Sot. Sci. Med. Vol. 32, No. 3, pp. 321-326, Printed in Great Britain
0277-9536/91$3.00+ 0.00 Pergamon Press plc
1591
THE PUBLIC PRESTIGE OF MEDICAL SPECIALTIES: OVERVIEWS AND UNDERCURRENTS STEPHEN M.
ROSOFF’and MAIIIIBW C. LEONE*
‘School of Human Sciences & Humanities, University of Houston, Houston, TX 77058, U.S.A. and 2Department of Criminal Justice, University of Nevada, Reno, NV 89557, U.S.A. Abstract-This investigation offers a comprehensive analysis of the relative social prestige of various medical specialties. The specialties were evaluated in terms of ascribed esteem by a lay sample of 400 respondents. Several attributes were then tested in order to measure their contribution to overall prestige. The results affirm that a stable prestige hierarchy exists among medical specialties, with certain ones, such as surgery and cardiology, consistently ranked at the top, and others, such as dermatology and psychiatry, consistently resting at the bottom. A specialty’s relative standing in perceived income and assigned social value are the best predictors of its hierarchical position, with income being the single best predictor. Moreover, the prediction of a specialty’s prestige appears to improve significantly when both variables-
income and value-are considered inclusively. Key words-medical specialty, occupational prestige, social status, social value, physician income
INTRODIJCIION of physician has figured prominently in almost all occupational status investigations. American studies over the previous seven decades [l-7] consistently have reported that physicians enjoy very high prestige relative to other occupations in general and other skilled professions in particular. Moreover, the medical profession has stood first in the status hierarchy in studies of occupational prestige in Great Britain [8] as well as many other industrialized nations [9]. While considerable empirical attention has been paid to the social standing of the medical profession, the matter of status differences within the genus ‘physician’ has been accorded far less scrutiny. The question (to paraphrase Orwell) of whether, in the public mind, some doctors are more equal than others remains conspicuously unattended. The handful of previous specialty investigations usually have been internally focused, i.e. specialties have been rated by samples of physicians and/or medical students [lo-141. Such studies reveal a stable prestige hierarchy, with certain specialties, such as surgery and cardiology, consistently finishing in the top tier, and others, such as dermatology and psychiatry, consistently finishing near the bottom. These investigations typically have measured specialty status according to a basic summary format in which respondents simply are asked to rate the general prestige of specialties. While this format often has served as a useful index of a specialty’s relative position, some researchers [IS, 161have recommended a multi-dimensional methodology, arguing that unidimensional measures of occupations have ignored the important question of why certain occupations are regarded more highly than others. The present study proposes to determine a summary hierarchy of selected medical specialties, as rated by a lay sample, and then endeavors to elaborate on this hierarchy by analyzing
The occupation
a number
of proposed variables in terms of their relative contribution to specialty status. Thus, the present study differs in several significant ways from most prior analyses of specialty prestige. First, it offers a consumer evaluation of medical specialties-an issue that often has been neglected. The raters here are not doctors (or soon-to-be doctors), who are apt to base their evaluations on subtle or technical distinctions within their profession. Instead, these lay raters are likely to rely upon broader criteria, such as popular reputation-a process far more typical of the manner in which occupational prestige is publicly conferred. Also, by comparing the general standing of specialties with their relative standing along contributing dimensions, the present study is able to address comprehensively the heretofore overlooked question of why one specialty may be more esteemed by the public than another. METHOD
Subjects Respondents were 400 college undergraduates at a California university. The age range was 18-58 with a mean of 21.4. Two-hundred and forty-six of the respondents (61.5%) were female, and 154 (38.5%) were male. One-hundred and forty-eight (37%) were freshmen; 85 (21%), sophomores; 87 (22%), juniors; and 80 (20%), seniors. In terms of academic majors, the breakdown was as follows: social science/social ecology 237 (59%); biology/chemistry 78 (20%); engineering/computer science 68 (17%); humanities/ fine arts 17 (4%). Participation was voluntary. These 400 individuals served as respondents in all test conditions within the present study. Procedure Esteem. A randomly ordered list of 10 medical specialty types was employed. The specialty types were: radiologist, psychiatrist, neurologist, dermatologist,321
322
STEPHENM. Resow and MATTHEWC. LEONE
general practitioner, ophthalmologist, cardiologist, surgeon, internist, and pediatrician. A brief standardized description of each specialty type was provided in order to control for possible lack of understanding by some respondents of the specialty types. Respondents were instructed to rank the list according to the personal esteem in which they hold each specialty type. Esteem was used as a surrogate for occupational prestige, in lieu of the more ambiguous phrase, ‘general standing’. Comprehensibility. This attribute is rooted in one of the earliest examinations of specialty status utilizing lay respondents. Hartmann [ 171 hypothesized that the relative standing of 25 health professions (many of them physician specialties) is, to a large exent, a consequence of public familiarity with their occupational descriptions and functions. Hartmann’s data appear to support his hypothesis. While surgeon and general practitioner were rated very highly, the specialties with ‘harder’ titles tended to fare poorly in relation to more ‘orthodox’ medical specialties and health professions, e.g. ophthalmologist was ranked lower than registered nurse, and orthopedist was ranked lower than pharmacist. Hartmann concluded that acquaintanceship with a specialtywhich he termed ‘comprehensibility’-leads to a higher appraisal of its comparative standing. Two measures of comprehensibility were employed in the present study: (1) a randomly ordered list of 12 health professions-the 10 specialty types under consideration and two nonphysician professions (chiropractor and optometrist); (2) a randomly ordered list of 16 occupations-the 10 specialty types under consideration and 6 nonphysician distracters. The respondents were instructed to identify which professions on list 1 they believe require an M.D. degree. Upon completing this task, they were further instructed to provide brief functional definitions for the occupations in list 2. Responses were coded on a 2, 1, 0 scale, in accordance with definitions provided by a dictionary of occupational titles. In ambiguous cases, responses to list 1 were used to aid scoring. For example, if a respondent offered a reasonable, but overly simplistic, definition of radiologist, such as, ‘Takes X-rays’, full credit was given if the respondent had correctly identified radiologist as an M.D., while only half credit was given if the respondent had failed to do so. Mean scores were calculated for each specialty, and the specialties were ranked in terms of comprehensibility. In addition, scores were correlated with esteem ratings. Since the esteem instrument provided definitions of the IO specialties under consideration, the ‘comprehensibility’ tests were adnuni~rcred first. IIKO/?IC,.On; of the most frequently self-reported criteria for the ascrrption of high social standing in the original NORC study [3] was high pay. Duncan [18] regressed a set of NORC scores on income data for each occupation and reported that income was a significant predictor of status. Coleman and Rainwater [6] analYzcd their hierarchy 01’ magnitude estimations along smlilar lines, and their regression coefficient indicated that the status value attributed to an occupation in 1974 increased roughly one point for every $250 of mean income. The present study hypothesizes that those medical specialists perceived by the lay
