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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. THE SOCIAL CONSTRUCT OF THE DOCTOR-PATIENT RELATIONSHIP: ORIGINS AND POTENTIAL FOR CHANGE

DISSERTATION

Presented in Partial Fulfillment of the Requirements

for the Degree Doctor of Philosophy in the

Graduate School of The Ohio State University

Maryanna Danis Klatt M.A.

*****

The Ohio State University 2002

Dissertation Committee: Approved by Professor Seymour Kleinman, Adviser

Professor Lesley Ferris Adviser Professor Thomas Kasulis College of Education

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UMI Number 3049051

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Copyright by Maryanna Danis Klatt 2002

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ABSTRACT

This dissertation is an exploration of the ways in which the doctor-patient

relationship evolved into a functional social construct that remained fairly constant

through most of the 20th century, yet is in a state of transformation at the beginning of

the 21st century. This research illuminates factors shaping the relationship, and the

elements necessary to build positive doctor-patient relations from the perspective of

both doctors and patients.

A doctor-patient relationship portrayed in Margaret Edson’s play, WIT, was

used as a case study, and as a prompt, for audience members to reflect upon their own

doctor-patient relations. Audience members, including doctors, patients, and medical

students, were interviewed to explore how they construct their own roles within this

relation, in an effort to examine how the construction impacts communication.

College students were surveyed to explore younger adults’ conception and

expectations of the same relation. Societal reaction to WIT was tracked to gauge the

importance of issues raised in the play, as evidenced by the scope of the attention it

received. Lastly, an ethnographic experience of teaching a medical school class in

which medical students were asked to examine their professional identity construction

of “physician” was detailed. ii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Patients, doctors, and medical students all considered the social expectations

within the doctor-patient relation to be in a state of transformation. Satisfaction with

the doctor-patient relation across the board was most clear when the doctor and

patient described sharing congruent expectations with the other in this relation.

Communication within this relation reflected the perceived role o f the self within the

doctor-patient relation. Patients and college students indicated that the most desired

approach to treatment by a doctor was “treating them as a whole person.”

Cultural influences impacting this relation include openness to various

paradigms of wellness and health, a shift toward viewing patients as consumers who

are most satisfied with patient-centered care, and acceptance of the Internet as a factor

in health information, and potentially, in health communication. A model of

communication across cultural difference is explored and recommended as a tool to

enhance and facilitate communication within a patient-centered approach to the

doctor-patient relation.

iii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGMENTS

This doctoral dissertation came to fruition because of the help and support of

many people. Completion of this project was made possible through the friendship

and editorial insights of my friend Anne Barnes. The warmth, laughter, and journey

traveled together during the past few years were gifts I am fortunate to have

experienced. For this, I express deep gratitude.

The doctoral research process was enriched by the guidance and

encouragement by members of my committee, Seymour Kleinman, Thomas P.

Kasulis, and Lesley Ferris. All three members offered me unique steps in this “dance

of qualitative research” for which I am most thankful.

The research participants that opened their hearts and lives to me through

stories of their health care relationships enriched my life and research in a way that

convinced me that attainment of a positive health care experience is possible, and is

worth seeking and creating.

I thank Darcy Lord and Jennifer Strickland for sharing this process that

demands community. Most of all, I celebrate my family. My children, Will, Anna,

and Joseph Klatt made this project possible by affirming the essential nature of

process in each and every goal. For being together in the goal of process, I thank my

life-long friend and husband, Bill Klatt, who knows who I am iv

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. VITA

June 28, 1960 ...... Bom - Dayton, Ohio

1982 ...... B.A. Psychology, Kenyon College

1989 ...... M.A. Religious Studies, University of Virginia

2001...... M.A. Education, The Ohio State University

1983-1985 ...... Faculty Member, Bishop Hartley High School

1985-1996 ...... Faculty Member, Bishop Watterson High School

1996-1997 ...... Adjunct Faculty Member, Franklin University

1996-1997 ...... Adjunct Faculty Member, Ohio Dominican College

1999 - 2001 ...... Graduate Teaching Assistant, The Ohio State University, College of Education

