working with Optomet rists (Nine Equivocal Responses Deleted) 8l iv CHAPTER I THE NATURE GP THE STUDY Statement of the Problem The growth of industrial society with its rapidly accelerating technological development has not merely created a wide range of new occupations, but has changed some of the functions and some of the methods of work of older occupations* Assumptions long held by established occupational groups are tested and modified as members of these groups find themselves increasingly working in organ izational frameworks as members of a production team. The medical and ancillary professions are no exception to the organizational trend. The study of groups in association i and especially the examination of the effects of their increased interaction and mutual dependency can add to the cumulative study of the properties of social arrangements. In the course of developing their fields and, i [ mapping out their areas of professional domain, two ' professions in the United States have defined their roles in such manner as to be overlapping. Optometry and oph thalmology, with their overlapping functions, have been extremely competitive and often in conflict. 2 This study is concerned with the effects upon role relations of each group of practitioners when they exist together in a prepaid, medical group, and was designed to investigate the potential for harmony and a redefinition of roles in such a setting as contrasted with private practice relationships. The fundamental assumption of the study is that the conflict which exists is not inherent in the two pro fessions per se, but that its origin is to be found in the usual mode of practice of each group, that is, in fee-for- service economic competitiveness. Statement of Hypotheses Hypothesis I— In an organization structure of nonfee-for-service practice, a professional role accommodation will evolve in which relations between optometrists and ophthal mologists will tend to be har monious. Hypothesis II— Ophthalmologists who have not worked with optometrists in nonfee- for-service group practice will be more negative about the possibility of role accommodation between oph thalmologists and optometrists. 3 Hypothesis III— The diplomate in ophthalmology will be more favorable in attitude toward working with optometrists than will the nondiplomate. Hypothesis IV— Ophthalmologists who have held office in professional societies will be more favorable in attitude toward working with optometrists than will ophthalmologists who have not held office. Significance of the Study Occupational involvement and occupational role relations as aspects of man's social experience provide a laboratory for the study of social interaction* Durkheim has stated that the cohesive force in a complex society is the mutual interdependence of special ized occupational groups. A complex productive organi zation, in this case a health team, can be viewed in this perspective* In the rapidly expanding application of an increas ingly complex and highly specialized health care, govern ment agencies and medical groups will find themselves involved with teams composed of members of different professions. Role relations of the past are subject to alteration as members of different occupations become 4 associated in mutually interdependent endeavors. As Zander, Cohen, and Stotland stated, "If we knew the condit ions under which a given function heccmes the property of a role, we would he able to make progress in understanding the nature of role conflict" (19575157)* CHAPTER II ; I REVIEW GP THE LITERATURE The literature pertinent to this thesis will be found in studies of social interaction, occupational groupe» organizations, role theory, and group dynamics. This review of the literature embraces three cate- ; gories of relevant material: the general, the analogous, and the specific. The latter category is only partially realized because there are no specific role studies of General ' The general literature is most essential for per- j spective. Many writers in anthropology and sociology have ; contributed to concepts of role relations and the nature Î of group relations in teams and in division of labor settings. The study of any specific group setting must be ' related to general theory and can then reaffirm or call into question theoretical assumptions. There is too much that is indirectly relevant in the literature to review it all. A complete review of the literature of the very large social fields on which this study impinges is beyond the I scope of this paper; however, a few works have been 5 6 selected for discussion which are especially germane to this study* I In a discussion of status and role, Linton described status as "a collection of rights and duties" and role as "the dynamic aspect of a status" (1936:113-114)* Linton further observed that society functions more smoothly as its members are more well adjusted to their statuses and Weber, in discussing types of division of labor, commented : A mere glance at the facts of economic action reveals that different persons perform different types of work and that these are combined in the service of common ends, with each other and with the non-human means of production, in the most varied ways (194? : He mentioned that the ways in v&ich work may be carried on within a social group may be classified "technically" and Durkheim*8 view of specialization as the cohesive element in ccmplex society is generic to many studies of the mutual dependency of differentiated occupational groups. His theme appears reiterated again and again in most studies of work organization. To Durkheim the division of labor produced consequences far beyond the economic or expedient level. We are thus led to consider the division of labor in a new light. In this instance the economic services that it can render are picayune compared to the moral effect that it produces, and its true function is to create in two or more persons a feeling of solidarity He further stated: To be sure, when men unite in à contract, it is because, through the division of labor, either simple or complex, they need each other. But in order for them to co-operate harmoniously, it is not enough that they enter into a relationship, nor even that they feel the state of mutual dependence in which they find them selves* It is still necessary that the conditions of this co-operation be fixed for the duration of their relations. The rights and duties of each must be defined, not only in view of the situation such as it presents itself at the moment when the contract is made, but with foresight for the circumstances which may arise to modify it. Otherwise, at every instant, there would be conflicts and endless difficulties Goffman stated : Each teammate is forced to rely on the good conduct and behavior of his fellows, and they, in turn, are forced to rely on him. There is then, perforce, a bond of reciprocal dependence linking teammates to one another# When members of a team have different formal statuses and rank in a social establishment, as is often the case, then we can see that the mutual depen dence created by membership in the team is likely to out across structural or social cleavages in the estab lishment and thus provide a source of cohesion for the establishment (1959-^2). In The Organization Man Whyte stated, "People don't co-operate just to co-operate; they co-operate for sub stantive reasons, to achieve certain goals, and Unless these are comprehended, the little manipulations for morale, team spirit, and such are fruitless" (1 9 5 7:439-44o). Sherif and Sherif concluded from their studies of group interaction that interdependence must be perceived 8 for the attainment of solidarity: Harmony and tension between groups is determined at the same time by the nature of functional relations between groups* As with solidarity and morale within in-groups, it is necessary in intergroup relations to have an actual and perceived condition of interdepen dence for theattainment of common goals which are inherent and real in the process of living and inter- In A Manual of Intergroup Relations Dean and Rosen made the following observation: "Major changes in indi vidual prejudices occur most quickly and thoroughly from exposure to social interaction in a new social environment rather than from information and exhortation alone" (1955: 93). Dean and Rosen (1955:61, 91) saw leaders of an institution as a force for altering intergroup practices in the institution within a wide range of community customs. %ey also claimed that a newcomer to a new nonsegregated environment takes his cues for interaction from the regular participants and that the new forms of interaction may then be more significant in regulating his behavior than his past experiences. These are both Indications that norms may develop within the one group about the intergroup situation. Leavitt ( 1 9 5 8: 29 7), among others, conceived of a as a social role a person has to fill. Whyte (1 9 5 5: 22 2) analyzed the factors that contri- 9 bute to a worker's position in a plant and found them to be economic status and social status with an overlap of the two, plus skills required and productive importance. Dalton's (1955:41,45) observation that "rate- busting" is a characteristic of company-oriented workers in a factory suggested comparison with some optometrists* "rate-busting" proclivities in a medical group. Blau's ( 1955) excellent description of social behavior in an office situation Indicates possible approaches to status perception in situations similar to the present study* Mills perceived new professional work situations as follows: As the old professions and the new skills have become involved in new middle-class conditions, pro fessional men and, women have become dependent upon the new technical machinery and upon the great institutions within whose routine the machines are located. They work in some department, under some kind of manager; while their salaries are often high, they are salaries, and the conditions of their work are laid down by rule. What they work on is determined by others, even as they determine how a host of subprofessional assistants will work. Thus they themselves become part of the managerial demi- urge (1953:114). Homans reminded us: . . . institutions do not keep going just because they are enshrined in norms, and it seems extraor dinary that anyone should, ever talk as if they did. They keep going because they have pay-offs, ulti mately pay-offs for individuals (1961:390). 10 Analogous Tfiere is a sufficient body of contemporary socio logical investigation of medical and ancillary fields to be of value in indicating areas for awareness and possible similarities in the kinds of relationships to be discussed*' It would appear from this literature that the most parallel situation to the ophthalmologist-optometrist relationship is that of the psychiatrist-psychologist* Thompson, in considering entreprenurial specialists such as physicians, concluded: * * * the advance of specialization will force them all into organizations eventually--in the case of medical doctors because specialized equipment would be too costly for an individual to own and because the health of the patient will require the co ordinated services of many specialists (l96l:2l)* The consequences of specialization and the related change of practice organization have been touched upon by Sommers and Sommers: are well known and often proclaimed* The price of specialization is less often acknowledged* But frcm it stem most of the pressing problems and controver sies in the organization and financing of medical care today: the increasingly difficult role of the general practitioner, the trend to hospital, the conflict over "corporate medicine," the conflict over "solo" versus group practice, the changing character of the doctor-patient relationship (1961:8). Becker observed, "... any change in institutional practice has many and varied ramifications, so that its consequences could not be restricted to the specific areas 11 the innovator wants to affect" (1963:443). Caplow stated, "It is chiefly in comparison with other professions that each professional group exaggerates I its-own importance and deprecates its own rewards, so that ' interprofessional cooperation is sporadic at best" (1954: 13 1). A survey of optometric and ophthalmologic writing in the competitive framework is consistent with Caplow*s statement (see Chapter IV). Lortie, in his study of the development of the professional roles of anesthesiologists, wrote, ". • * a system of specialties depends in large part upon the ability of the specialists concerned to demonstrate their special value in the daily work of the profession" (1958: 412). i In reporting on the practice of pairing student I ! nurses and student physicians in a cooperative approach , to patient care, Ingles and Bogdonoff stated: Although initially the residents, interns, and student physicians reacted unfavorably to the student nurses assuming a colleague role and resisted accept ing them as associates in patient care, today this role is taken for granted, nurses are expected to i function as associates, and the role appears to have : been institutionalized as appropriate (1963:180)# ' A related statement on physician-nurse relations was made by Schotfeldt; 1 Scientific advances and technologic developments have brought about significant changes in medical ' practice and in health care services. Unless the 12 roles of both physician and nurse are examined and their functions critically assessed in light of modern concepts of professional practice, neither profession is adequately fulfilling its responsi bility to patients, to society, or to the profession Itself (1 9 6 5: 7 7 7). Wilensky wrote: The competition among clinical psychology, psychiatry, and other brands of psychotherapy for the right to practice therapy is typical. But even more clearly technical occupations, like medicine, find themselves doing battle with marginal prac titioners— with peaceful absorption as one outcome (osteopathy) and all-out war as another (chiro- pratic) (1964:145). Zander, Cohen, and Stotland, in Role Relations ii the Mental Health Professions, explored the relations. occupational groups when they are employed together in institutional practice* If the members of a certain profession expect and accept specific relations with others, this acceptance does much toward eliminating strain in role relations* It is therefore more in^ortant to change role re lations by reorganizing role prescriptions than to attempt to change attitudes by discussion or per suasion alone (1957:154). Pearsall stated, in a preface to a bibliographical compilation of writing in medical behavioral science: Today there is a large and expanding literature on most major professional roles (physician, nurse, medical student, nursing student, and ancillary personnel) and on the principal organizational con texts (mental hospitals, general hospitals, sanitaria, out-patient clinics, and more recently "halfway" houses and various types of therapeutic associations)• Dentistry, however, has been almost totally ignored except for a few recent studies of dental students (1963:viii). Optometry, too, has been largely ignored in this literature, and it appears particularly timely to consider it in relation to a new setting. Sociological study of the profession of optometry is scant. The inclusion of the statements