Working diagnosis: The medical labour process and the classification of suffering.

Medical sociologists argue that diagnosis is a critical component of medicine and that diagnosis is most obviously exercised by doctors. This scholarship, however, largely ignores other medical workers. I extend the concept of working diagnosis to help solve this problem. These are partial and preliminary medical classifications of suffering that are imposed between informal experiences of illness and formal classifications of disease. In a complex division of medical labour where doctoring is a minority practice, working diagnoses are critical forces that shape, and are shaped by, the relational conditions of medical production. To illustrate the analytical promise of this concept, I sharpen it through an ethnography of ambulance work in California. Working diagnoses in this case are officially referred to as 'primary impressions'. I show how these impressions are deeply embedded in the relations of paramedical production. Three are specifically highlighted: the relations between ambulance crews and their patients, the relations between ambulance crews and their nurse and police counterparts and the relations between ambulance crews and their managers. I work towards a simple but rarely stated conclusion: medical sociologists should focus more heavily on how diagnostic processes influence labour processes and vice versa.

Producing paramedicine: Case studies in the medical labor process.

How is medical labor power, that being the capacity to assemble, adjust, or arrange medical subjects, converted into medical practice? Drawing on three qualitative case studies in the United States, Canada, and the United Kingdom, we argue that this conversion is shaped by pressures channeled through the relations that medical workers enter into with patients "from below" and managers "from above." We demonstrate this by examining a common empirical object: ambulance labor. In addition to providing a unique window into the varieties of medical work, paramedicine offers a strategic venue for examining the kinds of productive relations that medical laborers enter into. Our research shows how the labor process is shaped by patient requests that can either conform or contradict workers' shared sense of vocation. We also detail how this same process is simultaneously pressured by managers who are generally focused on increasing both the flexibility and the visibility of their workers. Many of these pressures, we argue, can be linked to common forces of neoliberalism across our three nations. Our analysis of the medical labor process inspires some practical recommendations to reform ambulance-based care. However, our primary aim is to advance a labor-centric approach to studying medicine.

Neighborhood Poverty and 9-1-1 Ambulance Response Time.

BACKGROUND: Are 9-1-1 ambulances relatively late to poorer neighborhoods? Studies suggesting so often rely on weak measures of neighborhood (e.g., postal zip code), limit the analysis to particular ambulance encounters (e.g., cardiac arrest responses), and do little to account for variations in dispatch priority or intervention severity. METHODS: We merged EMS ambulance contact records in a single California county (n = 87,554) with tract-level data from the American Community Survey (n = 300). After calculating tract-level median ambulance response time (MART), we used ordinary least squares (OLS) regression to estimate a conditional average relationship between neighborhood poverty and MART and quantile regression to condition this relationship on 25th, 50th, and 75th percentiles of MART. We also specified each of these outcomes by five dispatch priorities and by three intervention severities. For each model, we estimated the associated changes in MART per 10 percentage point increase in tract-level poverty while adjusting for emergency department proximity, population density, and population size. RESULTS: Our study produced three major findings. First, most of our tests suggested tract-level poverty was negatively associated with MART. Our baseline OLS model estimates that a 10 percentage point increase in tract-level poverty is associated with almost a 24 s decrease in MART (-23.55 s, 95% confidence interval [CI] -33.13 to -13.98). Results from our quantile regression models provided further evidence for this association. Second, we did not find evidence that ambulances are relatively late to poorer neighborhoods when specifying MART by dispatch priority. Third, we were also unable to identify a positive association between tract-level poverty and MART when we specified our outcomes by three intervention severities. Across each of our 36 models, tract-level poverty was either not significantly associated with MART or was negatively associated with MART by a magnitude smaller than a full minute per estimated 10 percentage point increase in poverty concentration. CONCLUSION: Our study challenges the commonly held assumption that ambulances are later to poor neighborhoods. We scrutinize our findings before cautiously considering their relevance for ambulance response time research and for ongoing conversations on the relationship between neighborhood poverty and prehospital care.

Neighborhood Poverty and 9-1-1 Ambulance Contacts.

BACKGROUND: Neighborhood poverty is positively associated with frequency of 9-1-1 ambulance utilization, but it is unclear whether this association remains significant when accounting for variations in the severities and types of ambulance contacts. METHODS: We merged EMS ambulance contact records in a single California county (n = 88,027) with data from the American Community Survey at the census tract level (n = 300). Using tract as a proxy for neighborhood and negative binomial regression as an analytical tool, we predicted 16 outcomes: any ambulance contacts, ambulance contacts stratified by three intervention severities, and ambulance contacts varied by 12 primary impression categories. For each model, we estimated the incident rate ratios for 10 percentage point increases in tract-level poverty while controlling for geographic patterns in race, citizenship, gender, age, emergency department proximity, population density, and population size. RESULTS: Our study produced three major findings. First, tract-level poverty was positively associated with ambulance contacts (incident rate ratio [IRR] 1.45; 95% confidence interval [CI] 1.34 to 1.57). Second, poverty was positively associated with low severity contacts (IRR 1.48; 95% CI 1.35 to 1.61), medium severity contacts (IRR 1.38; 95% CI 1.28 to 1.49), and high severity contacts (IRR 1.40; 95% CI 1.30 to 1.51). Third, poverty was positively associated with 12 primary impression categories: abdominal (IRR 1.48; 95% CI 1.36 to 1.61), altered level of consciousness (IRR 1.37; 95% CI 1.25 to 1.50), cardiac (IRR 1.28; 95% CI 1.14 to 1.42), overdose/intoxication (IRR 1.59; 95% CI 1.40 to 1.81), pain (IRR 1.56; 95% CI 1.41 to 1.73), psych/behavioral (IRR 1.50; 95% CI 1.34 to 1.67), respiratory (IRR 1.42; 95% CI 1.29 to 1.56) seizure (IRR 1.52; 95% CI 1.38 to 1.68), stroke (IRR 1.14; 95% CI 1.01 to 1.28), syncope/near syncope (IRR 1.23; 95% CI 1.12 to 1.36), trauma (IRR 1.44; 95% CI 1.31 to 1.58), and general weakness (IRR 1.31; 95% CI 1.20 to 1.42). CONCLUSION: Our study suggests poverty is a positive, strong, and enduring predictor of ambulance contacts at the neighborhood level. The relationship between neighborhood poverty and ambulance utilization should be considered at multiple levels of EMS decision making.