FIELDS OF STUDY

Major Field: College of Education

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS

Page

Abstract ...... ii

Acknowledgments ...... iv

Vita...... v

List of Tables ...... ix

List of Figures ...... x

Chapters:

1. Introduction ...... 1

1.1 The problem ...... 1 1.2 Using theater as a means to examine the problem ...... 3 1.3 The problem plays out: real life consequences ...... 12 1.4 Assumptions and limitations ...... 18 1.5 Expected contributions of the study ...... 19 1.6 Overview of chapters ...... 20

2. Framing the doctor-patient relation ...... 23

2.1 Science and the socially constructed identity of doctor-patient ...... 23 2.2 Physician as professional ...... 34 2.3 Doctor-patient roles within medical discourse and the communicative process ...... 40 2.4 Moving beyond exclusive medical discourse ...... 47 2.5 Conclusion ...... 56

3. Design and methodology ...... 58

3.1 Pilot study ...... 58 vi

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3.2 The use of theater as a case study ...... 63 3.3 Qualitative interviews with audience members ...... 66 3.4 Survey of college students ...... 71 3.4.1 Quantitative surveys ...... 73 3.4.2 Open-ended questionnaire ...... 74 3.5 Impact of WIT on culture ...... 74 3.6 Action research - teaching a medical school class ...... 77 3.7 Summary...... 82

4. Data results and analysis ...... 83

4.1 Qualitative interviews of audience members ...... 83 4.1.1 Patients ...... 84 4.1.2 Doctors ...... 97 4.1.3 Medical students ...... 106 4.2 Survey of college student audience members ...... 112 4.2.1 Quantitative data analysis ...... 112 4.2.2 Open-ended questions ...... 122 4.3 Evidence of W ITs impact on culture ...... 127 4.4 Medical students consider the identity of physician ...... 132 4.5 Summary of data results and analysis ...... 140 4.5.1 Qualitative interviews with patients, doctors, and medical students ...... 140 4.5.2 Surveys given to college students ...... 143 4.5.3 The cultural success of WIT...... 145 4.5.4 Ethnographic reflections teaching a medical school class... 146 4.6 Limitations of the study ...... 146

5. Conclusions and recommendations ...... 148

5.1 Satisfaction with the doctor-patient relation ...... 149 5.2 The iuture of the doctor-patient relation ...... 151 5.3 Current winds o f change within medicine ...... 156 5.3.1 The concept of medical professionalism ...... 157 5.3.2 Patient-centered care ...... 158 5.3.2.1 The medical interview ...... 159 5.3.2.2 Kasulis’ theory of cultural difference enriching medicine ...... 163 5.3.3 Cybermedicine: empowerment for better care...... 164 5.3.4 Medical education ...... 167 5.3.5 Patients choosing alternative care ...... 172

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendices:

Appendix A Materials relating to qualitative interviews with audience members ...... 175 Appendix B Survey of college student audience members ...... 185 Appendix C Materials relating to the medical school course, The Physicians Identity ...... 188 Appendix D Numerical results of college student survey...... 198 Appendix E Societal interest in doctor-patient communication ...... 206

Bibliography ...... 208

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF TABLES

Table Page

D. 1 Response frequency by gender for each question ...... 199

D.2 College students’ perception of (actors determining doctor-patient relation ...... 202

D.3 Impact of gender on questions 1-12...... 203

D.4 Degree to which “planning on becoming a health care worker” impacted other responses ...... 204

D.5 Degree to which students’ experience with serious illness impacted other responses ...... 205

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF FIGURES

Figure Page

3.1 Interview distribution by role, gender, and age ...... 70

4.1 Distribution of responses to question 1 ...... 113

4.2 Distribution of responses to question 2 ...... 113

4.3 Distribution of responses to question 3 ...... 114

4.4 Distribution of responses to question 4 ...... 114

4.5 Distribution of responses to question 5 ...... 115

4.6 Distribution of responses to question 6 ...... 115

4.7 Distribution of responses to question 7 ...... 116

4.8 Distribution of responses to question 8 ...... 116

4.9 Distribution of responses to question 9 ...... 117

4.10 Distribution of responses to question 10 ...... 117

4.11 Distribution of responses to question 11 ...... 118

4.12 Distribution of responses to question 12 ...... 118

4.13 Factors determining the nature of the doctor-patient relationship as perceived by college students ...... 120

4.14 Frequency of items pictured in drawings distinguishing oneself as a physician ...... 134

C. 1 Examples of medical student drawings of self as doctor ...... 194 x

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 1

INTRODUCTION

“I've heard it said that there is a window that opens from one mind to another but if there is no wall, there’s no need for fitting the window or the latch.” -Rumi