of military physicians in this section may appear to be a one-sided paean to the optometric role in the military medical situation; however, the statements are included because they are relevant to the thesis. Military physicians and military optometrists are mutually involved in nonfee-for- service practice. The official pronouncements of these high ranking military physicians in regard to optometry is at variance with official medicine's attitudes outside the military. Some of the contentious aspects of opto metric -ophthalmologic relations as they appear in the literature of optometry and ophthalmology are shown in Chapter IV. Here we have, then, the setting for a crucial test of the second hypothesis. In Sociological Perspectives of the Profession of Optometry Orzack and Uglum suggested an approach for the analysis of the profession of optometry. Tentatively for mulated questions are presented, as are speculative answers. The intent of the paper was "to present a per spective of selected aspects of the profession of opto 14 metry" (1958:407). They stated: Attention has been directed recently to the de velopment of pre-paid and insurance plans of group care and health centers, where optometrists may or may not participate with other specialists in inter professional relationships. These shifts in the structural context of optometry, to the extent that they are occurring in various settings, may touch off significant changes in optometric practice, so that it is less typically an independent practice (1958: 413). In an issue of The Journal of the American Optomet ric Association concerned chiefly with military optometry, the following statements of high ranking military officers, of whom the first three are physicians, appeared : The Army Medical Service Corps optometry officer has a vital role . • . (Heaton 1966:336). The Navy Medical Department is proud of the splendid optometric services which it provides and which are so important to the accomplishment of its mission (Brown 1966:339). The importance of optometry in the medical mission (USAF) is well recognized by the directors of base medical services and their staffs (Bohannon 1966:342). A tremendous burden of responsibility is thus placed upon the shoulders of Army Optometry Officers. This responsibility is consistently discharged with professional competence, dignity, and a sense of purpose unsurpassed in the Army Medical Service (Hamrick 1966:337). In an issue of The Journal of the American Optomet ric Association concerned with public health optometry, Silberstein, in writing about the civil service optomet rist, stated: ... an essential requisite for success in his 15 position is his ability to develop a rapport with all personnel levels, subordinate or supervisory. His frequent contacts may include medical officers, internists, ophthalmologists. Industrial hygienists, safety specialists, management administrators, nurses, technicians, hospital aids, clerical personnel . . Haffner in the same issue, in writing of "Health Care Organization— The Next Frontier in Health," stated: The creation of new specialties, technologies and instrumentation bring a greater interdependence of one practitioner upon another and all of them upon a centralized facility . . . Group practice, the hospital as a health center, and the interdisciplinary health team as a reality rather than a myth represent the next major breakthrou#i in the growing health utility (1966:1016). Summary Throughout the general literature concerned with division of labor, role relations, occupational special ization, and relations of groups there appears to be agreement that the mutual dependence created by membership in a team is a cohesive force, but that a common goal must be perceived and comprehended by members of the team. Technical and economic factors may be the impelling reasons for creation of teams, especially in production, but the consequences lead to modification or restructuring of social relations between the involved individuals and/or groups. Tiere is agreement that occupational careers, in cluding medical practice, are increasingly being pursued in organizational milieus. CHAPTER III The Optometry Department of a prepaid medical group was observed from 1954 to 1967* While observation extended over a thirteen-year period, the problem for study was not formulated until 1965# ®ie techniques used in gathering information were observation of formal and informal behavior of the optometry staff and of other personnel including physicians; nurses, technicians, lay-assistants, and medical and non- medical administrators in the medical group, and dis cussions with these individuals singly and in groups. Also, records were examined that included clinical charts, statistical records of patients seen, correspondence of optometric patients with the administration, administrative memoranda that pertained to the eye service. To further test the validity of the assertion that a division of labor in a nonfee-for-service and noncompet itive setting is likely to produce a satisfactory and harmonious relationship, it was obvious that a broader 16 17 testing of the thesis would enhance the case description of the one setting considered in some detail in this study. There were not too many other examples extant of a similar practice arrangement, and further, the criticism could be raised that such group practice arrangements tend to be selective and not representative of the professional population. Because of ophthalmology's greater prestige the assumption is made by the researcher that optcaaetrists are more eager than are ophthalmologists for acceptance by the other group. A study of the mental health professions revealed this to be the case in comparing psychiatric social workers and psychologists with psy chiatrists (Zander ejb al. 1957 239* 40, 62, 6 3}. The researcher was of the opinion that a demon stration of a shift in attitude on the part of ophthal mologists as a consequence of functioning in a pro fessional division of labor situation similar to that at Glenway (the setting for the case study) would strengthen the thesis, especially if the situation was not deliber ately sought by the professionals involved. Such an analogous professional situation exists in military service. A questionnaire was sent to ophthalmologists throughout the nation to explore the change in attitude that military professional experience with optometrists 18 could be expected to bring about* (For copy of Questionnaire and cover letter, see Appendix*) In an attempt to ascertain the attitude of oph thalmologists toward establishing a working relationship with optometrists, the questionnaire was sent to 306 ophthalmologists in fifty states and the District of Columbia. Twenty-five questionnaires were sent out in December 1966, and the remainder were mailed in January The selection, obtained from the American Directory of Otolaryngologists and Qphthalmologists ( 1966), was a systematic geographical sample (not based on numerical distribution) and the mailing averaged six ophthalmologists in the fifty-one geographical entities, of whom four were diplomates in ophthalmology and two were nondiplomates. Where the number of communities and/or practitioners was sufficient, one ophthalmologist was selected from each of six communities within each state. A slight alphabetic bias existed in selecting from communities in some of the largest states. The total number of medical eye practitioners in the United States is 8,427 (Joumal of the American Medi cal Association 1966:899). of whom 4,798 are certificated, i.e. diplomates of the American Board of Ophthalmology (Directory of Medical Specialists I965-1966). Licensed optometrists nimber 20,610 (Blue Book of Optometrists If the questionnaire distribution had been according to population density, obviously more question naires would have been sent to urban areas of concen tration. %is was avoided because of the possibility that recipients may then have responded according to the attitude with vdiich the local professional society viewed the questionnaire, or conceivably the position may have been not to respond at all. GHAPŒR IV BAGKCmOUNP OF OPTOMETRIG-OPHTHALMCmOGIG RELATIONS The history of relations between medioine and optometry (or more specifically between ophthalmology and optometry) is interspersed with periods of cooperation and noncooperation> more usually the latter, with medicine as the more dominant group usually calling the play. The following excerpts, taken from journals of both professions, are but a few of many statements of both groups which have appeared over several decades, and which still appear today. The statements have varied from irate professional selfri^teousness and an extreme narrowness of view to an expression of a desire for seme rapprochement, the latter view more rarely propounded by ophthalmology than by opt one try. An attitude of suspicion and concern for the possibility of the other group's infringement has been a theme ccanmon to the writings of both groups. Ophthalmologists have stated; ... many optometrists desire to perform refractions, make fundus examinations, test visual fields, give orthoptic training, fit contact lenses, serve as consultants for medical practitioners, and to attain medical recognition of the title "Doctor”. Some would eliminate ophthalmologists from all of the Visual fields except surgery and medical treatment. The extreme ophthalmic point of view would be the elimination of optometrists from all fields and, on the other hand, no ophthalmologist would accept all of the suggestions of the most radical optometrists. Put in that light, the differences might seem insur mountable, but fortunately, in our democratic state there is a certain amount of give and take and a willingness to see the other fellow's point of view. Some compromise in these visual matters is essential to public welfare. Leaders of both groups should meet without ani mosity, in friendliness, and on an equal footing and, bearing in mind primarily the visual welfare of the public, should iron out their differences (Post 194?: 82-r It is a most difficult task implementing resolu tions pertaining to optcmetry because it involves the work of collecting information, writing reports, conducting a voluminous correspondence, and being ever alert to the possibilities of inroads into the practice of medicine by optometrists. It is obvious to most all of us that militant and aggressive action must be taken along these lines in view of the increasing aggressiveness on the part of optometry to interfere with the practice of oph thalmology and to take over some of its activities along medical lines (Vail 1956:874-875). There can be no justification for singling out the patient with ocular complaints for management by one with less training than the physician's. This is the issue between medicine and optometry (Jaeckle Optometrists have stated : We believe that medicine has no more professional or moral right in the field of refraction than optometry has in the field of medicine. We believe the time has arisen for optometry to step out of a defensive position into an offensive position and remain so until the field of nonpathological eye care is relinquished by medicine and assumed in its full scope by optometry (Southern Optometrist 1951 : 22 Resolved, sixth, that optometry believes that the fields of ophthalmology and optometry are broad and sufficiently defined to permit both professions to engage in interprofessional relations so that the public will enjoy the benefits of such relationship and continue to receive the best visual and eye care in the world (Koch 1955:433). It seems only a short time ago that optometrists were accused of being unable to recognize pathology* Now they are accused of encroaching upon medicine by knowing too much about pathology* Yet, at no time has any accredited optometric spokesman suggested that optometrists do anything with their knowledge of pathology other than to refer for ophthalmological care (Hirsch 1956:45). At present, official relations between ophthal mology and, optometry are nearly nil* Physicians have been constrained by resolutions Nos* 77, 78, and 79 of the American Medical Association (Journal of the American Medical Association 1955:938-939) from associating inter- professionally with optometrists, and this constraint has included relations in professional practice which could imply professional recognition of optometrists, to participation in optometric education* Although the resolutions of 1955 have colored most ophthalmologic- optometric relations, the taboos have not always been rigidly adhered, to in specific relationships between individual practitioners* Also, physician lecturers are found, on the faculties of optometric colleges and at optometric postgraduate seminars* Civil Service and, the Military Service are further examples wherein physicians and. optometrists are found, in mutually recognized, prof es- A recent resolution of the American Medical Association, June 1966, contains the following statement: The improvement of educational standards of optometry is a laudable objective. Doctors of medicine may as teachers participate in the education of optometrists within the legitimate scope of optometric practice (AMA News July 1 9 6 6: 8)* It should be stated, however, that in the recent (a little over a decade) period, ophthalmology and optometry have not been cooperating officially. This statement must be tempered by the exception of a few rare Instances where "gentlemen's agreements" or dis cussions have occurred unofficially between official In the light, then, of the situation that generally prevails, it is of significance to explore relations between ophthalmologists and other medical specialists on the one hand, and optometrists on the other, in a prepaid group setting where the organization goal would require mutually cooperative endeavor. CHAPTER V CASE SETTING The Keystone^ Medical Care Program is an organi zation whose "primary purpose is to organize medical services for the public on a pre-payment basis at costs which families with average incomes can afford." The Western Glenway^ Medical Group is one of the four independent and autonomous medical groups which bears the Glenway name and which contracts with Keystone Health Plan to provide professional care for Health Plan members within a given geographic area. A third organi zation in the structure of the program is the Keystone Hospitals, which contract with the Health Plan for hospitalization of members. 1 The Metro City unit is the largest of five area units in a section of the state and consists of a 345 bed hospital (soon to be expanded) and two large buildings near the hospital with outpatient offices for the various specialties. In addition there are other smaller clinics around the city, usually staffed, by general practitioners In this paper the names Keystone, Glenway, and Metro City are pseudonyms. 