52
THE OUTPATIENT DEPARTMENT AS SOCIAL SYSTEM:
STRUCTURE, IDEOLOGY AND BEHAVIOR
Carole Browner
Department of Anthropology
Wayne State University
Detroit , Michigan
Introduction
Two elements are characteristic of all bureaucratic sys-
tems. They maintain: (1) a network of social relations which
forms the structure of the system, and (2) a collection of
shared beliefs and values which serve to validate relation-
ships and influence behavior (Blau and Scott 1963; Caplow
1964; Georgopoulos 1972). This paper describes the structure
of a general medical clinic and shows the ways in which this
structure creates and maintains an explicit system of beliefs
which in turn influences the actual delivery of medical care.
The research here described was carried out during the
latter part of 1970 and the first months of 1972 in the Out-
patient Department (hereafter referred to as OPD or Clinic)
of Western Hospital and Medical Center1, a non-sectarian,
non-profit general hospital located in Northern California.
Typical of many urban outpatient clinics, Western draws its
patients principally from an indigent inner city population.
Medical care is administered primarily by house officers
(interns and residents) who are required to spend a portion
of each year in training as outpatient department physicians.
A number of attending staff physicians volunteer a limited
amount of service as well.
The structural core of the Clinic is formed by a staff
of nine people: a clerk, a licensed vocational nurse (LVN),
the nurse co-ordinator, a head nurse, a nursing supervisor,
a part-time medical director, a part-time consulting psych-
iatrist, a medical secretary, and a medical social worker.
These nine are the Medical Clinic's only salaried, perman-
ent staff and they derive a significant amount of prestige
and authority by virtue of this position. Further, many
53
staff members have worked in the OPD for a number of years.
This provides continuity based not only on the permanent set
of roles and interactive patterns that has evolved over the
years, but additionally because the same individuals have
performed these roles for a relatively long period of time.
Although they comprise little more than administrative mach-
inery set up to assist patients with obtaining health care,
and doctors with an opportunity for ambulatory care training,
in effect they color the actual character of doctor-patient
interaction by: (1) controlling patient and medical staff
access to each other and to services; (2) socializing
patients; and (3) restructuring the scope of the physician's
traditional authority.
Structural Constraints on the Physician's Role
The two elements traditionally integral to the physi-
cian's role, as formulated by Freidson (1970), are profes-
sional dominance and professional autonomy. That is, physi-
cians are granted self-regulation and control of their ac-
tivities because it is assumed that the public lacks the
training and expertise to make informed judgements and that
physicians, by virtue of their professional stature, will
serve as guardians of the public trust. These aspects of
the physician's role have been the target of recent criti-
cism (see Bloom and Wilson; Ehrenreich 1971; Goffman 1961;
Iaitzkin and Stoeckle 1972), but within the private sector
the physician-patient relationship has not undergone serious
change.
The Western Hospital Clinic, however, because of its
institutional structure, transforms the physician's role by
pre-empting some of his traditional dominance and autonomy.
First, the physician's authority is limited both by a body of
rules which set forth OPD procedure, and by administrators
(the medical director, nurse supervisor, and head nurse) who
have the power to countermand individual medical decisions.
For example, doctors may prescribe only the drugs appearing
in the OPD formulary unless authorization from the medical
director has been obtained. Requests for medical appliances
must be channelled through an eligibility clerk. Physicians
therefore cannot make decisions based solely on their rea-
soned medical judgement: certain recommendations must be
justified; others must be discarded entirely. The effect is
a clear restriction of traditional medical authority, and as
much it alters the nature of doctor patient interaction.
The right of doctors to make specific types of work-
54
related decisions is similarly constricted: a clerk decides
how many patients a doctor will treat each day, which par-
ticular patients that doctor will see, and the order in which
they will be treated - in effect, the amount of work a doctor
will do on any particular day. As one intern said:
Most of my patients are women. The nurses
set it up that way.... (For instance)
sometimes I get to do a history and physi-
cal on a young patient if Martha (the LVN)
wants to be nice to me.
And even the decision of whether to work in the OPD at all is
not made by the doctors themselves, since here, as in many
other hospitals, such work is mandatory rather than voluntary.