Delivery of a cancer diagnosis:

DR. KELEKIAN: “Well, yes. Now then. You present with a growth that, unfortunately, went undetected in stages one, two, and three. Now it is an insidious adenocarcinoma, which has spread from the primary adnexal mass - ”

VIVIAN (the patient): ‘Insidious”? (excerpt from WIT by Margaret Edson, 1999)

1.1 THE PROBLEM

Why is the interaction between doctor and patient often fraught with

confusion, frustration, and disappointment? Sometimes the medical news being

delivered is all of those things: confusing, frustrating, and extremely disappointing.

The messenger needs to be intensely careful in the mode of delivery. Yet, often this

is not the case. Doctors, under a myriad of professional pressures, are often criticized

for being “cold,” “uncaring,” and “impersonal.” Is this a fair characterization? What 1

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. do patients expect from their doctors? What do doctors desire from their patients? Is

it a difference in expectations that accounts for problems in communication between

patients and doctors?

The experience of Vivian Bearing, Ph.D., the protagonist in Margaret Edson’s

1999 Pulitzer Prize-winning drama called WIT, may be significantly like the

experience of many other Americans. Are patients befuddled by their doctor’s

instructions? This study uses the staged production of WIT as a prompt for audience

members to consider the doctor-patient relationship portrayed in WIT, and reflect

upon their own doctor-patient relationships.

WIT first opened in Costa Mesa, CA, in 1995. Since that time, it has played at

the Union Square Theater in New York City and has toured nationally and

internationally. WIT has been performed in over thirty medical schools in the United

States over the past two years (WIT Educational Initiative, 2000).

Doctors, patients, and medical students interested in commenting on WIT were

interviewed in an attempt to grasp the current construction of these two roles. They

were invited to imagine the kind of doctor-patient relationship they desire.

Interviewing both doctors and patients allowed access to the doctor-patient dyad and

how one envisions oneself and the other in this dynamic.

In addition to audience interviews, I surveyed undergraduate reactions to WIT.

A quantitative survey of all O.S.U. students enrolled in the course, Theater 100, in

Spring 2001 explored the expectations and personal conceptions of undergraduates

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. concerning the doctor-patient relationship. All students taking this course (n = 1001)

were required to attend a performance o f WIT. Participation in this study was not

required, yet a 57% response rate was achieved.

Teaching a four-week class in the Medical Humanities Program at Ohio State

University Medical School offered an opportunity to explore medical students

reaction to WIT and how it may affect their future. This was an elective offering in

the medical school curriculum, entitled The Physician's Identity. The classroom

conversations were treated as ethnographic data, gleaned from students preparing to

become doctors. I wanted to see how they envisioned themselves as “doctors.” After

experiencing the performance of WIT, all of the medical students agreed to be

interviewed.

Using theater to explore images of “the other” (e.g., patient looking at doctor,

doctor looking at patient) creates a space allowing for the deconstruction of self and

other. The interviews reveal that seeing oneself in the role of the other can be

threatening or disarming. Often expressed as anger, this response occurred among all

the populations involved: doctors, patients, and medical students. This very

discomfort may be the reason WIT proves to be a successful pedagogical tool.

1.2 THEATER AS A MEANS TO EXAMINE THE PROBLEM

Why use theater to examine a differential power relationship often played out

in the doctor-patient relationship? Theater can explore borders and border crossings.

Throughout history, it has been used to both transmit and challenge culture. Ernesto

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Laclau (1990) in New Reflections on the Revolution o f Our Time, comments that if

one wishes to push forward the political debate . . . it is necessary to construct a new

language - and a new language means. . . new objects, new problems, new values,

and the possibility of discursively constructing new antagonisms and new forms of

struggle. Theater can speak and struggle with such innovation.