24 or internists* The eye clinic occupies most of the space on one of the floors of an outpatient building. A directory of physicians and optometrists who have offices on that floor is placed near the elevator where it can be seen by patients exiting from the elevator at that floor* The list of names is in alphabetical order, with the degree designation after each name* There is an eye reception area and an eye appointment desk and chart room area which serve both optometry and ophthalmology. A corridor lead ing to waiting rooms separates the departments of opto metry and ophthalmology* Each department has its chief, but the chief ophthalmologist is Chief of Service which Includes all aspects of the eye service * At one end of the corridor is the optical dispensing area. %e nurses* station is situated In the ophthalmology wing. Patients alight from the building elevator, report to the reception desk for formal registration, and are then directed to the appropriate waiting room to await being summoned by the doctor* Nurses sumon the patients for the ophthalmologists, whereas optometrists summon their patients personally by appearing at the waiting room door and calling the patient's name. An average of just under 3,000 patient visits per month are credited to the optometry staff alone. Opto- 26 metrlsts are scheduled for seventeen refraction appoint ments per day, but because of last minute cancellations actually average fifteen refractions per day. A slightly lighter caseload is assumed by those engaged In visual field examinations, visual training evaluations, or the fitting of contact lenses. Before the patient leaves the clinic another appointment may be made at the appointment desk if it has been suggested* There are the following type and number of personnel within the eye clinic itself with whom the optometrists (nine full-time, one part-time, all male) may integrate daily: 1. Ophthalmologists (five full-time, three part- 2, Nurses (five, including the supervisor) 3* Receptionists and appointment desk personnel 4. Chartroom personnel (two) 5. Optical dispensers (six, including the super visor) 6. Other optical technicians (thirteen) Categories 3 and 4 have somewhat more interaction with optometrists than with ophthalmologists as nurses are usually interposed in ophthalmologists * relations with 27 more contact with optometrists than with ophthalmologists, as it is the optometrists who are primarily concerned with prescribing lenses. Other optical technicians are seen by optometrists much less frequently. (The ratio of ophthalmologists to optometrists Is somewhat higher at the Metro City facility of Glenway than at the other four Glenway Medical Centers. The population served at Metro City has a higher average age and hence a greater incidence of ocular pathology. Further, the Ophthalmology Department at Metro City functions In a consultative capacity to the other centers.) As has been stated, nurses are situated In the ophthalmological area and assist ophthalmologists Appointments are made in advance for patients with both optometrists and ophthalmologists and the clinic is essentially an appointment practice* Generally, the longer a practitioner has been with the organization, the greater is his personal following and hence the greater is his percentage of personal request appointments. Ophthalmologists see "walk-ins" when necessary. These latter are cases which may constitute medical urgencies. Similarly, optometrists may see "walk-ins" when referred by ophthalmology for an immediate visual field examin- ation or other necessary visual appraisal, and opto metrists may authorize their own "walk-in" appointments when necessary* In general, all routine examinations (refractions) are seen initially by the optometrist ; the patient Is referred by the optometrist to the ophthalmology depart ment only when the optometrist is of the opinion that an ophthalmological consultation is indicated* The recep tionists and the women at the appointment desk telephones are skillful In screening refractions from conditions requiring ophthalmological attention or treatment * The system of channeling the patients to either optometrists or ophthalmologists is fairly accurate; In addition to appointment and reception personnel, nurses may also participate In this screening process by telephone or in personal confrontation with patients* A patient's direct telephone conversation with either an optometrist or ophthalmologist will also screen the patient for proper referral* There Is In addition the factor of the patient's own self-screening for consultation* Errors in referral are simply redirected by the optometrist or ophthalmologist from one to the other* Nurses tend to run the clinics in that they are concerned that the scheduling operates smoothly. The number of patients to be seen is in general established by agreement of the medleal director and the chiefs of the various services; in the case of the optometry department, by the chief optometrist in agreement with the chief ophthalmologist and the medical director* In the eye department, the clinic supervisor (an R.N.) and the charge nurse both work at supervising the scheduling of patients in accord with the agreed upon patient load* Although the approach of both is oriented to smooth functioning, to placating patients and sometimes doctors (M.D.*s and O.D.»s) when variations occur, a subtle difference in the approach of each has been observed. One may be said to be more protective of the patient * s time and convenience, the other of the doctor's. This minor conflict, however, tends toward an equilibrium. The most efficient use of the physician's time is made possible by organizing the facilities and per sonnel so that the physician is given optimum tech nical support and, is relieved of non-professional tasks. Thus the doctor * s time is so arranged that he may utilize his training to the maximum while working ... (Western Glenway Medical Group Manual for Prospective Physician 3taff^embers 1963). Although the fields of ophthalmology and optometry do overlap, the clinic pattern in this group is consistent with the general policy of "the most efficient use of the physician's time." Each works at his maximum skill level; ophtlialmologists are chiefly concerned with diseases of the eye, their diagnosis and therapy; optometrists are primarily concerned with the nonmedical aspects of vision. 30 with the analysis and measurements of visual functions, with the correction of refractive errors and muscular imbalances; opticians are technicians who work on the fabrication of spectacles and their adaptation to the patient (theirs is largely a mechanical skill and is centered mainly on an appliance, spectacles, as prescribed by the optometrists). In the operation of the clinic, the two distinct professional occupations, ophthalmologists and optome trists are not usually diverted by concerns which can be delegated to others; the optometrist rarely becomes involved in opticianry, nor the ophthalmologist with The nature of clinic operation makes for a close professional relationship between ophthalmology and optometry* Optometrists refer pathology cases to the ophthalmologists and the ophthalmologists refer patients to the optometrists for refractions, examinations of the visual field, the fitting of contact lenses, and orthoptic The key role of the optometrist is patient care However, there are several aspects of this role: 1* Primary practitioner a) In this aspect the optometrist is also a writer of reports, letters, and a telephone consultant 2. Ophthalmological assistant and/or consultant 3* Consultant on referrals from other services It is in role aspect "2" that conflicts occasion ally arise. Some individual ophthalmologists prefer that the optometrist assume full responsibility and behave in role aspect "1" in a case referred by the ophthalmologist where the patient is undergoing treatment or diagnostic work-up; other ophthalmologists prefer that a referred ophthalmological case be returned with a complete opto- metric report of findings but with discretion as to application of these findings left to the ophthalmologist who is treating the patient. The problem can be stated simply that some ophthalmologists expect the optometrists to apply their skill and decide whatever in their judg ment should or should not be done refractively for the patient; others want to review the findings and decide themselves what shall or shall not be done with their patients. The optometrists come to know the expectancies of role of individual ophthalmologists ; also ophthalmolo gists who generally expect the optometrists not to exer cise their own responsibility in application of their findings to patients under ophthalmological therapy may vary their attitudes depending upon familiarity or long association with specific optometrists. The overlapping of functions of the two kinds of eye practitioner, the optometrist and, the physician, is thus resolved by the daily interaction of the two, by an accommodation of both groups to each other as groups of practitioners and. also as individuals with idiosyncrasies* Professional conflicts or real or imagined usurpation rarely arise, When they do, these differences are dis cussed directly by the practitioners involved or through the intercession of the chief optometrist or chief ophthalmologist, or both. An association of ophthalmologist and optometrist in private practice is almost invariably a situation in which the ophthalmologist is the e%#loyer, the dominant practitioner, the "doctor," and the optometrist is his more or less anonymous technical assistant. A goal in private practice, of course, is the establishment of the ophthalmologist as a successful, known practitioner. The division of labor in a prepaid medical group in which the professional participants are either partner ship associates (in the case of most of the physicians) or salaried professionals, results in a type of care which depends upon the "team" approach. Theoretically, private practitioner specialists would likewise be dependent upon each other in rendering health care. However, without the "organization," there are obstacles to the development of strong cohesion of various specialists; for status and/or 33 economic considerations there is often rivalry among specialists, i.e., physiatrists and orthopedists, inter- psychologists, ophthalmologists and optometrists. A reluctance to "share" the patient may cut across all specialty lines. In the clinic setting optometrists are often involved with the application of their skills to patients who are under ophthalmological (i.e., medical or surgical) treatment or surveillance. This occurs commonly in the clinic situation as contrasted with private practice and follows from the division of labor. It is primarily within the framework of prepaid group organization that the division of labor becomes a bond of mutual dependence of specialists. In the multispecialty group, in which an open relation exists among participants of all special ties, there are no economic Incentives for the physician to practice beyond his capabilities. Instead, he encounters no barriers to consultation, referral or assistance, and finds that a colleague's opinions and evaluations of medical problems are easily obtained (Gutting 1963:732). As has been stated, in private practice the official View of ophthalmology would place optometry in an extremely subordinate and practically nonprofessional ranking in the professional social system* The conditions of prepaid group practice secure for the optometrist a relatively stable niche in the organization with prestige Just below that of physician, but with recognition for his skill and for his contribution to the therapeutic The income for optometrists as a group in the organization is below that of physicians in the organi zation* This income difference derives from the same general monetary differential in outside practice and from the fact that optometric training (six years or more) is of shorter duration than medical training* Whyte stated : Let us say that the workers* position in the plant is a function of two factorsl his economic status and his social status* * * * we mean by social status, the prestige people attach to jobs in the plant. %iis prestige comes from the skill required by the job, from its impor tance in the production process, * • * from the money the job pays, and from other factors. Note that there is an overlap between these two concepts, since social status is affected by the money the job pays. On the other hand, the pay rate or earnings never completely determine the prestige attached to a job (Whyte 1955:222-223). It cannot be stated that the optometrist has always had a constantly clear and. secure position in the social structure of Glenway Medical Group. For the most part, however, the situation has been good when viewed against the varying disequilibrium of relations in private practice. The administration, the chief ophthalmologist, and the chief optometrist are concerned with the estab 35 lishment of a pattern of interrelations among the parti cipants in the system that will be effective in the reali zation of the organizational goal* %e basic requirements of the organization have always been met. This is a new pattern of practice and the initial emphasis of the ad ministration has been on meeting basic requirements in an innovâtional and rapidly expanding organization. It is mainly in recent years that the effactivity of the interrelational pattern in the eye service has been a focus of interest on the part of the administration and It appears that the present optometric staff has acquired greater status stability than heretofore. An important factor in this development is the constant utilization of the chief optometrist as a department head by the ophthalmologists, the nurses and lay assis tants in the clinic, the medical and managerial admini- Aside from differences in length of training, differences in historical precedents of prestige, differences in responsibility (the physician is expectedly more involved with disease processes in the patient), there is another status difference which exists in the organization that is dictated by medico-legal necessity; the Glenway Medical Group is a partnership of physicians. 