Added to these concrete restrictions are a series of more
abstract elements which further restrict the authority of the
clinic physician. The private and privileged communication
that classically characterizes physician-patient interaction
is broadened to include an entire staff who have access to
patients' medical and personal information. The consequence
is that staff members volunteer opinions and advice during
staff meetings and in private conversations with doctors and
patients. The tension this occasionally brings to physician-
staff interaction is described by the nurse co-ordinator:
Sometimes, because I know the patient, I
am able to make suggestions...but I have
to be very careful when I do this. Basic-
ally it depends on the doctor in charge.
If he is self-confident himself, he will
usually appreciate a suggestion that he
hasn't considered. But if he is insecure,
he often gets angry and tells me I'm
speaking out of line.
Similarly, patients tend to identify not with a partic-
ular doctor ("my doctor") but with "the Clinic," "the doctors,"
or "the staff." The effect is a dilution of affect within
the physician-patient relationship as patients cease to be
totally dependent on an individual doctor. Clearly, on a
55
number of levels the authority of the physician is restricted
as he finds his role transformed from an autonomous author-
ity to a highly skilled, but nonetheless easily replaceable,
technician.
Physicians try to establish greater control in the
clinic by provoking minor confrontations between themselves
and the staff. Most doctors, for instance, never learn
clinic routine although many have been exposed to it for
months or years. However often they are instructed in pro-
per procedure, doctors continue to fill out prescription
slips improperly, to misplace patients' charts, to fail to
call if they intend to arrive late. Since the staff has no
legitimate sanctioning authority over these physicians, this
type of manipulation achieves its goal of a symbolic show
of control.
Physicians further respond to their restricted position
by placing a very low priority on OPD work. While Clinic
doctors suggest their own reasons for this opinion - their
busy schedules or the low prestige and limited educational
opportunities that clinic work provides - the answer lies
deeper than this, for doctors are chronically pressed for
time, and in reality OPD work differs little from private
ambulatory care.
It appears that the explanation, in part, lies with the
structural position of the Clinic physician and his resulting
lack of dominance. In his office, the private physician
makes the rules; on hospital floors, the house physician
makes decisions and gives orders-- orders which may not be
challenged even by the hospitalized patient's private phy-
sician. This, then, may explain one intern's assessment of
the problems with OPD work:
All housestaff hate the Clinic. They see
every patient as "fat, black, and forty with
hypertension and headaches"... .The attendings
hate it even more than I do. They feel they
are doing the same shit they do all day in
their office, only they're doing it for free.
The rest of the staff likes it OK, but they
have to work with doctors that aren't inter-
ested, and they probably don't like that.
That is, the work that some find objectively tedious becomes
additionally distasteful when,   the position   of
authority of the physician is challenged or in some way re-
56
stricted. Therefore, any attempt by the staff to alter the
work load or work situation provokes an immediate and harsh
response on the part of OPD doctors:
The issue of housestaff coming to Medical
Clinic one additional afternoon a week to
reduce the backlog of intake physical exams
was raised during Resident's Report today.
One resident said he was completely opposed
to the idea. He felt it was more important
for the housestaff to be spending that time
on the wards. Another said he would refuse
to go down to the Clinic even if he were
ordered to do so. He said that he had too
many other things to do.
It becomes clear that the effect of these various structural
constraints on physicians' role performance results in a
minimal commitment to the Clinic and to institutionalized
ambulatory care.
The Patients and the Staff
Parsons, in his classic conceptualization of the doc-
tor-patient relationship (1950), suggests that patients
and doctors participate in a set of mutually complemen-
tary social roles which fit together in such a way that
the health needs of the patient - which Parsons defines
principally in sociological terms - are largely satisfied
in the course of interaction with the physician. But for
Parsons, the social universe of health and illness con-
sists of unmediated doctor-patient interaction, clearly an
incomplete version of the contemporary medical system. For
Parsons fails to consider the differing perspectives and
expectations which participants socialized in radically dif-
ferent social systems (the professional and the lay) inevi-
tably bring to the locus of interaction. Freidson, a struc-
turally oriented medical sociologist, builds the idea of
conflict into his analysis of physician-patient interaction.