Theater succeeds as a pedagogical tool (the critical factor to the pragmatist)

because it engages the entire person, in this case, the audience member. This is what

is referred to as the “somatic” process at work in current educational theory (Hocking,

Haskell, & Linds, 2001). These authors use the term “embodiment” which refers to

the whole experiencing person. Thomas Hanna (1970) defines this as “somatics,” or

the body as experienced from within. Experience is viewed not as a disembodied

concept or idea, but as a living, ongoing process. A theatrical event can be like this.

Each person brings his or her own configuration of life experiences and cultural

heritage to the theater. We all know that the same piece of theater can elicit a wide

and varied range of reaction - anger, joy, sympathy, frustration, compassion,

boredom - in various gradations and combinations. Insofar as such theatrical

participation involves the person’s whole complex of body, mind, and spirit, it

exemplifies such a somatic process. Yet that process is always mediated. Race,

gender, and cultural construction are important variables for investigating and

understanding how theater art addresses important cultural issues.

Throughout the ages, theater has been used to present societal dilemmas and

to consider ways and means of resolution. It can also be effective in exploring power

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. relationships. An example is the African playwright Wa Thong’o Ngugi who wrote

plays challenging the leaders of his country to allow cultural freedom. He knew the

necessity of writing plays in the vernacular: language itself constructs and/or limits

what can be said. Theater can flirt with messages that are often hard to hear because

theater itself intrinsically examines what it means to “represent” and to be

“represented.” Theater invites the audience member to be the one to take the piece of

theater beyond representation, having it impact his or her own life. This possibility

resides in the real space between theatrical presentation and the audience member. In

particular, Margaret Edson comments on the role of the audience in the theatrical

presentation of WIT:

The play is an interactive relationship between the actress and the audience. It is the relationship between actress and audience that drives the play forward. The audience plays a lot of different roles during the evening - a group of students, close friends, and even judges.1

Theater involves the audience in a unique pedagogical way. The audience

member is a personal witness to the story itself and has somatic reactions to the piece

of theater. Theater elicits emotions and visceral responses, which can be strong

motivating elements, both in learning (LeDoux, 1996; Pert, 1997; Goleman, 1995)

and societal change (Ngugi, 1993).

John Dewey (1934) would describe a theatrical presentation as “an

experience” of art for audience members if the audience member is transformed in

some way by the experience. WIT fits his description of “art as experience.” Eric

Jensen (2000) stresses that it is novel or high contrast stimuli (or stimuli of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. sufficiently strong emotional intensity) that best captures a learner’s attention. If a

way to get people thinking about something important is to engage people somatically

in the experience of it, then Margaret Edson’s WIT does just that for the doctor-

patient relationship. WIT stresses both the importance of treating patients as whole

persons and the agony of its absence. The play positions the audience to somatically

experience the doctor-patient relationship. Edson reveals this relationship to be a

location of empowerment, a relationship affecting healing. Margaret Edson knows it,

and so does the audience by the last scene. She provides the audience with difficult

and complex questions that they need to explore outside the theater, questions that are

central to an examined life in this new world of medical possibility: life, death, and

that critical comma between them.

This piece of self-conscious theater also explores the seeming contradiction

between being “academically at the top of your game” and being a compassionate

communicator. The protagonist in WIT is an academic who has treated her students

with the same rigid formality with which her doctors treat her. WIT “stories” Vivian

Bearing, Ph.D., an English professor, who is in battle with her doctors as she is

treated like a discrete disease to be conquered, rather than as a whole human being

suffering from a terminal illness. She calls into question the hegemonic culture of

academia and research: both hers and that of medicine. She breaks down the real

space between actor and audience by pushing the edge of the performance space, and

by inviting us into the abyss of her professional life from the perspective of a patient,

1 Quoted from an interview with playwright Margaret Edson by Laura Jones, Editor, Last Acts, http://www.lastacts.org. 6

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. stripped of identity, professional or otherwise. Let me introduce to you to Vivian

Bearing, professor of H^-century poetry, as she finds herself in the new role of being

a patient.