36 and physicians become eligible for election to partnership after three years of service as a salaried employee. No optometrist may bec<me a partner, but this also holds for other nonmedical categories such as psychologists or biochemists, the reason being that limited qualification or limited licensure does not permit of the sharing of responsibility for all therapy of all parts of the human Improvement of work satisfaction of the staff was one of the goals of the chief optometrist. One of the regulations made operative was a definite limitation of time a patient could be late for an appointment beyond which the optometrist would not be required to see the patient, and a definite limitation of time in the event of a cancelled appointment or a patient's failure to appear beyond which a "fill-in" appointment could not be substituted* Because all work days in professional work are not alike, the receptionists are instructed to telephone the optometrist in the event of a "borderline" late arrival of a patient and to inquire whether his schedule situation will permit him to see the latecomer. Often the patient cannot be seen at the time, but frequently the optometrist agrees to see the patient. The individual! optometrist is the judge of the feasability of seeing the 37 patient under those conditions* There are also occasions when a "walk-in" patient (one without an appointment) may wish to have a brief discussion with his optometrist (as in the case of a patient who is experiencing some distress after having just obtained his new glasses at the dispensing depart ment) • These are infrequent requests on the part of patients, and the optometrist will see these individuals provided that his schedule that day will permit him to do so* It is significant that the safeguards instituted against too great pressure on the optometrists and the granting of some degree of control of the work situation to the individual optometrists have not resulted in a decrease in the number of patients seen; on the contrary, patient statistics show a slight increase and staff morale is definitely higher* An important factor in work interest has been the increased opportunity to specialize in part. In addition to the routine type of optometric clinical examinations (refractions), three of the men do visual field examin- ' ations (a detailed exploration of the patient's total extent of visual response in all directions and a corre lation of defects in the field of vision with ocular, neurologic, or general pathology affecting vision), two 3S1 are engaged in visual training (training to improve binocular coordination), and three are engaged in the fitting of contact lenses (contact lenses are fitted in the clinic at this time for therapeutic reasons only, such as in postoperative cataract or irregular cornea, but not for cosmetic reasons)# In a professional group, work satisfaction may be closely tied to a feeling of "professionalism" and nity of the individual* In observation of staff optome trists* attitudes, an increase in satisfaction reflected itself in an increase in professional self-esteem which in turn positively affected attitudes toward the organi zation and interprofessional relations with teammate ophthalmologists. Hie extent to which members of an organization seek each other out during lunch or free periods can be an indication of cohesiveness (Blau 1955:61)* Hie follow ing report is a day-by-day account for four weeks of the informal lunch groups which included optometrists that formed in the cafeteria in the building housing the clinic* The medical specialties in the building (aside from the eye section) are psychiatry, neurology and neurosurgery, gynecology, and physical medicine* The clinic work day for optometrists starts one- half hour earlier than that of ophthalmologists and most 39 of the other medical specialists mentioned above, hence most of the optometrists are usually in the cafeteria slightly earlier than the medical specialists. Other medical specialists whose clinics are located in buildings nearby, but who are listed in the lunch groups below, are occasional visitors to the building cafeteria. Although all the professionals mentioned, in cluding optometrists, may be detained by professional considerations from arriving at lunch on time, the opto metrists are somewhat more regular in their appearance at the cafeteria because their work is usually confined to the clinic, whereas the physicians may be at the hospital or at other facilities. Members of the psych iatry department (including psychologists and social workers) tend to group together almost exclusively at lunch. Instances of individual optometrists lunching with groups other than their colleagues do occur but are not reported below. Four members of the optometric staff have a week day afternoon off and each usually leaves without lunching at the clinic on his free half day. Also, personal errands occasionally keep the optometrists from lunching at the cafeteria. At times, two or more optometrists will lunch together in an outside restaurant. The cafeteria regularly serves approximately 40 350 persons at lunch dally, including professional personnel, employees of the medical organization, and some clinic patients whose appointments occur around the middle of the day. For composition of lunch groups of optometrists observed in the building cafeteria over a four-week period (twenty working days) see Table 1. It can be seen from these figures that ophthal mologists are the occupational category most frequently found lunching with optcmetrists (on twelve occasions out of twenty observations) and that nurses (usually eye j nurses) are the second in frequency (ten occasions out of I twenty observations). I Not all of the optometrists take a coffee break at about 10:00 A.M. and 3:00 P.M. daily, but all the ophthalmologists generally do, and on these occasions the two groups will almost invariably be found together. In ten observations made of coffee break periods, both categories were found together each time. No attempt was made to determine the extent of social relations after working hours of optometrists with other personnel, but it is apparent from conver sations with optometrists that these do occur. A note may be added on optometrist-nurse re lations. In 1955 an optometrist in the clinic was 41 table 1.— Composition of lunch groups of optometrists observed in the building cafeteria over a four-week period (twenty working days) 1 chartroom clerk (eye) 1 receptionist (eye) 1 optical dispenser 3 optometrists 1 2 ophthalmologists 2 nurses (eye; 1 nurse (eye) 1 appointment secretary (eye) 1 receptionist (neurology) 1 ophthalmologist 1 4 2 1 1 1 optometrists pediatrician neurologist pathologist 4 2 nurses (eye) 2 receptionists (eye) 6 optometrists 1 ophthalmologist 7 optometrists 3 optometrists 1 neurosurgeon 2 nurses (eye) 3 optometrists 2 physiatrists 1 ophthalmologist 2 nurses (1 eye, 1 neurology) 6 optometrists 2 ophthalmologists 4 optometrists 1 ophthalmologist 1 nurse (eye) 1 ophthalmologist 1 nurse (eye) (2 optometrists separate table, alone) 5 optometrists 1 ophthalmologist 3 optometrists 1 ophthalmologist 1 chartroom clerk 1 appointment secretary (eye) 2 nurses (l eye, 1 neurology) 3 ophthalmologists 1 nurse (eye) 4 optometrists 2 nurses (eye) 2 receptionists (1 eye, 1 neurology) 1 appointment secretary (eye) 4 optometrists 3 ophthalmologists 1 optical dispenser 42 observed to make a simple but unavoidable request of a nurse in relation to a patient only to be met with an intense and extremely hostile rebuff: "I don't take my orders from anybody but doctors1" (meaning, of course, physicians). It is true that the nurse in question was an extremely hostile individual and had troubled re lations with most of the personnel in the department, including her nurse colleagues, but it is unthinkable that any nurse could have manifested this attitude since 1956 or 1957, when long familiarity and professional understanding of each other's roles began to increase bonds between optometrists with nurses and ophthalmolo gists. Althou#i as individuals optometrists and nurses appear to find each other agreeable, which may partially explain lunching together, their professional relations appear smooth and mutually respectful, and there is a pro fessional bond underlying their "shop talk." This kind of easy, coffee-break relationship has been observed else where among student physicians and student nurses in a co operative setting: "... and during those pauses between clinical activities they sat down together, drank coffee together, and talked, about their patients" (Ingles and Bogdonoff 1 9 6 3: 181). This is of interest in relation to optometrists, because traditionally nurses acknowledge physicians as the only primary practitioners in patient care. "The ideology of the nurse will not permit her easily to accept the competence of people other than herself and the doctor to deal with patients" (Wessen The professional attitudes of physicians undoubt edly influence the attitudes of nurses. Optometrists at Glenway participate in the education of nursing trainees from a local college who are assigned to observe all department activities at the institution. The optomet rist * s function in this instance is to give the nursing students an insight into the optometric activities in GIÎAPTER VI CHANOES WITHIN THE OPTOMETRY DEPAR’ PIENT In the flztst few years of the institution's existence the optometry staff numbered two to three members who were part-time or who, at best, regarded their employment as transient* In 1954, when the inves tigator's contact with the organization commenced, there were two full-time and four part-time optometrists of whom each of the latter worked from one to three days a week* Through the years the number of full-time staff gradually increased, as did the benefits for full-time personnel* Morale within the optometry group, however, varied considerably, but could never be considered as high* Although the optometric staff was working for the institution, as a group they did not consider themselves as belonging in the same sense as other professionals. All felt that it was necessary to be always alert to outside opportunities that could arise. Indeed oppor tunities did frequently arise that attracted men away from organizational employment * In the two-year period from December I96I to December 1963, with the full-time staff numbering six individuals, there was a 50 per cent turnover of optometric full-time personnel. 45 With the earlier optometric staff of the clinic (pre-1965)> most of the staff had professional ccmanlt- ments outside their clinic employment, either In their own outside practices or In association with outside practitioners. The attitude prevailed that what one could develop or earn outside the organization was of greater Importance for one’s future than what one did In the organization. It was known by the optometry staff members that more than one optometrist had, used sick leave time (granted only for Illness) to attend to other prof essional commitments. The organization was generally regarded as a temporary phase of the individual’s career. ! Those who really liked prepaid practice were disillusioned about what they regarded as their social and professional location within the medical group society. The role of the optometrist began to change In early 1965 with the appointment of the present chief optcmietrlst. Concurrent with a proscription of outside professional commitments came a doubling of the annual incentive dividends that optometrists with over two years’ service had been receiving. This combination of limiting professional commitment to the organization and rewarding this commitment with a greater share of the organization’s financial returns has shaped the optometrist’s role In the organization more closely to the physician’s role. Staff ____________________________________________________________________________ i physicians In the group have never been permitted outside The orientation of the foamier optometric staff had been largely In the direction of rapid patient hand- I ling; at present, the orientation Is Increasingly ; 1 centered on goals other than the rapid Impersonal expediting of patient visits. The Introduction of greater professionalization with emphasis on quality care has had Interesting concomitant developments* Ihere has been an Increase In on-the-spot consultations^ between optomet rists; there Is a greater tendency to act In a consult ative capacity when seeing patients who are under ophthalmologlcal supervision rather than as mechanically responding assistants; that Is, there Is a greater frequency of response as professional consultants with opinions and Insights which may be noted on the chart or discussed directly with the referring ophthalmologist; note on the social reciprocity of consultation: Blau ( 1955)f In his study of a Federal Agency, showed that the agent who Is a consultes gains advice but acknowledges his Inferiority; the consultant, on the other hand, gains prestige but at the cost of some disruption of his own work. The questioning agent Is able to perform without exposing areas of Ineptitude, difficulty, or Ignorance to his supervisor. Among optometrists, however, as with physicians, a consultative request Is not an acknowledg ment of Inferiority, In fact Is usually considered a sign of professional commitment and Interest. A consultation Interaction Is not hidden from higher administrative authority, but Is highly regarded by that authority. J 47 there Is a significant decrease In patient complaints reported to the administration (personal conversations j with administrators). The Increased professionalIzatIon j of the optometric staff has been responsible for increased’ i Interaction with ophthalmologists. Professional exchange occurs more readily when orientations are presumed mutual. At the time just prior to prohibition of outside practice. In early 1965> there were two part-time opto metrists and eight full-time optometrists on the staff. Of the eight full-time men, three were strongly oriented In the direction of full-time careers with the organi zation, one was uncertain about which course to follow, and four were obviously using the Institution as an Interim stage In their professional careers. In the case of the three pro-organisâtIon men and the uncertain Individual, their attitudes were that professional life In the organization could be a satisfactory arrangement If the organization were somehow different, i.e.. If there could be assurances that the work schedule would not be Intensified beyond that of a proper professional norm. If they could look forward to longevity or merit Increases In remuneration or preferably both. If their participation and status In the organization would Increase. It Is significant that of the four aforementloned 48 staff members (those who had intended to make careers in the organization), three had outside professional commit ments . They stated that they were not pleased with what they regarded as the necessity to maintain these "moon lighting” commitments. In fact, were resentful of the after-hours time these situations required. They felt, however, that their insecurity in the organization and the additional monetary gain made these activities essential. The other four optometrists were frank about their lack of organizational commitment and their greater con cern with outside professional activity. It is signifi cant, too, to note that these latter four were less concerned with the weight of the professional schedule than were the other men* They had stated that they would be willing to work under an Increased patient load for additional remuneration In spite of the fact that the workload would already be considered a demanding one by the vast majority of optometrists. (The Intensity of labor was sometimes given as reason for declining employ ment on the part of prospective staff applicants and occasionally mentioned by resigning members In past years as reason for departing.) There are at least two explan ations for this; first. It was observed that these optometrists spent little time In professional discussion with their patients; and second, the men regarded their j I positions as temporary anà any opportunity to Increase | Income In this Interim period would be welcome. On i questioning two of these Individuals about time spent per | patient In their own practices. It was learned that patient time for refraction far exceeded that which they thought necessary to assume for the organization. In a division of labor setting the rate of work appears to have an effect upon Interprofessional relations.] The optometrist who Is less pressured by his schedule may I take the time to consult face-to-face with an ophthal mologist In regard to a specific patient. (Ophthalmolo gists, too. Initiate discussions with optometrists In regard to mutual patients.) In referring a patient to the ophthalmology department, the optometrist who Is pressed