He writes:
...the separate worlds of experience and
reference of the layman and the professional
worker are always in potential conflict....
The practitioner, looking from his profes-
sional vantage point, preserves his detach-
57
ment by seeing the patient as a case to
which he applies the general rules and
categories learned during his protracted
professional training. The client, being
personally involved in what happens, feels
obligated to try to judge and control what
is happening to him (1961:175).
However, the client uses his own and not the professional's
criteria to reach judgements about his own course of action.
The essence of the conflict therefore lies with the doctor's
expectation that his recommendations will be followed and
the patient's desire not to relinquish control. More gener-
ally, though, the conflict is grounded in the differing
assumptions that individuals performing contrasting roles
bring to their interaction (Merton 1957).
A further shortcoming of the Parsonian model is its
failure to consider the larger context in which much con-
temporary medical treatment takes place. For while the dy-
adic model continues to dominate sociological analyses, solo
private practice has been serving as the arena for medical
treatment in a progressively smaller proportion of total
cases (Bloom and Wilson 1963). Instead, patients are turn-
Ing to outpatient clinics, prepaid group practices, and
other institutionally based health plans since they can no
longer easily afford the high cost of private care. As
such, the traditional physician-patient relationship is
transformed as it is mediated by the health institution and
its professional and para-professional staff.
The institutional staff is in a powerful position to
affect the course of doctor-patient interaction. For example,
it plays an important role in diminishing inter-group conflict
and tension, in part, by making the assumptions and expec-
tations of each group more comprehensible to the other. To
some extent, the staff at Western's Medical Clinic operates
simultaneously in both the doctor's and the patient's social
Worlds. In this way they serve as brokers (Mayer 1966;
Barth 1963) or cultural translators.
As a result of their professional or para-professional
training, as well as the demands of their professional roles,
the staff identifies with the clinic physicians, and they
have a generally sympathetic understanding of the basis of
Physicians' behavior. The medical director, for example,
commented:
The Clinic could be better organized. I'd
58
like to see the doctors happier...If
there were more supportive services we
might get more cooperation from the
doctors. Many of them are unhappy about
the lack of assistance they get.
A remark made by the clerk is even more to the point:
Some people expect too much of the doctors.
The Clinic is supposed to be a learning
situation, and so to schedule two Histories
and Physicals in one afternoon is too much.
And besides, the residents can't be asked
to do the H & P's because they generally
have a large patient following of their
own.
Interestingly, it is the medical director and the clerk, the
staff members positioned at absolute opposite ends of the
Clinic's hierarchical structure, who offer these remarks.
While the director is closest to the medical staff by virtue
of his background and training, the clerk is at the other end
in both categories - she is a black, high school-educated
woman. But by making herself a guardian of the medical staff's
interests, she integrates herself more securely into member-
ship on the Clinic's professional team.
At the same time, the staff members feel they understand
patient behavior and patient interests, and they try to make
them more comprehensible to the medical staff. The institu-
tional staff shares a number of ascribed characteristics with
many of the Clinic's patients, giving this understanding a
solid basis in reality. In addition to having class origins
which are often not far removed from those of the patients,
like the patients, the staff is largely outside most sources
of institutional power. Thus, for most staff, a distinct
advantage of OPD work, as compared with other hospital jobs,
is the increased responsibility and authority it affords them.
One staff member commented:
This is the most rewarding job I've ever
had. The challenge is great, but I've learned
a lot....I would never go back to the floors.
In addition, the Clinic's population is overwhelmingly fe-
59
male; roughly three fourths of Medical Clinic visits are made
by women. All of the Clinic's full-time staff are also
women, thus providing a further common interest bond between
patient and staff. For example, after recounting an incident
in which a patient failed to follow her doctor's instructions
because she wasn't feeling ill, a nurse went on to say:
We ourselves don't remember to take our meds,
get yearly Pap smears. How can we expect
patients to? When I have a bladder infection,
I stop taking pills the day the pain stops,
even though I know it will return if I do.
Identification with patients is therefore not difficult for
the supportive staff.
