Pathways to the doctor: "clinical iceberg" and "the long tail"

January 19, 2008

I have been reading and taking some wiki notes about ‘Pathways to the Doctor’ in the Information Age: the Role of ICTs in Contemporary Lay Referral Systems written by Nettleton and Hanlon. The article stars explaining the ‘clinical iceberg’ concept identified by social scientists (Last, 1963; Wadsworth et al., 1971) during the post-war years. This concept refers to how and why individuals do, or do not seek medical help. In 1973, Zola’s study of the reasons given by outpatients revealed that it was not symptoms per se that prompted people to seek help but rather it was their social circumstances. He identified five ‘distinct no-physiological’ triggers to the decision to seek medical aid’:

  • the occurrence of an interpersonal crisis;
  • the perceived interference of an illness with social relationship;
  • ‘sanctioning’ by another person that a visit is warranted;
  • perceived interference whith physical activities;
  • and temporalizing symptoms -‘if its no better by Monday’ (p.58).

In other words medical and health advice was proffered and sought within what came know as the ‘lay referral system’ (Freidson, 1970). Sociologists therefore cast light on the informal health care work undertaken by lay people and demonstrated that in seeking formal health care professionals saw only the tip of the iceberg of illness (p.58).

Echoing Pickstone’s periodisations of medicine, Smith (2002) conceptualises a move from what he calls ‘industrial age medicine’ to ‘information age healthcare’:

Going over my notes, I have found points in common between the ‘clinical iceberg’ and ‘the long tail’ concept. But even in this ‘Information age health care’ Nettleton and Hanlon concluded that people’s pathways to care are rooted in their wider social circumstances, their particular health care needs and, in terms of gender at least, are structurally constrained. But somewhat paradoxically there seem to be two processes at work here. On the one hand there is a growing diversity of health care provision and use, and yet on the other hand the norms and values that underpin notions of health care use are concurrently contributing to reinforcement of the caution and conventionality. It appears that the Internet use is actually more contextually specific and so the circumstances of use tend to be both embedded and embodied.