public to have the highest incomes are also assigned the highest prestige ratings. A national survey of IO,1 17 physicians in 18 specialties conducted by MedicoI Economics in 1984 [19] reported a mean net annual income hierarchy ranging from $179,690 for neurosurgeons to $68,600 for GPs. The top tier of the hierarchy is dominated by surgical subspecialists, while the bottom tier consists entirely of nonsurgical subspecialists. Included among the 18 specialties are the 10 under consideration in the present study. The respondents were instructed to rank the 10 specialty types under consideration according to estimated relative income. The present study presumes that most respondents would not know raw incomes of specialists. Consequently, ranked data were used, and ranks were substituted for raw income estimates, so that the rank order assigned to each specialty by a respondent became its income rating score. The specialties were then ranked according to mean rating scores, and a rank order correlation was determined between perceived income and ascribed esteem. Perceived income scores were also correlated with esteem ratings for each specialty type. As a measure of the accuracy of the public’s perceptions, the perceived rankings and the actual rankings yielded by the Medical Economics survey were also correlated. Social value. Nearly 50 years ago, Davis and Moore [20] presented a functionalist explanation of relative occupational status. They posited that, since some occupations are functionally more important than others, society must have a system of rewards to accord those valuable positions. From that system, social stratification arises. The functionalists maintain that the occupations most rewarded and most highly valued are those which have the greatest importance to society and require the greatest training or talent. Of these factors-social value and education -it is the former which appears more promising for the present study. AN doctors are extensively trained, regardless of specialty, but all specialists may not be equally valued by the public. If it is true, as the functionalists contend, that the status of physicians, relative to other occupations, is reflective of that profession’s value to society, it would follow that the status of medical specialties, relative to each other, might also reflect differences in popularly ascribed social importance. The respondents were instructed to rank the 10 specialty types under consideration according to social value. Since all physicians are likely to be rated high in importance, ranked data were again substituted for raw scores, forcing respondents to discriminate among specialties. The rank order assigned to each specialty serves as its social value score, so that the specialties can be ranked according to mean scores. A rank order correlation was determined between ascribed social value and assigned esteem. Social value rating scores were also correlated with esteem rating scores for each individual specialty. Doctor-patient interaction. A novel explanation by Shortell [21] of status differences within the medical profession rests upon the notion that a specialty’s status is highly related to the degree of control it typically exercises in doctor-patient interaction. Shortell’s idea stems from a classificatory model
Medical specialty prestige devised by Szasz and Hollander [22], which proposes three types of doctor-patient relationships: (1) activity-passivity (parent-infant prototype); (2) guidance-cooperation (parent-child prototype); (3) mutual participation (adult-adult prototype). As the doctor-patient relationship shifts from the activity-passivity model toward the mutual participation model, the patient’s dependency on the physician decreases, while personal control of his or her outcomes increases. Shortell suggests that specialties which fit the activity-passivity model would be assigned higher status, since individuals are more likely to accord greater esteem to physicians upon whom they are more dependent and who possess greater control over their fates. The data from all three groups of respondents in Shortell’s studydoctors, medical students, patients-strongly support this proposition, The present study re-examines the hypothesis, using a sample of lay respondents. The 10 specialty types under consideration were categorized according to the definitional criteria of the Szasz and Hollander schema, as they were in the Shortell design: activity-passivity (surgeon, radiologist, ophthalmologist); guidance-cooperation (general practitioner, internist, pediatrician, cardiologist, dermatologist, neurologist); mutual participation (psychiatrist). Respondents’ mean esteem ratings, obtained earlier, were analyzed using the Jonckheere test, a distributionfree k-sample measure of the significance of differences in ordered alternatives [23]. The hypothesis that a specialty’s status is positively related to the degree of control that it typically exerts over a patient’s fate anticipates that activity-passivity specialties would be assigned significantly higher esteem ratings than guidance-cooperation specialties; and that guidancecooperation specialties would receive significantly higher esteem ratings than psychiatry, the mutual participation specialty.
323
0.43. Thus, respondent pairs tend to give moderately similar esteem rankings to the 10 specialty types. The 10 specialties finish in the following order from most to least comprehensible: (1) surgeon; (2) cardiologist; (3) pediatrician; (4) general practitioner; (5) dermatologist; (6) neurologist; (7) ophthalmologist; (8) psychiatrist; (9) radiologist; (10) internist. The bottom three positions reflect the most common recognition problems encountered by respondents. While most respondents associated psychiatry with mental illness or emotional disorders, many failed to identify psychiatrists as M.D.s-apparently confusing psychiatry with clinical psychology. Likewise, most respondents linked radiology with X-rays, but many failed to attach a medical degree to this specialty. The biggest problem occurred with internist, which was misconstrued by a number of respondents as intern -a position of far less stature. These confusions undoubtedly depress the association between comprehensibility scores and esteem ratings-a moderate rank order correlation of +0.49. When the association between comprehensibility scores and esteem ratings are examined in terms of individual specialties (Table I), the correlations are significant at the 0.01 alpha level for each specialty except pediatrician, ophthalmologist, and dermatologist. However, all these significant correlations are negative. In other words, the less understood cardiology (for example) was, the higher its ascribed esteem tended to be. Table 2 shows the perceived income rankings, with mean rating scores included in parentheses. Also shown are the actual income rankings for the specialties as reported in the Medical Economics survey [19], with mean reported annual incomes included in parentheses. Reported income yields a modest rank Table 2. Comparison between reported income and perceived income for 10 specialties (N = 400) Specialty
RESULTS
Table 1 shows the esteem rank order and mean rank scores for the 10 specialty types. Because ranks are used as scores, low scores indicate high esteem and vice versa. The respondents yielded a coefficient of concordance (Kendall’s W) of 0.44. When W is converted into an average rank order correlation, the resulting coefficient is 0.43, meaning that if Spear-man’s r for all 79,800 possible pairs of respondents were computed, the average rank correlation would be
Surgery Cardiology Neurology Psychiatry Internal medicine Ophthalmology Pediatrics General practice Radiology Dermatology
Reported rank*
P&ceivcd rank**
4($117.940) 3($131,940) 5 (SlO8.830) 8 ($79,850) 7 ($89,660) 2 ($150.000) 9 (376,470) IO (S68,600) I ($159,820) 6 (5107,750)
I (2.07) 2 (2.75) 3 (3.01) 4 (5.41) 5 (5.45) 6 (5.95) 7 (6.79) 8 (7.23) 9 (7.74) IO (8.09)
*Source: Med. Econ. 9 Sept., 1985. **Lower scores= higher perceived income.