The staff's brokerage functions extend beyond merely
facilitating doctor-patient communication. Traditionally a
broker is a middleman who is able to obtain favors for his
clients from those with economic or political power. The
broker's own power is therefore indirect, and lies with his
ability to influence those with actual access to the power
structure (Mayer 1966, Barth 1963). However, the OPD staff
operates as brokers as they direct the flow of services
within the institution. As permanent, full-time workers in
an institution with an irregularly serviced clientele and
a temporary medical staff, the Clinic staff easily fits in-
to the middleman role. For as a rule, patients do not know
their doctors very well, and the time they spend in face-to-
face interaction with a doctor is only a fraction of the
total time spent in the Clinic; most of it is passed instead
in the waiting area, in the company of the staff. Further
strengthening of the staff's intermediary position comes
from their simultaneous functioning in the patient's and the
doctor's social worlds.
The staff willingly embraces the role of broker because
it affords them influence and authority greater than their
institutionally established position. The staff encourages
patients to transfer affective ties from the physicians - who
regard these ties as burdensome - to themselves. In this way,
the staff can function as legitimate representatives of pa-
tient interests. This, in turn, serves to increase their
prestige both with physicians and with patients, who are
grateful for any interest shown in what is otherwise an
essentially anonymous bureaucratic setting. Ties with par-
ticular patients are considered dyadic and strongly personal,
and such ties are jealously guarded by the staff. Newcomers
to the staff are advised that each current member has her own
60
group of patients who come to clinic solely to see her. They
therefore believe that attempts made by others to communicate
with these patients will most probably be received with si-
lence or hostility.
But although the staff serve as bidirectional brokers,
their primary influence lies with the patients. Here they
function as principal agents of patient socialization. For
instance, soon after a new patient registers in the Clinic,
she recognizes that merely being sick is not enough to guar-
antee medical treatment; she must know how to manipulate the
Clinic's social world as well. As one new registrant re-
marked:
I wasn't told anything in Eligibility: Not
when to make appointments or how to make
appointments or what kinds of doctors you
could see....
An array of specialized knowledge not required with a pri-
vate doctor is now needed. And a new medical role in addition
to the familiar sick role (Parsons 1951) must also be mas-
tered: That of the clinic patient. Such a patient must
accept, among other things, a rotating staff of doctors, none
of whom the patient has selected and none of whom will be her
personal doctor for very long; a seemingly endless series of
laboratory tests, procedures, referrals, and x-rays; and long
waits in the pharmacy, in the laboratory, and in the doctor's
waiting room. Many clinic patients are relatively new or
attend clinic only infrequently. Their socialization is
generally incomplete, and they are less accepting of the
frustrating aspects of the Clinic's services. As one patient
said:
I've been coming here for three months and
I haven't been helped at all. They haven't
done anything but send me from one doctor
to another, and from one clinic to another.
Why don't they just admit me to the hos-
pital once and for all so they could do a
complete series of tests. This way all that
happens is I lose time from my job; I just
sit here and wait for hours.
Patients more familiar with OPD routine better understand what
is required of them as clinic patients, and they often see as
assets what newer patients regard as disadvantages. One long-
61
time patient, for example, said:
The doctors here seem to take a real interest
in you. They confide in each other about you
and try to do everything possible...I don't
even mind waiting here; as a matter of fact,
I come here even earlier. I can talk to
people and it takes worries off my mind
(Zborowski 1966).
Socialization by the Clinic's staff ranges from explicit
health education to more subtle instruction on behavior ap-
propriate to clinic patients. As one nurse suggested during
a discussion of patients' perceived shortcomings of the
Clinic:
Patients complain because they want an unattain-
able ideal. They like the warmth and the per-
sonalism here, but they also want the efficiency
of (the University Hospital)...but they can't
really have both. The patients just have to
be educated not to be so demanding.
An additional aspect of the staff's role as agents of
socialization is their encouraging behavior in patients which
approximates the physician's image of the ideal patient, there-
by reinforcing the physician's own conceptualization of that
role. According to clinic physicians, two essential compon-
ents of the model patient are that: (1) the illness be a phy-
sical one without significant emotional overtones; and (2)
the patient be responsible and motivated to follow the pre-
scribed treatment regimen. First, the staff assists in fos-
tering the former by encouraging patients to bring their
emotional problems and social concerns to them rather than to
the medical staff. The director and nursing supervisor sup-
port the staff's functioning in this capacity, and they en-
courage the development of warm, personal relationships be-
tween patients and supportive staff members. Second, the
staff regard training in "responsibility and motivation" as
part of their broader socialization goals. As the nurse co-
ordinator remarked:
We haven't succeeded in properly teaching the
patients responsibility to us. We don't give
them the proper orientation toward what we
expect. Part of the population we have here
62
has never had to be responsible to or for
anything, keeping appointments, for example...