for time Is likely to refer the pathology case (or pathology suspect) with a minimum of findings whereas with more time he tends to supply more workup and data on the same patient. In this situation of mutual Inter dependence the optometrist’s value to the ophthalmologist Is enhanced by a less pressured schedule* As reported earlier In this paper, optometrists average fifteen refractions per day each at Olenway. An estimate by the chief of the optometry section. Medical Service Corps, U.S. Air Force, is approximately twelve 50 per day per optometry officer (Birchard and Elliott 1967)# and an estimate from his counterpart in the Army is fifteen per day per optometry officer (Birchard and Elliott 1967). Although the Army figure Is the same as that at Glenway, the Glenway load represents greater intensity of labor because the patient population is a more diverse and unselected group containing a larger proportion of the elderly and visually subnormal than exists In a military population* Dalton ( 1 9 5 5:4l, 45) Indicated that "rate-busters" are more highly coiranltted to the organization, and he showed that "restrlcters" are peer-oriented rather than factory-oriented and tend not to trust the factory. The setting he Investigated, however, was a factory organization; although it may be true that workers who agree to repeat a productive act more frequently per unit of time may be more organization-oriented, the evidence at Western Glenway Medical Group Is precisely opposite In the case of optometrists. The more organi zation committed optometrists resist diminution of time spent per patient. It Is the observer’s impression that among professionals "rate-busting," rather than being a measure of normative compliance, may be an Indication of cynicism. In other respects, the observer would agree with Dalton that "restrlcters" tend to be more concerned 51 about the welfare of the peer group (fellow optometrists) and that "rate-busters" have a strong drive for "social mobility." Within several months of the establishment of the new regulations and new leadership, all four of the ardent private practice optometrists had resigned from the organization (all staff members had been given a reasonable time in which to disengage themselves from outside commitments)♦ The replacements for these men were carefully selected by the chief optometrist with attention to their attitudes toward prepaid group practice and their professed professional goals In addition to the usual academic and other professional background qualifications. The new members were given an orientation In some of the fundamentals of prepaid group care. The present staff has been stable since the replacement of the four, no changes of personnel having occurred since. During the period preceding the present staff membership, when outside commitment was deemed all impor tant by the staff, a prestigious staff ophthalmologist remarked to the investigator that he usually avoided taking a coffee break with the optometrists because he felt that their attitude was, in his view, "unprofes- sional." The same ophthalmologist now regularly takes his coffee break with ophthalmologists and optometrists and, is on friendly personal and professional terms with the Organization orientation Is closely linked with ophthalmologic-optometrIc relations at Glenway for two primary reasons : first ophthalmologists are either partners or partnership eligible In this organization of medical specialists and are thus Identified as members of the employing group, and second, acceptance of the organization goal of teamwork with each group functioning at Its highest skill level In patient care furthers the In recognition of the value of procuring and retaining career-oriented group-minded optometrists, the following statements by the medical director appeared In a memorandum (1965) to area medical directors, chief ophthalmologists, chief optometrists, and clinic admini strators : "In order to attract better qualified, full time optometrists, the following policy has been adopted with reference to starting salaries for optometrists with varying amounts of prior experience: . * . This was followed by a guide for matching professional experience with an appropriate beginning pay level. The memorandum concluded : "The career advantages for physicians In the Group are always explained to physicians; In the case of optometrists this has not always been done; It would be helpful to explain the system of benefits and the ad vantages of prepaid Group practice." The present chief optometrist has provided active ly participant leadership, has stressed the primacy of patients’ needs and the professional upgrading of the department. Lewin stated ; As long as group standards are unchanged, the individual will resist changes more strongly the farther he Is to depart from group standards. If group standard. Itself Is changed, the resistance which Is due to the relation between Individual and group standard Is eliminated (1952:210). A new Innovation has been optometry department staff meetings which are quarterly dinner meetings spon sored by the medical group at which a few Informal papers or reports of professional Interest are presented by the optometrists themselves, and at which problems of depart ment functioning or matters of general professional Interest are discussed. The staff Is unanimous in Its expression of personal and professional satisfaction with these meetings. Although on a lower Income scale, optometrists enjoy many of the privileges extended to physicians: staff dinner meetings, a share In the profits of the medical group, educational leave with pay, a professional position close to that of the physician In prestige. In 1967 the five optometry departments of Western Glenway Medical Group are presenting the first symposium to which members of the local optometric society are invited; the various medical specialties within the group have long held professional symposiums which Include their fellow specialist practitioners In the community. In the view of the administration the rating of the optometry department has jumped markedly since early 1965 and would be considered high. The rating Is based on the cohesiveness of the group; that Is, the degree to which the members of the group function as a team, on the patient orientation of the group, on the degree of professionalization of the group which would Include consultative relations and academic Interest, and the extent to which the optometrists Identify with the major organization, the medical group. This Is reflected In reduced patient complaints. In reduced Interdepartmental and Interservice complaints; in short. In overall smoother operation (discussions with chief medical director, clinic administrator, chief ophthalmologist, eye service supervisor, health plan representatives)♦ For the administration, substantiation of Its view of the optometry department Is also derived from the attitudes of staff ophthalmologists. These aspects of the "rating" of the department are matters which occupy the interest and. energies of the chief optometrist who regards his position as a dual role : he feels responsible to the individuals on his staff and In a larger sense to the profession which he and they represent, and he regards himself as an ally or represen tative of the administration in this department. A term which can be used to describe the dual role is one that has been used in another context, that of the relationship of a university department chalman and members of his department, on the one hand, and the chairman’s relation ship to the dean, on the other; that is, the role of "sympathetic intermediary" (Caplow and McGee 1 9 6 5: 6 5). 1 Although the role of leaders as a force for change has not been the subject of this Investigation, It Is recognized that the chief optometrist, the chief ophthal mologist and the medical director have contributed to the defining or shaping of professional goals and relation ships In this division of labor practice arrangement. CHAPTER VII CASE SETTING RELEVANCE TO FUTURE PATTERNS OF PRACTICE In a Durkheiinian sense, the prepaid medical group organization is a community of specialists whose basis for Integration may be viewed as the recognized mutual inter dependence of specialist groups. The effect of inter dependence upon group toleration, however, is not a rigidly predictable social situation, but one In which the actors may shape relationships within the framework of this mutual Interdependence. "It hardly needs to be mentioned that social Interaction Is considered to be a major source of change In social attitudes, role defin itions Included" (Turk 1963:175). The Institutional Identity which a group such as optometrists may have within the larger organization Is defined not only by the organization but by the optome trists themselves. Conditioned by the external society to what they regard as an unfair professional and/or status relationship with medicine, the attitude may be brought Into an organization which has a different Durkhelmian construction. To refuse to recognize this difference, this interdependence, is what existentialist 56 Jean-Paul Sartre might call "bad faith." The rationale for assuming or pretending that existence within the organization unfortunately follows outside strictures can be attributed to the anticipated difficulty or paln^ In altering one’s role In the new framework or to an Indifference on the part of those who regard, their stay as temporary. %e sociological question Is, will this type of setting Invariably produce a cooperative relationship? It did In the Glenway clinic. Would the prepaid arrange ment produce the same attitudes wherever It occured? Was the Glenway experience unique? Wllensky stated : . . . each ccanplex organization, having multiple functions, requires its own distribution of role orientations; and each man’s biography Is In some respects unique. We would therefore expect diverse workplaces to display central tendencies toward one or another role orientation. Among Individuals recruitment, training and Indoctrination being everywhere Imperfect, man and Job never fitting precisely— we would further expect mixed orien tations to be frequent (1964:151-152). While this Is as true of a prepaid medical organ ization as of any other, the professional role attitudes ^Thls reaction has been described by Milosz (1 9 5 3: 80): "... Ketman means self-realization against something. He who practices Ketman suffers because of the obstacles he meets; but if these obstacles were suddenly to be removed, he would find himself in a void which might perhaps prove much more painful." 58 outside such organizations might well be expected to be equally if not more diverse. Fee-for-service practice often has not acknow ledged a legitimate division of labor between optometry and ophthalmology and has been uneasy about the overlap ping functions of the two fields. It has not yet produced a consistent complementary professional rapprochement. The questionnaire study considered in a later chapter will shed further light on the attitudes such a situation generates* The number of optometrists presently employed in group practice, especially prepaid group practice. Is small,^ but as prepaid group practice expands, and it is expanding rapidly, the number of optometrists partici pating in these groups will increase. To prepare the way for the greater utilization of optometrists In prepaid medical organizations, at least four perspectives must be considered ; 1. The individual optometrist The requisite psychological characteristics ^In an economic survey reported by the Journal of the toerlcan Optometric Association (1966), of 4,544 American Optometric Association optometrists who reported modes of practice, 1 per cent were associated with hospi tals. In an unpublished outline of the "Scope of Opto metric Services presented to those attending an American Optometric Association Public Health Conference in St. Louis, January 1967, the number of optometrists employed in group health centers and clinics is reported as over 200. 59 necessary for fruitful participation In or ganization life are essential (Etzlonl 1964: The optometrist who Is extremely anbltlous financially and whose sights are unerringly leveled at the goal of private practice will not be happy In group practice. Even though he may be In group practice as a temporary measure while Investigating possibilities for entering private practice and accumulating funds, he tends to be dissatisfied with the group situation. Impatiently biding his time for the real business of the main chance. On the other hand, there are those who have Intended to join the group for an interim or between a previous job situation and the establishment of private practice who have found prepaid group practice to their liking and who have remained. The group Is a stimu lating environment for many Individuals, and the constant association with one’s profes sional colleagues and their easy accessibility for discussion or consultation can be of great personal and professional satisfaction. In 60 addition, the ideological concept of prepaid group care with doctor-patient economic relationships removed Is attractive for some Usually a job description does not say much about the psychological pressures of a job; but If we think of the job as a social role a person has to fill and if we realize that Individuals occupy many roles In their lives, we can begin to see how and when a particular role will or will not work out for a particular Individual (Leavitt 1958:297). 2. The colleges of optometry With some exception there appears to be some cultural lag In the training centers and In optometric academic circles In the awareness of the sociological changes In health care practice; in Its economic, philosophical, and organizational aspects. A thoughtful probing of these changes Is In order In con trast to the usual solo practice orientation 3* The organization j 1 "Professionals have superior authority over 1 the major goal activities of the organization"^ (Etzlonl 1964:78). ! The above statement Is true of the setting investigated, and Is a positive element In the feelings of all professionals Involved 6 l in that they feel they are not bucking an insurmountable lay bureaucracy. A prepaid medical group of high commitment, as a normative organization employing members of another normative group, optometrists, diminishes the need for "control" and upgrades the professional performance of its optomet rists by these possible (and essentially demonstrated) means; a) Selectivity of prospective staff members (Etzioni 1964:68) Certain personality types find difficul ties in adjusting to the group environ ment, in accepting the professional appraisals of their colleagues, in accepting the organizational goals. b) Socialization Inclusion of optometrists in orientation programs of the medical group and constant exposure of optometrists to the philosophy underlying the medical group’s goals. A program of professional education carried on within the department. c) Professional status acknowledgment professional subordinates are ... 