Table I. Correlations between esteem ratings and comprehensibility scores, perceived income ratings. and social value scores for IO scecialties (N = 4001 Specialty Surgery Cardiology Neurology Internal medicine Pediatrics Ophthalmology General practice Psychiatry Radiology Dermatology
Esteem** 2.62 2.99 3.15 5.09 5.82 5.95 6.39 6.71 7.34 8.39
Comprehensibility -0.11’ - 0.20. -0.19. -0.19. -0.04 0.02 -0.19* -0.11* -0.12* 0.01
*Significant at 0.01 alpha level. **Lower scores = higher rating. ***Value rankings and mean value scores are in parentheses,
Income 0.51. 0.43. 0.43’ 0.43’ 0.37’ 0.48. 0.47’ 0.34. 0.50’ 0.39’
Value*** 0.46’ 0.34’ 0.25’ 0.35’ 0.33’ 0.43’ 0.39’ 0.50. 0.3 I l 0.33.
(I. 2.54) (2. 3.68) (4.4.32) (6.5.59) (5.5.31) (7.6.28) (3.4.09) (8,6.91) (9, 7.43) (IO, 8.80)
324
STEPHENM. Rosorr and MAITHEWC. LEONE
order correlation of +0.16 with perceived income and + 0.13 with esteem. On the other hand, perceived income yields a rank order correlation of +0.87 with esteem, a finding that is significant at the 0.001 alpha level. The perceived income instrument yields a coefficient of concordance of 0.52 and an average rank order correlation of 0.51. This represents a slightly higher degree of concordance than was the case with the esteem instrument. Table 1 displays the correlation coefficient between respondents’ income ratings and esteem ratings for each of the specialties. All the correlations are significant at the 0.01 level of confidence. The ascribed social value test yields a coefficient of concordance of 0.40 and an average rank order correlation of 0.39-a moderate degree of rater agreement, though smaller than was the case with both assigned esteem and perceived income. Table 1 further displays the mean ascribed social value scores in parentheses. Social value yields a rank order correlation of +0X7 (the same as perceived income) with esteem, a finding that is significant at the 0.001 level. The correlation coefficients between respondents’ social value and esteem ratings for each specialty type are also shown in Table 1. All the correlations are significant at the 0.01 level. These data support the functionalist notion that ascribed social value is strongly associated with occupational status. This support is underscored by the significant correlations between value and esteem scores assigned by respondents for each specialty type and by the high rank order correlation between social value and esteem. Like perceived income, ascribed social value appears to be a highly effective attribute in the prediction of specialty status. When Jonckheere’s test for significant differences [23] is applied to the 10 specialties which were categorized according to the Szasz-Holiander schema, an S value of 5 is yielded. When S is divided by its maximum possible value (in this case, S/27), a modest rank order correlation (Kendell’s S) of +0.19 is derived. This result is not found to be statistically significant (P > 0.34). Because the variables of income and value appear to demonstrate such a strong positive association with esteem, it seems reasonable to examine specialty prestige in terms of these two contributing attributes. The perceived income and assigned social values scores of the respondents for each of the 10 specialties under consideration are analyzed by means of a stepwise multiple regression technique employing forward inclusion. Esteem ratings serve as the concomitant variable for each specialty. Income and value are entered in single steps, with the best predictor of esteem (i.e. the variable that explains the greatest amount of variance) entered first. In this manner, the relative contributions made by income and value can be weighed, and the degree of superiority of the two variables in tandem over the single best unidimensional predictor can be measured. Table 3 shows the percentages of explained variances (R2 values) for the stepwise multiple regressions of income and value on esteem ratings for the 10 specialties. About 23% of the variance in esteem ratings for ophthalmology, for example, is explained
Table 3. Stepwise regressions of income and value on esteem ratings of 10 specialties (N = 400) Specialty Stlrgery
Ophthalmology Radiology General practice Internal medicine Cardiology Dermatology Neurology Pediatrics Psychiatry*
Income (R’) 0.260s 0.2301 0.2497 0.2163 0. I863 0.1819 0. I494 0. I827 0.1396 0.3066
Value (RI) 0.3258 0.3057 O.tES9 0.2717 0.2195 0.2189 0.21 IS 0.2080 0.2010 0.2507
*The stepwise regression for psychiatry proceeds in the opposite direction (value to income) from the other 9 specialties.
by perceived income. When both income and value are considered, about 3 1% of the variance is explained. Thus, the inclusion of both variables explains about 35% more variance than the single best predictor of surgeon esteem-perceived income. Income is also the best unidimensional predictor of esteem in every other case, except psychiatrist (for which ascribed value explains the most variance). Overall, the prediction equation for specialty esteem is: Y’ = 3.09 + 0.35(income score) + 0.29(value score). DISCUSSION
A notable methodological adjustment occurs in the present study. In earlier occupational status examinations, respondents typically assigned rating scores to a large number of heterogeneous occupations, ranging from professional to menial. Mean rating scores were generally sufficient to establish a status hierarchy. This method would be problematic with a homogeneous sample of medical specialties, since all physicians are likely to generate high raw scores. Thus, respondents in the present study are instructed instead to rank the specialties relative to each other, and mean ranks are substituted for mean raw scores. By employing students in lieu of more general population samples, an unknown degree of generality may be sacrificed. However, past occupational prestige investigations have reported that status hierarchies tend to be quite stable from subgroup to subgroup within population samples, in terms of the degree to which various classes of respondents look up to occupations [18]. Grasmick [16] compared the prestige ratings of the student raters in his study with those of the 1963 NORC replication [7] and concluded that the judgment of college students regarding occupational status is notably similar to that reported by a representative national sample (r = 0.97). Grasmick’s respondents came from a large introductory sociology course, which, typically, would comprise a range of classes and majors-with freshmen social science majors somewhat overrepresented. As such was the case in the present study as well, the present findings may thus be satisfactorily generalizable. The esteem hierarchy appears to be largely consistent with prestige standings obtained in earlier studies. Surgery is a clear first choice, and dermatology rests firmly at the bottom, with the remaining specialties falling into place more or less as expected. This fundamental test is the linchpin for the present study,
Medical specialty prestige since esteem is almost certainly a blanket measure of occupational status. The relative esteem ranking of the specialties serves as a reference point for other, more narrow, attributes, which are compared to this summary status measure. The negative correlations obtained between comprehensibility and esteem fail to support Hartmann’s original hypothesis [17]. In most cases, as familiarity goes up, esteem ratings tend to go down. This failure may well be explained by the changes in public awareness and attitudes since 1934. It seems likely that the level of familiarity with medical specialties has risen substantially. This increased sophistication, coupled perhaps with an increased resentment of some aspects of the contemporary physician’s role, may have created a situation, less rare than in 1934, in which greater familiarity with a specialty could produce a loss of esteem. However, correlations are not statistically significant in every case, so, while provocative, a hypothesized negative association between comprehensibility and esteem is not inferable across all specialty types. In any event, the comprehensibility attribute, while perhaps useful in the cases of certain specialties, appears to be of dubious value as an overall predictor of the specialty prestige hierarchy. Income has been included as an attribute in virtually every multidimensional study of occupational prestige. In most instances, relative income ranking is a reasonably easy task, and respondents tend to be fairly accurate. Almost everyone recognizes, for example, that doctors generally earn more than sociology professors, who in turn generally earn more than janitors. Such intuition does not apply to medical specialties, however, as evidenced by the low rank order correlation between reported and perceived incomes. Respondents tended to be poor judges of actual relative positions within the income hierarchy. In the cases of psychiatrist (8 vs 4) ophthalmologist (1 vs 6) and dermatologist (6 vs lo), respondents were off by four places in their relative rankings. In the case of radiologist, respondents could hardly have been less accurate; radiologists reported the highest mean income among the specialties under consideration, but were perceived to be the second lowest. Actual income ranking, therefore, is not a very useful predictor of specialty status. As expected, it is perceived income level that is far more strongly associated with esteem. Moreover, the correlations between perceived income and esteem are highly significant for all 10 specialties. The data support the functionalist notion that ascribed social value is strongly associated with occupational status. This support is underscored by the significant correlations between value and esteem scores assigned by respondents for each specialty type and by the high rank order correlation between social value and esteem. The present study fails to support Shortell’s hypothesized relationship between level of control and status [20]. This failure perhaps suggests that Shortell’s significant findings, based upon samples of doctors, medical students, and hospitalized patients, are not generalizable to nonpatient lay samples. Thus, while the control hypothesis seems useful as a predictor of certain effects, such as patient attitudes toward specialists, it appears to be inoperative as a more general barometer of specialty prestige.