In the future, as part of my job, I'd like to
interview every new patient and orient them
to the Clinic to tell them what their respon-
sibilities to us are and what are ours to
them.
The staff, therefore, sees itself as not only helping patients
become better clinic patients, but better citizens as well.
In this way they represent an intermediate level between
doctor and patient, as they transform the goals and intentions
of the medical system into terms laymen are more likely to
understand and more willing to accept because they are
offered by those who present themselves as representatives of
the patient interest.
The Staff's Construction of Reality
Although not a group in the formal sense (Mair 1972;
Nadel 1951), the Clinic's staff is organized around principles
of permanency: it is a bounded, highly structured unit in
which pre-existing standards determine both the recruitment
of new members and the bases of internal organization. As
such, the staff creates and maintains explicit and readily
articulable belief systems which legitimate and orient their
own activity within the OPD. These systems of shared beliefs
and values, which include ideas about the group's goals and
purposes, play a fundamental role in maintaining solidarity
and internal organization in the Clinic (Parsons 1951; Mal-
inowski 1944). However, rather than one single belief system
to orient all activity, the staff simultaneously maintains at
least two competing systems, and each is called into action
depending on staff needs.
The set of beliefs which form the basis of OPD ideology
is a coherent set of principles which describes the staff's
stated attitudes toward the Clinic's social world: toward
patients, doctors, their own jobs, and the OPD itself. In
brief, it is philosophically humanistic, drawing heavily on
the "patients are people; treat the patient, not just the
disease" approach that is currently popular among health ed-
ucators and social scientists (Balint 1957; Bloom 1963; Kosa
1969; Norman 1969; Simmons 1958). As one nurse summed it up:
"We try to set it up so patients have a different feeling
about this place. We try to be flexible to patient needs."
Another remarked:   "...the real advantage is our attempt to
deal with the entire patient. In most medical offices they
63
never look beyond the heart and lungs."
Since the total patient is seen as the proper target for
all medical treatment, the staff place the highest value on
direct verbal interaction with patients, and their vaguely
defined conception of "quality care" has this concept at its
core. One staff member said:
I'd like to be able to spend more time with
patients...If we had more time to talk with
them and visit with them, I think we would
be able to help them. I think we would cut
down on the number of visits patients make
to the doctor.
Conversation with staff is thus considered the adequate, if not
preferred, treatment for many patient complaints.
This humanistic perspective leads some of the staff to
see the appropriate role of the Clinic extending far beyond
the usual medical and socio-psychological services such facil-
ities typically provide to include legal advice, assistance
with insurance policies, consumer advocacy and the like.
Patients are thought to lack the social skills and emotional
resources that the more privileged classes have for tangling
with bureaucracies. For in addition to being powerless,
patients are generally seen as insufficient, multi-problemed
personalities whose connections with the larger society are
at best fragile ones. "I don't think patients take advantage
of the clinic," said a nurse. "They have so little to start
with, they try to get everything out of us that they can.
They deserve everything they get. We'll try not to give it
to them, only they have so little to begin with." This
"humanitarian" view of patients allows the staff to see them-
selves as patrons (Foster 1967) who can successfully manipu-
late worlds patients ordinarily find closed to them. But this
definition of the patient's world additionally serves to re-
inforce the structurally dominant position of the staff by
defining "quality care" in terms so broad that it may poten-
tially be mediated by staff members in a multitude of areas
not directly related to medical care.