62 treated differently from regular sub ordinates; they are not treated as are lower ranks in a line structure, but as "staff", a term wiiich desig nates positions outside the regular chain of command, of "line" and implies a certain amount of autonomy (Etzioni Optometrists as individual profession als have the ultimate responsibility for their professional decisions* They are In most Instances not wider direct medical supervision as are many other medical anclllarles. An awareness of the opto metric function and of the analogous normative orientation of the optometrist and the physician can result in a mutual rapport and. a harmonious dependency. 4. Ophthalmologists Although, as can be shown in the case of Glenway, the participation of optometrists in a prepaid medical group can create a satis fying relationship with other medical special ties, especially ophthalmology, and with medical ancillaries, it appears that ophthal mologists are frequently ignorant of the training, the competence, and the proper usefulness of optometrists because of the economic and political competitiveness of the 63 two professions* In a successful prepaid, group setting, the medical staff, including all the specialties, come to acknowledge the specialized professional contribution that optometrists make to the effectiveness of a health plan* The discussion In this chapter refers to perspec tives for and aspects of the professional utilization of optometrists In medical group practice* The point is made that deliberately gearing optometrists to new role relations through selection and through relevant orien tation In academic centers will facilitate this utili zation as will an awareness on the part of organization administrators and ophthalmologists of the potential of the optometric role* In the Integration of hitherto conflicting groups Into group practice. It would appear that In this juxtaposition there are means for abetting the accommodation when new role relations are Introduced. The Durkhelmian framework of mutual Interdepend ence exists In group organization practice of varied specialties; the manner In which the specialist groups and Involved Individuals Interact (with greater or lesser efficiency and greater or lesser satisfaction) Is largely determined by the Individuals concerned. Practitioners of optometry and ophthalmology 64 have opportunities in group health centers to evolve the most suitable roles for each in meeting the eye care needs j of the nation. j The experience of Western Glenway Medical Group I suggests that the structuring of an Interdependent , I relationship free of economic competitiveness Is conducive to the prevention and resolution of conflict. CHAPTER VIII THE CROUP SITUATION AS AN EXTENSION OF ACADEMIC INTEREST AND PROFESSIONAL ORIENTATION Inherent in this discussion of division of labor and skill specialization are some assumptions about what professionals want. When one considers skill as merely representing a higher or lower level of professional responsibility or training one may overlook the fact that specialization permits of a focusing of Interest and a higher degree of proficiency within the area of profes sional concern. It cannot be assumed, however, that all practitioners enjoy the constant exercise of their highest skills. There Is an Impression of the Investi gator that among some of the more than fifty private practice ophthalmologists and optometrists Interviewed and observed, the flexing of professional skills Is not always of as much concern as the total remunerative activity of the Individual’s practice at any level of skill Involvement. This latter view Is not usual. Most practitioners In the eye professions enjoy functioning In the differing areas of coi#etence and responsibility that specialization creates. Their training and the 65 research orientation of their respective fields reinforce this. Optometrists and ophthalmologists In a clinical group practice generally employ different means to attain their shared professional goal, the best treatment of the ocular condition of the patient. The differing approach of each Is consistent with the academic stress of each In their respective training Institutions and with the generally Implied orientation and Interest of each professional group. Table 2, a reproduction of a table compiled by Peters (1966), Is a classification of the research publi cations In 1964 of both the Department of Ophthalmology and the School of Optmietry of the University of Califor nia and Indicates the primary Interests of ophthalmology and optometry. It may be seen that there is very little overlap In content, thus perhaps testifying to the reduced area of competition that respective professional specialization of the two occupations brought about In the group under study. 67 TABLE 2*— Classification of the research publications in 1964 of both the Department of Ophthalmology and the School of Optometry of the University of California® Classification Ophthalmology Optometry (Per Cent) (Per Cent Anatomy 7 Disease 12 Experimental pathology 77 Neurosensory Physiology 2 12 Optics and refraction 45 Visual physiology 2 41 General 2 100 100 ^Peters 1966:1116 CHAPTER IX QUESTIONNAIRE The questionnaire mailed to ophthalmologists and an accompanying cover letter are reproduced In the Appendix. The main focus of this study Is the testing of the hypotheses that relations between optometrists and ophthalmologists will tend to be harmonious In nonfee- for-servlce group practice (hypothesis I) and that ophthalmologists who have not worked with optometrists In such practice will be more negative about the possi bility of role accommodation between the two occupational groups (hypothesis II). The case study alone, thou^ useful for testing hypothesis I could not of Itself supply data for testing of hypothesis II. The questionnaire, however, was designed specifically to test the second hypothesis and Inferentlally the first. The questions used for this were concerned with the opthalmologlst*s work experience with optometrists and the setting In which this may have occurred (question 3) and whether the ophthalmologist considered It professionally desirable to work with 69 optometrists (question 4)* I The questions about the ophthalmologist’s chief I means of practice (question l) and secondary means of I practice (question 2) were included for possible corre lations of method of practice to attitude toward working with optometrists. These questions did not elicit useful 'Information for the purpose for which they were Intended, jMost of the respondents were private practitioners and I where both questions were answered, there was no way of determining for how long the primary and secondary means 1 ; of practice had been concurrent. Also, from the con- 'structlon of questions 1 and 2 it was not possible to determine whether other means of practice had been experienced or for how long or when abandoned* i In several cases the remarks of the ophthalmolo- I jgist more clearly indicated the attitude toward working with optometrists than did the check mark in question number 4. For example, the answer "yes" followed by the statement "but very qualified on a referral basis only" Indicates a receptivity to referrals from optometrists but does not imply a willingness to work with optometrists This was classified as a "no" response. Fortunately, the remarks were generally consistent with the "yes" or "no" responses, and only the truly equivocal or uncommitted were classified as "equivocal." In this latter category. for example, went the responses to question number 4 "undecided” and "there are pro's and con's." There were no real problems of classification of responses that could have significantly altered the statistical analysis, especially as regards military service experience with optometrists. There were two additional "yes" responses which, if added to the "yes" responses of those who have worked with optometrists in military service, would have further strengthened the thesis. These were practitioners who worked with optometrists in one case in a University Medical Center and in the other in a Veterans Administra tion Hospital. These examples are similar to the situation at Glenway and in the military in that they are division of labor arrangements in noncompetitive, nonfee- for-service settings. Because "selection" could be con sidered a factor in these cases, they were not included in the military experience group. One respondent re ported experience having worked with an optometrist in a fee-for-service group practice and his attitude was negative. There were eight who reported experience working with optometrists in private practice, of Wiom six answered "yes" and two answered "no" to question number 4. The example of these eight could be taken as indicating that any experience working in association with optometrists would be likely to result in positive 71 attitudes on the part of ophthalmologists; however, an association in private practice is as yet unique, repre- * sents a very small number of the respondents (less than : 5 per cent), and is a deliberately sought voluntary situation. Of 306 questionnaires mailed, ten were returned I because of no forwarding address or because the practit- I ! ioners were no longer in the ophthalmology ranks. One 1 I hundred and seventy ophthalmologists returned question naires, of whom two refused to answer questions and so ■ stated. The analyses of responses are based on the remaining 168 questionnaires, which represent 56 .7 5 per cent of 296 presumed to have been received. It is likely that some unreturned, questionnaires were sent to others I no longer in ophthalmology and that the sampling may I represent close to 60 per cent of those polled. ■ The different ratio of favorable to unfavorable I responses (Tables 3 and 4) for those with military pro fessional experience with optometrists compared to others I validates the "hunch" of the researcher about the effects I of such experience on attitude. Of those who did not I ' work with optometrists in military service, in reply to whether working with optometrists is professionally desirable, 6 6 .1 9 per cent were negative, 6.47 per cent were undecided, and 27.34 per cent were affirmative, where- 72 as of those who worked with optometrists in military service, 31 per cent were negative and 69 per cent were affirmative. Hiough the sampling is small, the shift in atti tude is clearly indicated. It can be stated that exposure to a noncompetitive, nonfee-for-service practice associa tion with optometrists will result in ophthalmologists being more favorably disposed toward working with TABLE 3#— Attitudes of I68 ophthalmologists toward working with optometrists Attitude Worked with Optometrists in Military Service Did Not Work with Optometrists in Military Service Number Per Cent Number Per Cent Favorable No commitment, equivocal Unfavorable 20 9 69 31 38 9 92 27.34 6 .4 7 6 6 .1 9 Total 29 100 139 100.00 73 o > 5 c m •p •H u -p i 45 & p 50 IÎ O 0 •D "O S S o r a -^8 CQ Pi P W CQ 0> •H 0 M r4 0 II IB x : 4> 8* % C Q ® 1 •H P P i I I rH «0 P a t Q •H p I o •H 0 0 P CO 0<§* >5 Wjp U O P P •H 4 - 1 I |s= •■g % 5 0 0 •H 1 m o 0 I I •H P §’ S-& r - l 0 liS i;- 11^ I v4 P P < 00 r4 m o % s o\ G\ m r - 4 % I —I o \ C V J 0 r~i j o t I I 0 M Xt i a S I —I 0 P B rH 0 s rH rH o o » 6 in 'O Q 1 —1 g »o • o 0 KÛ >) U r4 0 f it 4 - 1 A P 4 h 0 C O J h 0 0 O 0 P •H 0 U* <H $4 CO 4 h 50 p 0 •H 50 X3 JC * i H o CO rH 74 In addition to the main objective in the question naire of testing attitudes in relation to military experience, it was decided to test for any possible relationship between certification or the lack of it and attitudes toward working with optometrists. (Physicians may specialize without certification. A certificated specialist or diplomate in ophthalmolo^ has completed a prescribed residency and training and has passed an examination by the American Board of Ophthal mology.) The very existence of two types of ophthalmolo gists, not too dissimilar in number, led. to speculation about whether a difference in attitude would be found. On pure "reasoning" the hypothesis could be stated either positively or negatively. It could be argued that non- diplomates would tend, to be less sure of their status than dipl(mates and hence feel uneasy in relations with another group (optometrists) with overlapping functions. Conversely, it could be reasoned that association with a group whose scope does not include the treatment of pathology would place the nondiplomate in a securely differentiated prestige position. In the case of diplo mates the ready assumption could be that the solid fact of certification would tend to make them feel profession ally secure and accepting of others (optometrists). One 75 could also argue, however, that the diplomate in compari son with the nondiplomate has more of a vested interest by virtue of the effort, expense,and training required to achieve certification and could be reluctant about professional recognition of optometrists. It was decided to state the hypothesis positively because of a presumed analogous situation in a study of psychiatrists and psychologists (Zander et al.1957). *Kiis additional certification information was achieved by color-coding the return envelopes differen tiating diplomates from the nondiplomates. It will be recalled that twice as many diplomates were sent question naires as were nondiplomates* However, of the total 168 respondents, 120 were diplomates, forty-eight were non diplomates. The nondiplomates as a group were older and it may be that their lesser percentage of response is partially due to the number who have retired from active practice. Some of the nondiplomates were eye, ear, nose, and throat specialists, a specialty practice more charac teristic of an earlier period. The responses show no significant difference in attitude between diplomates and nondiplomates toward working with optcmetrists (Tables 5 and 6). Zander, et al. (1957:135) in interviews with psychiatrists, psychologists, and social workers, showed 76 TABLE 5*— Attitudes of diplomates and nondiplomates in ophthalmology toward working with optometrists Attitude Total Diplomates Nondiplomates Number Per Cent Number Per Cent Favorable 58 43 35.8 15 31.2 Equivocal 9 8 6.7 1 2.1 Unfavorable 101 69 57.5 32 66.7 TABLE 6.— Attitudes of diplomates and nondiplomates in’ ophthalmology toward, working with optometrists (nine equivocal responses deleted) Attitude Diplomates Nondiplomates Total Favorable 43 15 58 Unfavorable 69 32 101 Total 112 47 159 Chi Square « .507 No significance at .20 level 1 degree of freedom 77 that psychiatrists who regarded themselves as having relatively high power expressed more inclination to re lations with psychologists and social workers than did psychiatrists who saw themselves as having little power. In the present study it cannot be assumed that diplomates and nondiplomates have different views of their power to influence in relation to optometrists. The successful practice of one's profession may be sufficiently rewarding for self-esteem without certification in ophthalmology, and so the two kinds of ophthalmologists are not neces sarily analogous to the high and low power psychiatrists of the Zander study. Further information about attitudes as possibly affected by age, membership in professional organizations, and offices held was tabulated from the questionnaire and is shown in Table 7# In broadly considering three categories of responses to the question of whether it is professionally desirable to work with optometrists (question 4), all the favorable, all the unfavorable, and all the equivocal replies, it will be seen from Table 7 that there is no significant difference in age, number of organization memberships, or membership in the American Association of Ophthalmology as between "yes" and "no" respondents. The equivocal respondents are approximately five years 78 • * 0 rH A f i t * r J 0 0 X Î u 5 0 0 o 0 P 4 O C O in > P 0<£ C O m 0 • • u 0 E r H in c O 0 c in p * ÎH S S * H 0 0 •i 4 > A X I 0 0 P r H * H • d ^ U 0 - P P 4 0 O B > O 0 - P « H A 0 O o o X Î Æ P * H px: ^ 0 4 n 4 h p 4 4 0 * o O C O W 3 r H C O 0 0 0 0 • P 5 0 P X Î c 0 0 - =t C T \ Zf 0 S 3 c o m zf zt •H n H 0 0 5 0 .1 4 O > P O J l 4 f 4 0 0 U H r H G 0X : 0 Q ^ dt 0 % % S r H -O X X * 4 0 $ 4 < 4 < X : 0 B B p ^ r H P P X: o 0 B B A P 0 o • o < \ n 0 •H S 3 W X I 4 4 0 > O 0 3 < 4 O T D •H « H si m o 0 *0 P « H a P 0 P S 3 0X Î K » > ■ O * H M N 0 P C O H t - •HP • H ^ > z ^ P >- P P S 3 0 < • G ? * 0 0 0 0\O A 0 0 M O O •H A50 S ? 