325
The results strongly suggest that the attributes of perceived income and assigned social value are the most consistently useful predictors of overall specialty esteem. Indeed, it is well worth noting that earlier British studies have also singled out income [24] and social value [25] as significant correlates of occupational stratification. The results further suggest that income is likely to be the single best unidimensional predictor of relative status. This may well have a number of relevant implications to various specialty types. For instance, the low prestige ascribed to radiology reflects that specialty’s relatively low standing in perceived income-a standing sharply contradicted by reported income data [19]. Since radiologists, in fact, tend to earn more money than most other specialists, it could easily be hypothesized that if the lay public were made aware of its misperception, the relative prestige of radiology could increase substantially. Likewise, if the public were more cognizant of the functional importance of dermatology-in areas far more vital than its stereotypic reputation for treating adolescent complexion disorders and so-called ‘dirty’ diseases-this might also elevate that specialty’s ascribed status [26]. In addition, it appears that the positive predictor variables of income and value, acting inclusively, significantly exceed any single variable in their capacity to explain comprehensively the prestige popularly ascribed to a specialty. In other words, a layperson’s ascription of prestige to a medical specialty seems mostly a function of the rater’s perception of both the financial worth and beneficial service of that specialty. Although a multidimensional format is not without flaws-regression assumes a linear relationship and may be insensitive to other possible nonlinear, predictive relationships among the variables-it is still perhaps the best estimate of specialty status yet proposed. Acknowledgement-The authors gratefully acknowledge Gilbert Geis for his invaluable suggestions on the organization of this paper.
REFERENCES
1. Counts G. The social status of occupations: a problem in vocational auidance. School Rev. 33. 16-27. 1925. 2. Hall C. W. S&ial prestige values of a selected group of occupations. Psychol. Bull. 35, 696, 1938. 3. National Opinion Research Center. Jobs and occupations: a popular evaluation. Opinion News 9.3-13, 1947. 4. Hatt P. K. Occupation and social stratification. Am. J. Social. 55, 532-543, 1950. 5. Hodge R. W., Siegel P. M. and Rossi P. H. Oceupational prestige in the United States, 1925-1963. Am. J. Social. 70, 286-302, 1964. 6. Coleman R. and Rainwater L. Social Standing in America. Basic Books, New York, 1978. 7. Guppy N. and Goyder J. C. Consensus on occupational prestige: a reassessment of the evidence. Sot. F&es 62, 709-725, 1984. 8. Hall J. and Jones D. C. Social grading of occupations, Br. J. Social. 1, 31-55, 1950. 9. Inkles A. and Rossi P. H. National comparisons of occupational prestige. Am. J. Social. 56,329-339, 1956. 10. Reader G. Development of professional attitudes and capacities. J. med. Educ. 33, 164-177, 1958.
326
STEPHEN
M. ROSOFFand MATTHEWC. LEONE
Il. Kritzer H. and Zimet C. N. A retrospective view of medical soecialty choice. J. med. E&c. 42, 47-55, 1967. 12. Schwartzbaum A. M.. McGrath J. H. and Rothman R. A. The perception of prestige differences among medical subspecialties. Sot. Sci. Med. 7, 365-371, 1973. 13. Gough H. G. Specialty preferences of physicians and medical students. .I. med. Educ. SO, 581-589, 1975. 14. Zimet C. N. and Held M. L. The development of views of specialties during four years of medical school. .I. med. Ed&. SO, 157-165; 1975: 15. Rossi P. H. and Inkeles A. Multidimensional ratinns of occupations. Sociometry 20, 234-251, 1957. 16. Grasmick H. G. The occupational prestige structure: a multi-dimensional scaling approach. Social. Q. 17, 90-108, 1976. 17. Hartmamt G. The relative social prestige of representitive medical specialties. J. appl. Psychol. 20, 659-675, 1934. 18. Duncan 0. D. A socioeconomic index for all occupations. In Occupations and Social Status (Edited by Reiss A. Jr), pp. 139-161. Free Press, New York, 1961.
19. Owens A. Doctors’ earnings: the year of the big surprise. Med. Econ. 195-215, 9 Sept., 1985. 20. Davis K. and Moore %‘. E. Some principles of stratification. Am. Social. Rev. 10. 242-249. 1945. 21. Shortell S. M. Occupational prestige differences within the medical and allied health professions. Sot. Sci. Med. 8, 1-9, 1974. 22. Scasz T. S. and Hollander M. A. A contribution to the philosophy of medicine: the basic models of the doctor patient relationship. AMA Archs intern. Med. 97. 585-592, 1956. 23. Jonckheere A. R. A distribution free k-sample test against ordered alternatives. Biometrika 41. 133-140. 1954. 24. Martin F. M. Some subjective aspects of social stratification. In Social Mobility in Britain (Edited by Glass D. V.), pp. 51-75. Routledge, London, 1967. 25. Goldthorpe J. H. and Hope K. The Social Grading of Occupations: A New Approach and Scale. Clarendon. Oxford, 1974. 26. Rosoff S. M. and Leone M. C. The prestige of dermatologists: are they “last among equals”? Inf. J. Dermatol.