The picture of patients as weak and helpless beings further
works to the staff's own advantage for it augments their role
in the Clinic as it allows them to transform themselves from
ancillary employees to workers indispensable to patient care
and well-being. This is important on two levels: (1) Since
most of the staff's responsibilities involve day-to-day routine
chores (e.g., paperwork, answering telephones, assisting doctors),
their contribution to patient care is characteristically un-
64
dramatic. But by highlighting the interpersonal aspects, the
staff have the ready potential for making a meaningful con-
tribution to patient recovery. (2) Supportive staff roles
are generally undervalued by physicians, and the frustrations
this brings to supportive staffs during daily interaction is
amply documented in the literature (Kramer 1969; Mauksch 1969;
Smith 1955). But by attempting to create an ideological
alliance with patients by offering them a service not other-
wise available (e.g., sympathetic conversation), the staff
tries to solicit them to be their supporters, challenging
doctors to deal with staff members on a more professionally
equal basis. Furthermore, the solidarity created between
patients and staff, through exclusion of doctors, also serves
to increase the staff's own sense of professional self-esteem.
But like a true ideology (Berger 1963; Mannheim 1936),
this humanitarian view is, in some ways, a distortion of the
actual social reality. The staff's conception of patient
needs, for example, applies to only a small number of OPD
patients who do use the Clinic as a source of emotional sup-
port or stability. The overwhelming number of OPD visits,
however, are made by otherwise healthy patients suffering
acute episodes of illness. These patients want only quick,
efficient, effective medical treatment. Nevertheless, by
emphasizing the needs of the few, the staff strengthens
their own position on the medical team.
When staff behavior is examined, the differences between
the values they express and those on which they base their
activity become clearer. Instead of a humanistic orientation,
the values of rational bureaucracy are most evident, because
decisions which maximize efficiency, equilibrium, and control
are preferred. Conversation with patients, for example, is
given low task priority, and structural change is in the
interest of preserving the status quo. The medical director,
for example, regrets that his door is often closed to patients,
but feels that administrative meetings demand priority; the
nursing supervisor and the head nurse also allow administrative
duties to come before time spent in direct patient interaction.
The nurse co-ordinator spends several hours a week on paperwork
she admits could easily be done by a clerk. In these and
other ways, the staff's definition of quality care more closely
approaches the rationally bureaucratic one.
What is seen is the staff maintaining multiple, job-
oriented value systems, and selecting among these systems as
it suits their purposes at a given point in time, choosing
the humanistic system when they seek to legitimize their
structural position and the rational one when it is expedient
in practical terms to do so. As Firth writes:
65
The notion of value involves judgement
on a preference scale, a grading....
Choice is exercised in the light of
these values. From among the available
means, those are chosen which seem most
appropriate to the given ends...Choice
at some level of consciousness is re-
quired for most types of action (1961:123).
The staff therefore operates within at least two value
systems: one which orients their behavior (the rational) and
another which legitimates ideology (the humanistic). In the
course of their interactions with the other two important
groups in the OPD - patients and doctors - the staff exploits
the system that is suitable for their needs in a particular
situation, choosing the humanistic, for example, when an
alliance with patients will strengthen their position in the
organizational hierarchy and the rational when objective work
demands require that chores be efficiently completed.
Summary and Conclusion
The elements which characterize all bureaucratic systems -
namely the existence of a network of social relations which
forms it structure and the presence of a shared system of soc-
ial beliefs - exist in the Western Hospital Outpatient Clinic
in forms which explicitly affect the quality of interaction
within the organization. This paper has described some of
the ways in which this structure not only influences the
manner in which the staff perform their own roles, but ad-
ditionally some of the ways that the structure affects the
behavior of physicians and patients, the other two groups in
the Clinic. By controlling access to patients and to the
administration of medical services, the staff defines the
boundaries of physicians' performance. By mediating doctor-
patent interaction, the staff translates the expectations of
each group into terms meaningful to the other. And by main-
taining multiple value systems, the staff manipulates social
reality to retain structural control despite their actual an-
cillary positions. In these ways a group formally low in an
institutional hierarchy is able to establish and maintain
situational dominance and control.
NOTES
Acknowledgements. This study was supported in part by an N.I.H.
Training Grant (GM 1224). The author wishes to thank Professors
66
Burton Benedict, George M. Foster, E.A. Hammel and Dr. Mark
Zborowski for their helpful comments on an earlier draft of
this paper.
1 A pseudonym.
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