4 fH S 4 0 0 0 P O 0 O O a 0 > P 4 n H 3 0 d % x : c r O 0 0 * o s c O 0 O J C O « t in o\ 1 0 in zt 5 0 b- < 3 j • 4 ^ S 3 S 0 0 a • H * H m no V < 0 0 B 0 5 0 g 0 I rH r H O J O C O rH B s XI § B • » 1 P O J > zj- < 4 C O { 3 C 0 • H i 79 younger, appear to rank with the "yes” respondents in percentage who have held office, and show higher figures than the other two groups in organization memberships and in membership in the American Association of Ophthalmol ogy. However, their number (nine) is too small to indi cate any trend* The American Association of Ophthalmol ogy, which emerged in the 1960*8, was originally called the National Foundation for Medical Eye Care, which was founded in 1956 and was stated to have the purpose of informing the public about what constituted "medical" eye care as distinct from "nonmedical," and was open in its intent to prize the former and denigrate the latter. Optometry has regarded the viewpoint and adtivities of this organization as an aggressive, partisan, and highly biased political and public relations arm of ophthalmol ogy* It is then especially interesting to note that membership in the American Association of Ophthalmology is the same for both the "yes" and. "no" groups. Among ophthalmologists who have held office, the percentage of "yes" respondents to the question of the desirability of working with optometrists (question 4) was slightly higher than among ophthalmologists who have not held office. The total number of offices held per individual is not included, here although the total number of offices reported by the respondents bore a constant relationship to the number who held office* It is felt that the total number of offices cannot be determined by the question as asked because the column for offices held does not allow for the fact that frequently individuals hold more than one office in the same organization, advancing from post to post* %e numbers reported indi cate individuals who have held at least one office* Although there is no clearly significant difference in attitude between those who have held office in profes sional societies and those who have not (no significance at *05 level), there appears to be some slight tendency for office holders to be less negatively inclined toward working with optometrists than those who have not held office (Table 8). If office holding is viewed as a prestige characteristic (as can certification, previously analyzed), then it can be stated that prestige within his own field as indicated by office holding has a slightly positive influence on the attitude of the ophthalmologist toward working with the optometrist. Zander, et al. (1957:37) found that there is "some slim evidence" that psychia trists with more prestige within the field are willing to grant increased influence to psychologists. It is sometimes assumed by optometrists (personal conversations) that the ophthalmologists who welcome co 81 operation with optometrists are the rank-and-file, those not in the professional power structure, but this is cer tainly not supported by data from the questionnaire. TABXE 8.— Attitudes of ophthalmologists who have held office and ophthalmologists who have not held office in professional societies toward working with optometrists (nine equivocal responses deleted) Attitude Held Office Did Not Hold Office Total Favorable 26 32 58 Unfavorable 33 68 101 Total 59 100 159 Chi Square 2.33 Significant at .20 level 1 degree of freedom The hypotheses that the diplomate in ophthalmology will be more favorable in attitude toward working with optometrists than will the nondiplomate (hypothesis III) and that ophthalmologists who have held office in profes sional societies will be more favorable in attitude toward working with optometrists than will those who have not held office (hypothesis IV) were not conceived as necessarily related to major hypotheses I and II. It was felt by the investigator, however, that hypotheses III and IV could, also be tested as part of the questionnaire. Questions of age, certification, organization membership and offices held, would appear to be proper questions in any study such as this* The fact that little influence on responses are a consequence of these factors will, if anything, add to and not detract from the support of the major hypotheses (I and II). Ophthalmologists' Comments The comments in the questionnaire by some of the respondents under "remarks" reflect a spectrum of atti tudes with a few predominant themes. Listed below are some comments which indicate the attitude range that underlies the simple "yes" or "no" answer to the question about the desirability of working with optometrists (question 4). There can be no professional association between physicians and technicians who lack medical training. Carried to its logical conclusion, you would have the idiots running the asylum. Poor question, vague— they advertise too much— try to do too much--training inadequate. Some acquaintances have tried having optometrists work in their offices but the associations have all terminated unfavorably so I have not attempted such I feel an optometrist may serve satisfactorily if serving as a recognized non-professional ancillary worker in an ophthalmologist *s office doing strictly non-diagnostic or therapeutic procedures .... 83 Too much difficulty in supervising them to the standard of medical ethics that I wish to maintain. Our professional activities with optometrists in state of . . . has always been very good as a general rule, excepting, of course, spots where it is not good. Various states around have had legislative conflicts which we have up to the present time not experienced. It [optometry] should be under the aegis of medicine and in some way made cooperative with oph thalmology. The details must be worked out by leaders in both fields and the success will be determined by time and the presence or lack of conciliation, moti vation and honesty on both sides. I have always been of the opinion that an ophthal mologist should have an optometrist as an associate. To spend seven years after finishing college and then use most of the day doing refractions that could be done well by a person spending 4 to 5 years of college work in optometry [six at present] does not seem realistic. Since there are so few ophthalmologists it is necessary to work with optometrists. In the Air Force it worked well. Association very good with selected optometrists in service, very poor in private practice since then. In those situations, e.g., the military, where a clear-cut status of "authority-subordinate" is established, and economic considerations are removed, I have not had any occasion to think a single harsh thought about the profession of optometry. CHAPTER X RECENT INTERPROFESSIONAL DEVELOPMENTS; FACTORS IN THE EMERGING CHANGING RELATIONSHIPS While this study was in process, the following article appeared in the AMA News, December 26, 1 9 6 6: OPTOMETRY STATUS TOLD Optometry is not a cult and an ophthalmologist may employ an optometrist to assist him, provided the optometrist is identified as an optometrist and not as a doctor of medicine, the Judicial Council of the American Medical Association said. The Council said, however, the ophthalmologist has an ethical responsibility to take affirmative measures to make sure patients will not be given the impression the optometrist is also a doctor of medicine* MD May Teach: The same opinion, announced by E* G. Shelley, M.D*, North East, Pa., chaiimmn of the Council, said a physician may teach in recognized schools of optometry. The statement added that physicians may teach in such schools for the purpose of improving the quality of optometric education. The scope of this teaching may embrace subjects within the legitimate scope of optometry which are designed to prepare students to engage in optometry within the limits prescribed by law, the statement said. Frequent Discussions: The relationship between doctors of medicine and optometrists has been dis cussed by the House of Delegates for more than 30 years (AMA News, December 1966:1) 84 85 The pendulum has swung again and professional relations between the two professions are now presumably officially sanctioned by the American Medical Association. It is interesting to speculate on the cause of the present First, optometrists have been working satisfac torily with physicians in clinical groups, especially in prepaid groups, and this fact is known to the medical profession and to government and public health officials concerned with medical manpower. Optometrists have filled an important need for their professional services in the military in World War II, and have been commissioned in all the military branches since then. Commissions for optometrists were opened in the United States Department of Public Health in 1 9 6 6* In short, the aforementioned opportunities for interaction have led increasingly to the inevitability of sanctioned mutual interaction between the two professions* This does not mean that the conflict between the two groups will instantly cease— the history of conflict is too long for that— but that it is easing somewhat is apparent. The statement that "the optometrist is identified as an optometrist and not as a doctor of medicine" (AMA News December 1966) is curiously at variance with the 86 previous view expressed in the late fifties and early sixties by the National Foundation for Medical Bye Care. %is group insisted that where optcanetrists were employed by physicians, their identity was to be as technicians. This has usually been the case in private practice employer-employee relationships. A patient of an ophthal mologist -optometrist private practice team would not likely find the optometrist's name and degree on the door nor on the roster of the building directory of a medical office building. It has been essentially in prepaid group practice and in the military services (also not a fee-for-service arrangement) that the mutually interdependent relationship ; based on a division of labor and mutual professional recognition has occurred, and it has been in these cir cumstances that optometrists have been clearly identified It may be that in this "Medicare" period when the economics of medical practice and the deployment of medical manpower are of great concern to government, labor, management, and all the recipients of professional care, that organized medicine is cognizant of the many interest ed and knowledgeable observers of the medical scene. Because interest in health insurance and health care services has involved so many outside the medical profes- 87 8Ion, it has become more difficult for medicine to main tain an attitude that would deny the validity of opto metry's role in the provision of professional services* An article in Consumer Reports, which was prepared by Consumers' Union medical consultants, has this comment on the physician-optometrist dispute: * * . the dispute has made it difficult for ophthal mologists and optometrists— by training the most logical team in medical care of the eye and correction of vision defects— to work together* There are signs that the dispute may be easing ( 1 9 6 7: 1 7 2)• In Medical Economics'(1966) national study of private practitioners* frustrations and satisfactions, ophthalmologists, as a group, appear to be at the top of the satisfaction scale among medical specialists (p*15 8)* In analyzing frustrations of ophthalmologists, the survey shows that the second most frequent item on the frustra tion list is "the boredom of doing routine refractions, which constitute a large part of many ophthalmic prac- Growls one man: "I'm a glorified optometrist nine-tenths of the time * In the other tenth, I do a little eye surgery and feel like a doctor again. But I feel that as a glasses-fitter. I'm wasting my medical training" (P.15 9). To summarize, then, three factors appear to be significant in the emerging situation of the official accommodation of optometrists in the general health care scene : 88 1* The existence of a satisfactory role accommo dation in prepaid clinical groups and in the military services; 2. The intrusion of the third party (government, health insurance organizations, medical sociologists, and economists into the medical care complex; and 3# The probability that many ophthalmologists enjoy the professional situation created by the division of labor in a mutually inter- GHâPŒR XI CONCLUSIONS Hypotheses The hypothesis that role accommodation will evolve in #iich relations between optometrists and ophthalmolo gists will tend to be harmonious in an organization structure of nonfee-for-service practice is supported* The hypothesis that ophthalmologists who have not worked with optometrists in nonfee-for-service group practice will be more negative about the possibility of role accommodation between ophthalmologists and optome trists is supported* Hie hypothesis that the diplomate in ophthalmol ogy will have a more favorable attitude toward working with optometrists than will the nondiplomate is not Hie hypothesis that ophthalmologists who have held office in professional societies will be more favorable in attitude toward working with optometrists than will ophthalmologists who have not held office is only weakly supported* Hiere appears to be a slight tendency for more of the office holders to be favorably 89 90 Inclined, Findings in Relation t6 the Literature The findings of this study of role relations of two occupational groups in a changed setting of mutual dependency are consistent with Durkheim's view of special ization as a cohesive element. Durkheim did not over- siiKplify division of labor relations but indicated that unanticipated or possibly undesired effects of cooperation could occur. This is consistent with the view expressed in this study that the division of labor is a framework for cooperative role relations, but that these relations are also affected by the participants, Goff man, without mentioning the division of labor per se, stressed team-performance as resting upon mutual dependence, Hiis is consistent with division of labor as a cohesive force in this study because the two occupation al groups considered become teammates through the division of labor in an organization setting. Dean and Rosen stated the case slightly differently from Zander, Cohen, and 8totland, but they are essentially in agreement with each other and with the findings of this study in their contention that exposure in a new setting \ with reorganized "role prescriptions" (Zander, et^ al. 1957:15^) is more effective in changing