28, 377-380,
1989.
0277-9536/91$3.00+ 0.00 Pergamon Press plc
1591
THE PUBLIC PRESTIGE OF MEDICAL SPECIALTIES: OVERVIEWS AND UNDERCURRENTS STEPHEN M.
ROSOFF’and MAIIIIBW C. LEONE*
‘School of Human Sciences & Humanities, University of Houston, Houston, TX 77058, U.S.A. and 2Department of Criminal Justice, University of Nevada, Reno, NV 89557, U.S.A. Abstract-This investigation offers a comprehensive analysis of the relative social prestige of various medical specialties. The specialties were evaluated in terms of ascribed esteem by a lay sample of 400 respondents. Several attributes were then tested in order to measure their contribution to overall prestige. The results affirm that a stable prestige hierarchy exists among medical specialties, with certain ones, such as surgery and cardiology, consistently ranked at the top, and others, such as dermatology and psychiatry, consistently resting at the bottom. A specialty’s relative standing in perceived income and assigned social value are the best predictors of its hierarchical position, with income being the single best predictor. Moreover, the prediction of a specialty’s prestige appears to improve significantly when both variables-
income and value-are considered inclusively. Key words-medical specialty, occupational prestige, social status, social value, physician income
INTRODIJCIION of physician has figured prominently in almost all occupational status investigations. American studies over the previous seven decades [l-7] consistently have reported that physicians enjoy very high prestige relative to other occupations in general and other skilled professions in particular. Moreover, the medical profession has stood first in the status hierarchy in studies of occupational prestige in Great Britain [8] as well as many other industrialized nations [9]. While considerable empirical attention has been paid to the social standing of the medical profession, the matter of status differences within the genus ‘physician’ has been accorded far less scrutiny. The question (to paraphrase Orwell) of whether, in the public mind, some doctors are more equal than others remains conspicuously unattended. The handful of previous specialty investigations usually have been internally focused, i.e. specialties have been rated by samples of physicians and/or medical students [lo-141. Such studies reveal a stable prestige hierarchy, with certain specialties, such as surgery and cardiology, consistently finishing in the top tier, and others, such as dermatology and psychiatry, consistently finishing near the bottom. These investigations typically have measured specialty status according to a basic summary format in which respondents simply are asked to rate the general prestige of specialties. While this format often has served as a useful index of a specialty’s relative position, some researchers [IS, 161have recommended a multi-dimensional methodology, arguing that unidimensional measures of occupations have ignored the important question of why certain occupations are regarded more highly than others. The present study proposes to determine a summary hierarchy of selected medical specialties, as rated by a lay sample, and then endeavors to elaborate on this hierarchy by analyzing
The occupation
a number
of proposed variables in terms of their relative contribution to specialty status. Thus, the present study differs in several significant ways from most prior analyses of specialty prestige. First, it offers a consumer evaluation of medical specialties-an issue that often has been neglected. The raters here are not doctors (or soon-to-be doctors), who are apt to base their evaluations on subtle or technical distinctions within their profession. Instead, these lay raters are likely to rely upon broader criteria, such as popular reputation-a process far more typical of the manner in which occupational prestige is publicly conferred. Also, by comparing the general standing of specialties with their relative standing along contributing dimensions, the present study is able to address comprehensively the heretofore overlooked question of why one specialty may be more esteemed by the public than another. METHOD
Subjects Respondents were 400 college undergraduates at a California university. The age range was 18-58 with a mean of 21.4. Two-hundred and forty-six of the respondents (61.5%) were female, and 154 (38.5%) were male. One-hundred and forty-eight (37%) were freshmen; 85 (21%), sophomores; 87 (22%), juniors; and 80 (20%), seniors. In terms of academic majors, the breakdown was as follows: social science/social ecology 237 (59%); biology/chemistry 78 (20%); engineering/computer science 68 (17%); humanities/ fine arts 17 (4%). Participation was voluntary. These 400 individuals served as respondents in all test conditions within the present study. Procedure Esteem. A randomly ordered list of 10 medical specialty types was employed. The specialty types were: radiologist, psychiatrist, neurologist, dermatologist,321
322
STEPHENM. Resow and MATTHEWC. LEONE
general practitioner, ophthalmologist, cardiologist, surgeon, internist, and pediatrician. A brief standardized description of each specialty type was provided in order to control for possible lack of understanding by some respondents of the specialty types. Respondents were instructed to rank the list according to the personal esteem in which they hold each specialty type. Esteem was used as a surrogate for occupational prestige, in lieu of the more ambiguous phrase, ‘general standing’. Comprehensibility. This attribute is rooted in one of the earliest examinations of specialty status utilizing lay respondents. Hartmann [ 171 hypothesized that the relative standing of 25 health professions (many of them physician specialties) is, to a large exent, a consequence of public familiarity with their occupational descriptions and functions. Hartmann’s data appear to support his hypothesis. While surgeon and general practitioner were rated very highly, the specialties with ‘harder’ titles tended to fare poorly in relation to more ‘orthodox’ medical specialties and health professions, e.g. ophthalmologist was ranked lower than registered nurse, and orthopedist was ranked lower than pharmacist. Hartmann concluded that acquaintanceship with a specialtywhich he termed ‘comprehensibility’-leads to a higher appraisal of its comparative standing. Two measures of comprehensibility were employed in the present study: (1) a randomly ordered list of 12 health professions-the 10 specialty types under consideration and two nonphysician professions (chiropractor and optometrist); (2) a randomly ordered list of 16 occupations-the 10 specialty types under consideration and 6 nonphysician distracters. The respondents were instructed to identify which professions on list 1 they believe require an M.D. degree. Upon completing this task, they were further instructed to provide brief functional definitions for the occupations in list 2. Responses were coded on a 2, 1, 0 scale, in accordance with definitions provided by a dictionary of occupational titles. In ambiguous cases, responses to list 1 were used to aid scoring. For example, if a respondent offered a reasonable, but overly simplistic, definition of radiologist, such as, ‘Takes X-rays’, full credit was given if the respondent had correctly identified radiologist as an M.D., while only half credit was given if the respondent had failed to do so. Mean scores were calculated for each specialty, and the specialties were ranked in terms of comprehensibility. In addition, scores were correlated with esteem ratings. Since the esteem instrument provided definitions of the IO specialties under consideration, the ‘comprehensibility’ tests were adnuni~rcred first. IIKO/?IC,.On; of the most frequently self-reported criteria for the ascrrption of high social standing in the original NORC study [3] was high pay. Duncan [18] regressed a set of NORC scores on income data for each occupation and reported that income was a significant predictor of status. Coleman and Rainwater [6] analYzcd their hierarchy 01’ magnitude estimations along smlilar lines, and their regression coefficient indicated that the status value attributed to an occupation in 1974 increased roughly one point for every $250 of mean income. The present study hypothesizes that those medical specialists perceived by the lay
