This, incidentally, is not the only indication of the fact that the majority. of these doctors feel it better to appear modern in their drug use than to appear conservative. Gammanym had two older competitors, drugs of the same general type, that had been released some years earlier. We shall call them “alphanym" and "betanym" in the order of their appearance. Doctors were asked which drug of this type they currently used most frequently, and their answers were compared with the drug that appeared most frequently in their recent prescription record.

The largest percentage in each column of Table V is not located at the diagonal, where the two readings correspond, but below the diagonal. That is to say, there is a strong tendency to update one's prescription habits (at least with respect to this family of drugs) and to update to the very newest thing.

The interview statements, in brief, would seem to yield a correct ordering of most (though not all) of the doctors according to the promptness of their use of gammanym but not to reproduce the precise dates. In view of this fact, does the earlier finding (Table II) really mean that each doctor has some over-all tendency to try new drugs early or late or does it merely prove that those who exaggerated, in their memory, their promptness with one drug will exaggerate their promptness with other drugs? If the association between the stated introduction dates of three drugs is merely a result of the doctor's varying tendencies to exaggerate their promptness, then the doctors who exaggerate most (in either direction) should show the association most, and the doctors who give accurate accounts should not show it at all. Table VI therefore divides the sample of doctors according to the degree of accuracy of their stated gammanym introduction dates (Table IV) and records for each resulting group separately the degree to which the reported introduction dates of three drugs go together.

Table VI shows clearly that the tendency to show equal promptness with regard to the introduction of several drugs is at least as high among the more accurately reporting segment of the doctors as among the whole group. In fact, it is the less accurately reporting segment which shows the lower association. Since distortion in the interview does not raise the apparent tendency to equal promptness with regard to the several drugs, it may be concluded that this tendency is not merely apparent but real. (Finer breakdowns as to accuracy than those used in Table VI give completely parallel results but are not shown because

of the small frequencies involved.) These doctors do indeed differ from each other in a generalized tendency to adopt each new drug early or late after its release, a tendency which expresses itself anew each time a new drug appears.

TABLE VI.
TIMING OF FIRST USE OF THREE NEW DRUGS SHOWN SEPARATELY FOR DOCTORS
GIVING MORE AND LESS Accurate AccountS OF THEIR INTRODUCTION DATE OF GAMMANYM

†The figures for this group differ slightly from those in Table II because here only those doctors are considered on whom prescription as well as interview data on gammanym are available.

THE EXTENT OF USE OF NEW DRUGS

The discussion so far has revolved around the question, "How soon after its release will a doctor introduce a new drug into his practice?" We now turn to the question, “How extensively will the doctor use a new drug, once it has become established?" This is a rather complex topic. It was necessary to concentrate on some one family of drugs, so that the doctors could be questioned about its use in considerable detail. Antibiotics, applicable in a wide variety of situations, were selected. The first question to be considered here is, "For what range of indications does the doctor use the newer drugs?" Doctors were asked what antibiotic or sulfonamide they most commonly used for gastrointestinal, genitourinary, and respiratory tract infections. Many doctors preferred penicillin or sulfa drugs for all three of these types of infections; a few preferred the newer drugs (broad-spectrum antibiotics and special antibiotics like bacitracin, neomycin, polymyxin, etc.) for all 3 infections; still others preferred penicillin and sulfa drugs for some of these infections, and the newer drugs for others (Table VII).

TABLE VII. PREFERENCE FOR NEWER ANTIBIOTICS OVER PENICILLIN OR SULFONAMIDES IN THREE INFECTIOUS CONDITIONS

A second meaning of the question, "How widely does the doctor use the newer drugs," is "How early in the course of the diagnosis of a given case is the decision to use the newer drugs reached?" This question is, of course, especially relevant in the case of antibiotics. Doctors answered detailed questions about their treatment of "pneumonia," broadly defined as suspected cases of any kind of pneumonia or pneumonitis. The largest group of doctors indicated that they treated such cases initially with penicillin and had recourse to one of the broadspectrum drugs when penicillin failed. Another group administered the broadspectrum drugs initially, either with or without penicillin. A third group indicated that they prescribed broad-spectrum drugs only after laboratory or other special diagnostic procedures had satisfied them that they dealt with "virus pneumonia," and a final very small group said that they never used broadspectrum antibiotics for cases of pneumonia (Table VIII). Are the doctors who prefer the newer antibiotics for a wide range of infectious conditions more likely than others to use them early in the course of the diagnosis of a given case? Table IX gives the answer. A fairly strong relationship between these two tendencies is seen to exist. One-quarter of those who prefer the newer antibiotics for a wide range of conditions, contrasting with only 8 per cent of those who usually prefer penicillin or sulfa drugs, administer broad-spectrum antibiotics as soon as "some kind of pneumonia" is encountered. Conversely, only 13 per cent of the former group but 33 per cent of the latter refuse to prescribe broadspectrum drugs for pneumonia patients without a laboratory diagnosis, if then.