attitudes than 91 discussion or exhortation. The similar observations of both Whyte (1957) and Sherif and Sherif on the necessity for the awareness of goals are confirmed in the day-to-day observation of a clinic group where functional relations are influenced by the orientation to the goal of comprehensive patient care. Mills* statement (supra, p.8) described what is occurring as bureaucratic institutions invade all pro fessions, but is perhaps too rigidly propounded for the case of physicians and optometrists in a medical organi zation. Mills did make this observation : ". . .at the top, the free and the salaried professionals make their own curious adaptation to the new conditions prevailing in their work" (1953:115). Limitations of the Study The study under consideration is an approach based on a survey of the literature, a survey of the history of the interrelations of two professional occu pational groups, observation of a clinic group, and the use of a questionnaire to ophthalmologists. It could have been strengthened had a random selection of opto metrists, too, been surveyed by questionnaire, although the rationale has been that optometrists are more eager 92 for acceptance by the higher prestige group, ophthalmolo gists. Although the focus of the study has been role re lations between two professional groups and the observa tion of role accommodation of optometrists in a clinical group, optometrists were the group more specifically reported on in the clinic study, and a geographical sample of ophthalmologists was reported on in the questionnaire study. Although the case for harmonious relationships in nonfee-for-service practice has been established, it is not certain that similar relationships could not develop in other forms of practice; in fact, they do indeed exist in isolated cases. Nonfee-for-service settings were selected for two reasons: first, in nonfee- for-service practice the situation exists for common perception and common acceptance of a goal which is a necessary requisite for functioning in mutual dependency; second, as has been stated, the usual modes of practice have thus far usually produced situations of conflict. Again, however, it cannot be stated unequivocally that harmonious relationships could not occur more widely in some forms of fee-for-service practice not yet anticipated. Suggestions for Future Research Will division of labor always tend to produce 93 cohesive feelings for professionals? It is possible that there may be a point of diminishing returns in the division of labor. The division of labor of optometrists and ophthalmologists in a prepaid medical group and in military service appears satisfying and is consistent with the training, preoccupation, and academic interests of each group. There is a question, however, about the tendency in medicine and allied fields to delegate more and more facets of patient care to ancillaries* This tendency is dictated by the growing complexity of professional fields, by the increasing numbers of patients who will be consumers of this sophi sticated medical care, by the shortage of medical man power, and by the "efficiency" orientation of administra tors# Hie question is, is there a point at which delegation or fragmentation becomes a source of irritation or frustration for the highly skilled professional? 95 Anthropology University of Southern California University Park Los Angeles, California 9OOO7 I am a graduate student working in Medical Socio logy in the Department of Sociology and Anthropology at the University of Southern California. The enclosed questionnaire is part of a case study in role accommodation. Your cooperation in completing and returning the enclosed questionnaire will be greatly appreciated* BERT ROBERTS 96 QUESTIONNAIRE l) What is your chief situation for practice at present? (Please check the appropriate How long in above situation? If you have a secondary means of practice, please check the appropriate description: Private Practice Q Welfare Clinic Q University Medical Center □ Military Service Q Group Practice (Pre-paid) Q Group Practice (Fee-for-servide) Q Other : Q If "other", please indicate type ; How long in above situation? a) Private Practice □ b) Welfare Clinic □ c) University Medical Center □ d) Military Service □ e) Group Practice (Pre-paid) □ f) Group Practice (Fee-for-service) □ s) Other ; If "other", please indicate type : □ 97 3) Have you ever worked, with an optometrist? yes □ no □ If so, where? Private Practice Q Welfare Clinic □ University Medical Center Q Military Service Q Group Practice (Pre-paid) Q Group Practice (Fee-for-service) Q Other Q If "other", please Indicate type:____ Please indicate approximate duration of time adjacent to any description checked in responses to above question (No. 3) :________ ________ 4) Do you think it is professionally desirable for ophthalmologists to work with optometrists in the provision of eye care? yes □ no □ 5) In which of the following groups do you hold member ship? Have you held,office in any of these groups? Organization Membership Held Office a) A,M*A. (including local and state medical associations) 98 5) Continued. Organization Local Ophthalmolo- e American Academy of Ophthalmology and American Ophthalmolo- gical Society American Association of Ophthalmol o^ Other Ophthalmological Societies (please name, if any) Membership Held. Office □ □ □ □ □ □ □ □ □ □ 6) Your age? 7) Remarks, if any: BIBLIOGRAPHY AMA NEWS July 11, 1966 December 26, BIBLIOGRAPHY Published by the American Medical Association, Chicago, Illinois. AMERICAN DIRECTORY OP OTOLARYNGOLOGISTS AND OPHTHALMOLOGISTS 1 9 65 -19 66 Editor and Publisher, Joe T. Smith, M#D., Knoxville, Tennessee. AMERICAN OPTOMBTRIC ASSOCIATION January, 1967 Scope of Optometric Services. Un published outline presented at American Optometric Association Public Health Conference, St. Louis, Missouri. BECKER, HOWARD S. Chicago, University BIRCHARD, CLIFTON H., February, I967 BLAU, PETER MICHAEL Boys in White, of Chicago Press. AND THEODORE P. ELLIOTT Part II; A Re-Evaluation of the Ratio of Optometrists to Popula tion in the United States in the Light of Socio-Economic Trends in Health Care. American Journal of Optometry and Archives of American Academy of Optometry 44:91-104. The Dynamics of Bureaucracy; a Study of Interpersonal Relations in Two Government Agencies. Chicago, University of Chicago Press. BLUE BOOK OF OPTOMETRISTS 1966 BOHANNON, R. L. April, 1966 Twenty-eighth edition. Chicago, The Professional Press, Incorpor ated. Letter. The Journal of the American Optometric Association 37:342. 100 101 BROWN, R. B. April, 1966 CAPLOW, THEODORE Letter* The Journal of the American Optometric Association 37:339. The Sociology of Work. Minnea polis > University of Minnesota Press. CAPLOW,, THEODORE, AND REECE J. McOEE The Academic Marketplace* Garden City, New York, Anchor Books, Doubleday and Company, Incorpor ated. CONSUMER REPORTS March, I967 CUTTING, CECIL C. October 3, I963 DALTON, MELVILLE Contact Lenses (article) No.3^ 32:168-173. Medical Care: Its Social and Or ganizational Aspects. The New England Journal of Medicine 269: 729-735. Restricters and Rate Busters. In Money and Motivation, by William Foote Whyte, et al. New York, Harper and Brothers. DEAN, JOHN P., AND ALEX ROSEN 1955 A Manual of Intergroup Relations. Chicago, The University of Chicago Press. DIRECTORY OF MEDICAL SPECIALISTS 19 6 5 -1 9 6 6 Published for the Advisory Board for Medical Specialties, Incor porated by Marquis— Who's Who, Chicago. DURKHEIM, EMILE i960 The Division of Labor in Society, translated by George Simpson. Glencoe, Illinois, The Free Press. 102 ETZIONI. AMITAI GOFFMAN, ERVING 1959 HAFFNER, ALDEN N. November, 1966 HAMRICK, WILLIAM A April, 1966 HEATON, LEONARD D. April, 1966 HIRSCH, MONROE J. January, 1956 HOMANS, (mORGE CASPAR 1961 Modern Organization. Englewood Cliffs, New Jersey, Prentice-Hall, Incorporated. The Presentation of Self in Everyday Life. Garden City, New York, Anchor Books, Doubleday and Company, Incorporated. Guest editorial. The Journal of the American Optometric Association 37: 1015-1016. Letter. The Journal of the American Optometric Association 37:337. Letter. The Journal of the American Optometric Association 37:336. Ocular Pathology and Interpro fessional Relations. American Journal of Optometry and Archives of American Academy of Optometry 33: 43- 45. Social Behavior, Its Elementary Forms. New York, Hare our t. Brace and World, Incorporated. INGLES, THELMA, AND MORTON D. BOGDANOFF 1963 JAECKLE, CHARLES E. December, 196I Some Reflections on a Changed Clinic System. In Clinic Nursing: Explorations in Hole Innovation, by Herman Turk and Thelma Ingles. Philadelphia, F. A. Davis Company. A Declaration of Medical Principle. American Journal of Ophthalmology 52:999-1002. 103 JEFFERS, WILLIAM N. October 3, 1966 Which Specialties Are Most Satis fying? Medical Economics 43:158-176. JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, THE July 1 6, 1955 Proceedings of the Atlantic City Meeting, 158:934-941. JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, THE November 21, 1966 Medical Education in the United States (prepared by the Staff of the Council on Medical Education) 1 9 8: 8 4 7-9 3 8. JOURNAL OF THE AMERICAN OPTOMETRIC ASSOCIATION, THE July, 1966 Economic Survey--Report No. 4, 3 7: 68 3-6 8 5. KOCH, CAREL C. August, 1955 LEAVITT, HAROLD J. LEWIN, KURT 1958 LINTON, RALPH 1936 LORTIE, DAN G. I95B Resolution Dealing with Interpro fessional Relations. American Journal of Optometry and, Archives of American Academy of Optometry 32:432-434. Managerial Psychology. Chicago, University of Chicago Press. Group Decision and Social Change. In Readings in Social Psychology Tthird. edition), by Eleanor E* Maccoby, Theodore M. Newcomb, and Eugene L. Hartley* New York: Henry Holt and Company. The Study of Man. New York: D. Appleton Century Company, Incorporated. Anesthesia: From Nurse's Work to Medical Specialty. In Physicians, Patients anHTCllness. Edited by E. Gartly Jaco. Glencoe, Illinois, The Free Press. 104 MILLS, C. WRIGHT 1953 MILOSZ, CZESLAW 1953 ORZACK, LOUIS H., August, 1958 White Collar. New York, Oxford University Press. The Captive Mind. Alfred A. Knopf* New York, PEARSALL, MARION 1963 AND JOHN R. UGLUM Soeiological Perspectives of the Profession of Optometry. American Journal of Optometry and Archives of American Academy of Optometry 35:407-424. Medical Behavioral Science, A Selected Bibliography. University of Kentucky Press. PETERS, HENRY B. December, 1966 POST, LAWRENCE T. January, SCHLOTFELDT, ROZELLA M. August, 1965 Vision Care of Children in a Com prehensive Health Program. Journal of the American Optometric Associa tion 37:1113-1118. Instruction in Ophthalmology by Ophthalmologists to Nonmedical Groups (editorials). American Journal of Ophthalmology, 30: 81-83. The Nurse's View of Nurse- Physician Relationships. Journal of Medical Education, 40:772-777. SHERIP, MÜZAFER, AND CAROLYN W. SHERIP 1953 - Groups in Harmony and Tension. New York, Harper and Brothers. SILBERSTEIN, IRVIN W. November, I966 Optometrists in Civil Service. The Journal of the American Opto metric Association 37 :104?-1051. SOMERS, HERMAN MILES, AND ANN RAMSAY SOMERS . 1961 Doctors, Patients and Health In surance. Garden City, New York, Anchor Books, Doubleday and ________________________Company, Incorporated.__________ SOUTHERN OPTOMETRIST January, 1951 - THOMPSON, VICTOR A. 1961 TURK, HERMAN 1963 VAIL, DERRICK May, 1956 WEBER, MAX WESSEN, ALBERT P. 1958 WHYTE, WILLIAM POOTE WHYTE, WILLIAM H., JR, 1957 WILENSKY, HAROLD L. September, 1964 An Offensive for Optometry (editorial) 4:34. Modern Organization. New York, Alfred A* Knopf. Clinic Role Innovation: Conclu sions in Social Action Theory. In Clinic Nursing: Explorations in Role Innovation, by Herman Turk and Thelma Ingles. Philadelphia, P. A* Davis Company. Time to Act (editorials). American Journal of Ophthalmology 41:874-875* The Theory of Social and. Economic Organization, translated by A. M. Henderson and Talcott Parsons* Glencoe, Illinois, The Free Press. Hospital Ideology and Communica tion between Ward Personnel. In Patients, Physicians and Illness. Edited by E. Gartly Jaco. Glencoe^ Illinois, The Free Press. Money and Motivation. New York, Harper and Brothers. The Organization Man. Garden City, New York, Anchor Books, Doubleday and Company, Incorporated. The Professionalization of Every one? American Journal of Sociology, 7 0: 13 7-1 5 8. 106 ZANDER, ALVIN, ARTHUR R. COHEN, AND EZRA STOTLAND 1957 Role Relations in the Mental Health Professions, Ann Arbor, University of Michigan Press.
Linked assets
University of Southern California Dissertations and Theses
Conceptually similar
PDF
The use of cubic splines for estimating the prognostic effect of age at diagnosis in childhood acute lymphoblastic leukemia
PDF
A comparison of training methods in cavity preparations in primary teeth for preclinical dental students
PDF
Choice making: A unit of study for tenth grade students
PDF
Nursing and gerontology: A study of professionalism
PDF
Determining diabetes risk assessment in the elderly dental patient
PDF
The effectiveness of nutritional counseling in nutritional status and behavior in the elderly
PDF
Some differences in factors related to educational achievement of two Mexican-American groups
PDF
Dental care of the aged patient: Implications of attitudes toward aging among dental students and dental hygiene students
PDF
A cineradiographic and electromyographic study of muscles used in glossopharyngeal breathing
PDF
The role of fifth finger position in a precision task
PDF
Health care personnel needs for long-term care in California: Projections through the year 2020
PDF
Dental health services and the aging: a gerontological perspective for social policy
PDF
The relation between high and low social service interest measured by the Kuder, and adjustment, as indicated by the MMPI
PDF
A study of professionalism as it relates to the field of counselor education and gerontology
PDF
Development of the University neighborhood: The University of Southern California
PDF
Searching for an identity: A study of residential care facilities for the elderly in California
PDF
A follow-up study of an unselected group of graduates of Chico Senior High School
PDF
Engagement in occupations and its relationship to delinquency scores among 10 to 13-year-olds
PDF
A study of the Los Angeles medical agencies providing care for certain classes of low income groups
PDF
Medical care for the middle classes as a social problem
Asset Metadata
Creator
Roberts, Bertam Leon
(author)
Core Title
Role accommodation: A study of optometrists in a prepaid medical group as perspective for viewing relations between two professiosl occupations
School
Graduate School
Degree
Master of Arts
Degree Program
Anthropology
Degree Conferral Date
1967-08
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
health and environmental sciences,OAI-PMH Harvest,social sciences
Format
application/pdf
(imt)
Language
English
Contributor
Digitized by ProQuest
(provenance)
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c37-186807
Unique identifier
UC11638258
Identifier
EP54617.pdf (filename),usctheses-c37-186807 (legacy record id)
Legacy Identifier
EP54617.pdf
Dmrecord
186807
Document Type
Thesis
Format
application/pdf (imt)
Rights
Roberts, Bertam Leon
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA
Tags
health and environmental sciences
social sciences