public to have the highest incomes are also assigned the highest prestige ratings. A national survey of IO,1 17 physicians in 18 specialties conducted by MedicoI Economics in 1984 [19] reported a mean net annual income hierarchy ranging from $179,690 for neurosurgeons to $68,600 for GPs. The top tier of the hierarchy is dominated by surgical subspecialists, while the bottom tier consists entirely of nonsurgical subspecialists. Included among the 18 specialties are the 10 under consideration in the present study. The respondents were instructed to rank the 10 specialty types under consideration according to estimated relative income. The present study presumes that most respondents would not know raw incomes of specialists. Consequently, ranked data were used, and ranks were substituted for raw income estimates, so that the rank order assigned to each specialty by a respondent became its income rating score. The specialties were then ranked according to mean rating scores, and a rank order correlation was determined between perceived income and ascribed esteem. Perceived income scores were also correlated with esteem ratings for each specialty type. As a measure of the accuracy of the public’s perceptions, the perceived rankings and the actual rankings yielded by the Medical Economics survey were also correlated. Social value. Nearly 50 years ago, Davis and Moore [20] presented a functionalist explanation of relative occupational status. They posited that, since some occupations are functionally more important than others, society must have a system of rewards to accord those valuable positions. From that system, social stratification arises. The functionalists maintain that the occupations most rewarded and most highly valued are those which have the greatest importance to society and require the greatest training or talent. Of these factors-social value and education -it is the former which appears more promising for the present study. AN doctors are extensively trained, regardless of specialty, but all specialists may not be equally valued by the public. If it is true, as the functionalists contend, that the status of physicians, relative to other occupations, is reflective of that profession’s value to society, it would follow that the status of medical specialties, relative to each other, might also reflect differences in popularly ascribed social importance. The respondents were instructed to rank the 10 specialty types under consideration according to social value. Since all physicians are likely to be rated high in importance, ranked data were again substituted for raw scores, forcing respondents to discriminate among specialties. The rank order assigned to each specialty serves as its social value score, so that the specialties can be ranked according to mean scores. A rank order correlation was determined between ascribed social value and assigned esteem. Social value rating scores were also correlated with esteem rating scores for each individual specialty. Doctor-patient interaction. A novel explanation by Shortell [21] of status differences within the medical profession rests upon the notion that a specialty’s status is highly related to the degree of control it typically exercises in doctor-patient interaction. Shortell’s idea stems from a classificatory model
Medical specialty prestige devised by Szasz and Hollander [22], which proposes three types of doctor-patient relationships: (1) activity-passivity (parent-infant prototype); (2) guidance-cooperation (parent-child prototype); (3) mutual participation (adult-adult prototype). As the doctor-patient relationship shifts from the activity-passivity model toward the mutual participation model, the patient’s dependency on the physician decreases, while personal control of his or her outcomes increases. Shortell suggests that specialties which fit the activity-passivity model would be assigned higher status, since individuals are more likely to accord greater esteem to physicians upon whom they are more dependent and who possess greater control over their fates. The data from all three groups of respondents in Shortell’s studydoctors, medical students, patients-strongly support this proposition, The present study re-examines the hypothesis, using a sample of lay respondents. The 10 specialty types under consideration were categorized according to the definitional criteria of the Szasz and Hollander schema, as they were in the Shortell design: activity-passivity (surgeon, radiologist, ophthalmologist); guidance-cooperation (general practitioner, internist, pediatrician, cardiologist, dermatologist, neurologist); mutual participation (psychiatrist). Respondents’ mean esteem ratings, obtained earlier, were analyzed using the Jonckheere test, a distributionfree k-sample measure of the significance of differences in ordered alternatives [23]. The hypothesis that a specialty’s status is positively related to the degree of control that it typically exerts over a patient’s fate anticipates that activity-passivity specialties would be assigned significantly higher esteem ratings than guidance-cooperation specialties; and that guidancecooperation specialties would receive significantly higher esteem ratings than psychiatry, the mutual participation specialty.
323
0.43. Thus, respondent pairs tend to give moderately similar esteem rankings to the 10 specialty types. The 10 specialties finish in the following order from most to least comprehensible: (1) surgeon; (2) cardiologist; (3) pediatrician; (4) general practitioner; (5) dermatologist; (6) neurologist; (7) ophthalmologist; (8) psychiatrist; (9) radiologist; (10) internist. The bottom three positions reflect the most common recognition problems encountered by respondents. While most respondents associated psychiatry with mental illness or emotional disorders, many failed to identify psychiatrists as M.D.s-apparently confusing psychiatry with clinical psychology. Likewise, most respondents linked radiology with X-rays, but many failed to attach a medical degree to this specialty. The biggest problem occurred with internist, which was misconstrued by a number of respondents as intern -a position of far less stature. These confusions undoubtedly depress the association between comprehensibility scores and esteem ratings-a moderate rank order correlation of +0.49. When the association between comprehensibility scores and esteem ratings are examined in terms of individual specialties (Table I), the correlations are significant at the 0.01 alpha level for each specialty except pediatrician, ophthalmologist, and dermatologist. However, all these significant correlations are negative. In other words, the less understood cardiology (for example) was, the higher its ascribed esteem tended to be. Table 2 shows the perceived income rankings, with mean rating scores included in parentheses. Also shown are the actual income rankings for the specialties as reported in the Medical Economics survey [19], with mean reported annual incomes included in parentheses. Reported income yields a modest rank Table 2. Comparison between reported income and perceived income for 10 specialties (N = 400) Specialty
RESULTS
Table 1 shows the esteem rank order and mean rank scores for the 10 specialty types. Because ranks are used as scores, low scores indicate high esteem and vice versa. The respondents yielded a coefficient of concordance (Kendall’s W) of 0.44. When W is converted into an average rank order correlation, the resulting coefficient is 0.43, meaning that if Spear-man’s r for all 79,800 possible pairs of respondents were computed, the average rank correlation would be
Surgery Cardiology Neurology Psychiatry Internal medicine Ophthalmology Pediatrics General practice Radiology Dermatology
Reported rank*
P&ceivcd rank**
4($117.940) 3($131,940) 5 (SlO8.830) 8 ($79,850) 7 ($89,660) 2 ($150.000) 9 (376,470) IO (S68,600) I ($159,820) 6 (5107,750)
I (2.07) 2 (2.75) 3 (3.01) 4 (5.41) 5 (5.45) 6 (5.95) 7 (6.79) 8 (7.23) 9 (7.74) IO (8.09)
*Source: Med. Econ. 9 Sept., 1985. **Lower scores= higher perceived income.