TABLE VIII. POINT IN DIAGgnosis of "PNEUMONIA" AT WHICH
BROAD-SPECTRUM ANTIBIOTICS ARE USED

TABLE IX. RANGE OF INFECTIONS FOR WHICH NEW ANTIBIotics Are PreFERRED, COMPARED WITH Promptness to Use Broad-Spectrum Antibiotics in the Course of DIAGNOSIS OF "PNEUMONIA"

This bespeaks a very consistent attitude of either enthusiasm or hesitancy toward the newer antibiotics. Since this attitude is also associated with preference for the newest product among the broad-spectrum antibiotics (not shown), it may be concluded that it is, at least to a certain extent, an expression of a tendency to prefer (or mistrust, as the case may be) new therapeutic agents.

EXTENT OF USE OF NEWEST DRUGS COMPARED WITH PROMPTNESS OF
DRUG INTRODUCTIONS

It remains to be seen whether a doctor's tendency to make wide use of newer drugs, discussed in the last few paragraphs, is related to the tendency to introduce new drugs quickly, which was discussed earlier. Table X therefore classifies doctors according to the average promptness with which they tried "gammanym," "cryptonym," and the "drug most recently tried" after their respective release dates. It becomes possible to see whether the doctors who were fast and slow to try new drugs differ correspondingly in the extent to which they make use of new drugs which have already become established.

In each of the two parts of Table X, the percentages differ from column to column, but the differences follow no consistent direction. This indicates that neither the range of conditions for which a doctor prefers the newer antibiotics nor his willingness to prescribe broad-spectrum antibiotics at various points in the diagnosis of "pneumonia" are systematically related to the promptness with which he tries new drugs. Thus it appears that the extent to which the newer drugs are used by preference to their older equivalents is not systematically related to the promptness with which a doctor tries a newly available drug. (It should be remembered that "extent of use," as used here, is not the same as prescription volume but means, rather, the number of different situations in which the new drug is used or the frequency with which it is used relative to its competitors.)

All the evidence considered up to this point referred to the use of new drugs— in fact, only to selected classes of new drugs. As far as this evidence goes, however, it is concluded that a doctor's early or late adoption of the particular new

TABLE X. Timing of First Use of Three New Drugs Compared WITH EXTENT Of Use of NEWER DRUGS

The three conditions considered are gastrointestinal, genitourinary, and respiratory infections.

drug that was first examined is not an isolated event but tends to be associated with certain other expressions of a positive or negative attitude toward innovations. Early users of one drug were very likely also to be early users of a second and a third drug. On the other hand, no connection could be proved between the promptness with which a physician tries newly released drugs and the extent to which he makes use of newer rather than older drugs, once the newer drugs have been in general use long enough that preferences for them have reached an equilibrium point.

But what of other innovations in medical practice besides the use of new pharmaceutical products? After all, the rapid development of new medications is only one of several ways in which contemporary medical practice is undergoing continuous change, and probably not the most important one. Are doctors who are progressive in their drug use, in any sense of the word, prone to be especially receptive to innovations of other types? We will now consider from this point of view doctors' reactions to the new doctor-patient relationship that has developed during recent decades. We will examine the possibility of rating doctors on a conservative-modern continuum by turning to their reactions to certain broader features of the practice of medicine at mid-century.

THE ROLE OF PSYCHOLOGY IN MEDICAL PRACTICE

One of the newer trends in medicine is that toward increasing attention to psychologic factors in organic ailments. In the course of these same interviews held in 4 midwestern cities, the doctors were asked the following question: "In recent years, there has been a lot of emphasis on psychosomatic medicine in the profession. Do you think there is too much emphasis on this, or not enough?"