Table I. Correlations between esteem ratings and comprehensibility scores, perceived income ratings. and social value scores for IO scecialties (N = 4001 Specialty Surgery Cardiology Neurology Internal medicine Pediatrics Ophthalmology General practice Psychiatry Radiology Dermatology
Esteem** 2.62 2.99 3.15 5.09 5.82 5.95 6.39 6.71 7.34 8.39
Comprehensibility -0.11’ - 0.20. -0.19. -0.19. -0.04 0.02 -0.19* -0.11* -0.12* 0.01
*Significant at 0.01 alpha level. **Lower scores = higher rating. ***Value rankings and mean value scores are in parentheses,
Income 0.51. 0.43. 0.43’ 0.43’ 0.37’ 0.48. 0.47’ 0.34. 0.50’ 0.39’
Value*** 0.46’ 0.34’ 0.25’ 0.35’ 0.33’ 0.43’ 0.39’ 0.50. 0.3 I l 0.33.
(I. 2.54) (2. 3.68) (4.4.32) (6.5.59) (5.5.31) (7.6.28) (3.4.09) (8,6.91) (9, 7.43) (IO, 8.80)
324
STEPHENM. Rosorr and MAITHEWC. LEONE
order correlation of +0.16 with perceived income and + 0.13 with esteem. On the other hand, perceived income yields a rank order correlation of +0.87 with esteem, a finding that is significant at the 0.001 alpha level. The perceived income instrument yields a coefficient of concordance of 0.52 and an average rank order correlation of 0.51. This represents a slightly higher degree of concordance than was the case with the esteem instrument. Table 1 displays the correlation coefficient between respondents’ income ratings and esteem ratings for each of the specialties. All the correlations are significant at the 0.01 level of confidence. The ascribed social value test yields a coefficient of concordance of 0.40 and an average rank order correlation of 0.39-a moderate degree of rater agreement, though smaller than was the case with both assigned esteem and perceived income. Table 1 further displays the mean ascribed social value scores in parentheses. Social value yields a rank order correlation of +0X7 (the same as perceived income) with esteem, a finding that is significant at the 0.001 level. The correlation coefficients between respondents’ social value and esteem ratings for each specialty type are also shown in Table 1. All the correlations are significant at the 0.01 level. These data support the functionalist notion that ascribed social value is strongly associated with occupational status. This support is underscored by the significant correlations between value and esteem scores assigned by respondents for each specialty type and by the high rank order correlation between social value and esteem. Like perceived income, ascribed social value appears to be a highly effective attribute in the prediction of specialty status. When Jonckheere’s test for significant differences [23] is applied to the 10 specialties which were categorized according to the Szasz-Holiander schema, an S value of 5 is yielded. When S is divided by its maximum possible value (in this case, S/27), a modest rank order correlation (Kendell’s S) of +0.19 is derived. This result is not found to be statistically significant (P > 0.34). Because the variables of income and value appear to demonstrate such a strong positive association with esteem, it seems reasonable to examine specialty prestige in terms of these two contributing attributes. The perceived income and assigned social values scores of the respondents for each of the 10 specialties under consideration are analyzed by means of a stepwise multiple regression technique employing forward inclusion. Esteem ratings serve as the concomitant variable for each specialty. Income and value are entered in single steps, with the best predictor of esteem (i.e. the variable that explains the greatest amount of variance) entered first. In this manner, the relative contributions made by income and value can be weighed, and the degree of superiority of the two variables in tandem over the single best unidimensional predictor can be measured. Table 3 shows the percentages of explained variances (R2 values) for the stepwise multiple regressions of income and value on esteem ratings for the 10 specialties. About 23% of the variance in esteem ratings for ophthalmology, for example, is explained
Table 3. Stepwise regressions of income and value on esteem ratings of 10 specialties (N = 400) Specialty Stlrgery
Ophthalmology Radiology General practice Internal medicine Cardiology Dermatology Neurology Pediatrics Psychiatry*
Income (R’) 0.260s 0.2301 0.2497 0.2163 0. I863 0.1819 0. I494 0. I827 0.1396 0.3066
Value (RI) 0.3258 0.3057 O.tES9 0.2717 0.2195 0.2189 0.21 IS 0.2080 0.2010 0.2507
*The stepwise regression for psychiatry proceeds in the opposite direction (value to income) from the other 9 specialties.
by perceived income. When both income and value are considered, about 3 1% of the variance is explained. Thus, the inclusion of both variables explains about 35% more variance than the single best predictor of surgeon esteem-perceived income. Income is also the best unidimensional predictor of esteem in every other case, except psychiatrist (for which ascribed value explains the most variance). Overall, the prediction equation for specialty esteem is: Y’ = 3.09 + 0.35(income score) + 0.29(value score). DISCUSSION
A notable methodological adjustment occurs in the present study. In earlier occupational status examinations, respondents typically assigned rating scores to a large number of heterogeneous occupations, ranging from professional to menial. Mean rating scores were generally sufficient to establish a status hierarchy. This method would be problematic with a homogeneous sample of medical specialties, since all physicians are likely to generate high raw scores. Thus, respondents in the present study are instructed instead to rank the specialties relative to each other, and mean ranks are substituted for mean raw scores. By employing students in lieu of more general population samples, an unknown degree of generality may be sacrificed. However, past occupational prestige investigations have reported that status hierarchies tend to be quite stable from subgroup to subgroup within population samples, in terms of the degree to which various classes of respondents look up to occupations [18]. Grasmick [16] compared the prestige ratings of the student raters in his study with those of the 1963 NORC replication [7] and concluded that the judgment of college students regarding occupational status is notably similar to that reported by a representative national sample (r = 0.97). Grasmick’s respondents came from a large introductory sociology course, which, typically, would comprise a range of classes and majors-with freshmen social science majors somewhat overrepresented. As such was the case in the present study as well, the present findings may thus be satisfactorily generalizable. The esteem hierarchy appears to be largely consistent with prestige standings obtained in earlier studies. Surgery is a clear first choice, and dermatology rests firmly at the bottom, with the remaining specialties falling into place more or less as expected. This fundamental test is the linchpin for the present study,
Medical specialty prestige since esteem is almost certainly a blanket measure of occupational status. The relative esteem ranking of the specialties serves as a reference point for other, more narrow, attributes, which are compared to this summary status measure. The negative correlations obtained between comprehensibility and esteem fail to support Hartmann’s original hypothesis [17]. In most cases, as familiarity goes up, esteem ratings tend to go down. This failure may well be explained by the changes in public awareness and attitudes since 1934. It seems likely that the level of familiarity with medical specialties has risen substantially. This increased sophistication, coupled perhaps with an increased resentment of some aspects of the contemporary physician’s role, may have created a situation, less rare than in 1934, in which greater familiarity with a specialty could produce a loss of esteem. However, correlations are not statistically significant in every case, so, while provocative, a hypothesized negative association between comprehensibility and esteem is not inferable across all specialty types. In any event, the comprehensibility attribute, while perhaps useful in the cases of certain specialties, appears to be of dubious value as an overall predictor of the specialty prestige hierarchy. Income has been included as an attribute in virtually every multidimensional study of occupational prestige. In most instances, relative income ranking is a reasonably easy task, and respondents tend to be fairly accurate. Almost everyone recognizes, for example, that doctors generally earn more than sociology professors, who in turn generally earn more than janitors. Such intuition does not apply to medical specialties, however, as evidenced by the low rank order correlation between reported and perceived incomes. Respondents tended to be poor judges of actual relative positions within the income hierarchy. In the cases of psychiatrist (8 vs 4) ophthalmologist (1 vs 6) and dermatologist (6 vs lo), respondents were off by four places in their relative rankings. In the case of radiologist, respondents could hardly have been less accurate; radiologists reported the highest mean income among the specialties under consideration, but were perceived to be the second lowest. Actual income ranking, therefore, is not a very useful predictor of specialty status. As expected, it is perceived income level that is far more strongly associated with esteem. Moreover, the correlations between perceived income and esteem are highly significant for all 10 specialties. The data support the functionalist notion that ascribed social value is strongly associated with occupational status. This support is underscored by the significant correlations between value and esteem scores assigned by respondents for each specialty type and by the high rank order correlation between social value and esteem. The present study fails to support Shortell’s hypothesized relationship between level of control and status [20]. This failure perhaps suggests that Shortell’s significant findings, based upon samples of doctors, medical students, and hospitalized patients, are not generalizable to nonpatient lay samples. Thus, while the control hypothesis seems useful as a predictor of certain effects, such as patient attitudes toward specialists, it appears to be inoperative as a more general barometer of specialty prestige.
325
The results strongly suggest that the attributes of perceived income and assigned social value are the most consistently useful predictors of overall specialty esteem. Indeed, it is well worth noting that earlier British studies have also singled out income [24] and social value [25] as significant correlates of occupational stratification. The results further suggest that income is likely to be the single best unidimensional predictor of relative status. This may well have a number of relevant implications to various specialty types. For instance, the low prestige ascribed to radiology reflects that specialty’s relatively low standing in perceived income-a standing sharply contradicted by reported income data [19]. Since radiologists, in fact, tend to earn more money than most other specialists, it could easily be hypothesized that if the lay public were made aware of its misperception, the relative prestige of radiology could increase substantially. Likewise, if the public were more cognizant of the functional importance of dermatology-in areas far more vital than its stereotypic reputation for treating adolescent complexion disorders and so-called ‘dirty’ diseases-this might also elevate that specialty’s ascribed status [26]. In addition, it appears that the positive predictor variables of income and value, acting inclusively, significantly exceed any single variable in their capacity to explain comprehensively the prestige popularly ascribed to a specialty. In other words, a layperson’s ascription of prestige to a medical specialty seems mostly a function of the rater’s perception of both the financial worth and beneficial service of that specialty. Although a multidimensional format is not without flaws-regression assumes a linear relationship and may be insensitive to other possible nonlinear, predictive relationships among the variables-it is still perhaps the best estimate of specialty status yet proposed. Acknowledgement-The authors gratefully acknowledge Gilbert Geis for his invaluable suggestions on the organization of this paper.
REFERENCES
1. Counts G. The social status of occupations: a problem in vocational auidance. School Rev. 33. 16-27. 1925. 2. Hall C. W. S&ial prestige values of a selected group of occupations. Psychol. Bull. 35, 696, 1938. 3. National Opinion Research Center. Jobs and occupations: a popular evaluation. Opinion News 9.3-13, 1947. 4. Hatt P. K. Occupation and social stratification. Am. J. Social. 55, 532-543, 1950. 5. Hodge R. W., Siegel P. M. and Rossi P. H. Oceupational prestige in the United States, 1925-1963. Am. J. Social. 70, 286-302, 1964. 6. Coleman R. and Rainwater L. Social Standing in America. Basic Books, New York, 1978. 7. Guppy N. and Goyder J. C. Consensus on occupational prestige: a reassessment of the evidence. Sot. F&es 62, 709-725, 1984. 8. Hall J. and Jones D. C. Social grading of occupations, Br. J. Social. 1, 31-55, 1950. 9. Inkles A. and Rossi P. H. National comparisons of occupational prestige. Am. J. Social. 56,329-339, 1956. 10. Reader G. Development of professional attitudes and capacities. J. med. Educ. 33, 164-177, 1958.
326
STEPHEN
M. ROSOFFand MATTHEWC. LEONE
Il. Kritzer H. and Zimet C. N. A retrospective view of medical soecialty choice. J. med. E&c. 42, 47-55, 1967. 12. Schwartzbaum A. M.. McGrath J. H. and Rothman R. A. The perception of prestige differences among medical subspecialties. Sot. Sci. Med. 7, 365-371, 1973. 13. Gough H. G. Specialty preferences of physicians and medical students. .I. med. Educ. SO, 581-589, 1975. 14. Zimet C. N. and Held M. L. The development of views of specialties during four years of medical school. .I. med. Ed&. SO, 157-165; 1975: 15. Rossi P. H. and Inkeles A. Multidimensional ratinns of occupations. Sociometry 20, 234-251, 1957. 16. Grasmick H. G. The occupational prestige structure: a multi-dimensional scaling approach. Social. Q. 17, 90-108, 1976. 17. Hartmamt G. The relative social prestige of representitive medical specialties. J. appl. Psychol. 20, 659-675, 1934. 18. Duncan 0. D. A socioeconomic index for all occupations. In Occupations and Social Status (Edited by Reiss A. Jr), pp. 139-161. Free Press, New York, 1961.
19. Owens A. Doctors’ earnings: the year of the big surprise. Med. Econ. 195-215, 9 Sept., 1985. 20. Davis K. and Moore %‘. E. Some principles of stratification. Am. Social. Rev. 10. 242-249. 1945. 21. Shortell S. M. Occupational prestige differences within the medical and allied health professions. Sot. Sci. Med. 8, 1-9, 1974. 22. Scasz T. S. and Hollander M. A. A contribution to the philosophy of medicine: the basic models of the doctor patient relationship. AMA Archs intern. Med. 97. 585-592, 1956. 23. Jonckheere A. R. A distribution free k-sample test against ordered alternatives. Biometrika 41. 133-140. 1954. 24. Martin F. M. Some subjective aspects of social stratification. In Social Mobility in Britain (Edited by Glass D. V.), pp. 51-75. Routledge, London, 1967. 25. Goldthorpe J. H. and Hope K. The Social Grading of Occupations: A New Approach and Scale. Clarendon. Oxford, 1974. 26. Rosoff S. M. and Leone M. C. The prestige of dermatologists: are they “last among equals”? Inf. J. Dermatol.
28, 377-380,
1989.