VIVIAN: I’ll never forget the time I found out I had cancer.

(DR. HARVEY KELEKIAN enters at a big desk piled high with papers.)

KELEKIAN: You have cancer.

VIVIAN: (To audience) See? Unforgettable. It was something of a shock. I had to sit down. (She plops down.)

KELEKIAN: Please sit down. Miss Bearing, you have advanced metastatic ovarian cancer.

VIVIAN: Go on.

KELEKIAN: You are a professor, Miss Bearing.

VIVIAN: Like yourself Dr. Kelekian.

KELEKIAN: Well, yes. Now then. You present with a growth that, unfortunately, went undetected in stages one, two, and three. Now it is an insidious adenocarcinoma, which has spread from the primary adnexal mass-

VTVIAN: “Insidious”?

KELEKIAN: “Insidious” means undetectable at an—

VIVIAN: “Insidious” means treacherous.

KELEKIAN: Shall I continue?

VIVIAN: By all means.

KELEKIAN: Good. In invasive VIVIAN: Insidious. Hmm. epitheliad carcinoma, the Curious word choice, most effective treatment Cancer. Cancel, modality is a chemotherapeutic agent.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. We are developing an experimental combination of drugs designed for primary-site ovarian, with “By cancer nature’s a target specificity of changing course stage three-and-beyond untrimmed.” No—that’s administration not it.

Am I going too fast? (To KELEKIAN) No.

Good.

You will be hospitalized Must read something about as an in-patient for cancer. treatment each cycle. You will be on complete Must get some books, intake-and-output articles. Assemble a measurement for three bibliography. days after each treatment to monitor kidney function. After the initial Is anyone doing research on eight cycles, you will cancer? have another battery of tests. Concentrate.

The antineoplastic will Antineoplastic. Anti: inevitably affect some against. Neo: new. healthy cells, including Plastic. To mold. Shaping. those lining the Antineoplastic. Against gastrointestinal tract from new shaping. the lips to the anus, and the hair follicles. We will Hair follicles. My resolve. of course be relying on your resolve to withstand some of the more “Pernicious” That doesn’t pernicious side effects. seem-

KELEKIAN: Miss Bearing?

VIVIAN: I beg your pardon?

KELEKIAN: Do you have any questions so far?

VIVIAN: Please, go on.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. KELEKIAN: Perhaps some of these terms are new. I realize -

VIVIAN: No, no. Ah. You’re being very thorough.

KELEKIAN: I make a point of it. And I always emphasize it with my students -

VIVIAN: So do I. “Thoroughness” - 1 always tell my students, but they are constitutionally averse to painstaking work.

KELEKIAN: Yours, too.

VIVIAN: Oh, it’s worse every year.

KELEKIAN: And this is not dermatology, it’s medical oncology, for Chrissake.

VIVIAN: My students read through a text once - once! - and think it’s time for a break.

KELEKIAN: Mine are blind.

VIVIAN: Well, mine are deaf.

KELEKIAN: (Resigned, but warmly) You just have to hope . . .

VIVIAN: (Not so sure) I suppose.

(Pause)

KELEKIAN: Where were we, Dr. Bearing?

VIVIAN: I believe I was being thoroughly diagnosed.

KELEKIAN: Right. Now. The tumor is spreading very quickly, and this treatment is very aggressive. So far, so good? (WIT, pp. 7-10)

I used WIT as a prompt for discussing the doctor-patient relationship because

it invites the audience to embody the postmodern sensibility that the modernist

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. narrative does not contain the whole story. At once, the audience is drawn into

Vivian’s experience of existential loneliness and the doctor’s inability and

responsibility to answer this plea. WU, as a performance piece and as a case study,

provided the advantage of discussing a “neutral” doctor-patient relationship, outside

the participants’ health experience. This allowed people being interviewed to be

more objective in the sense that he or she first examined the relationship from the etic

(an outsider’s) point of view. Only later in the interview was the emic (local)

experience of the interviewee’s own doctor-patient relationship examined.2

Using theater to engage intercultural dialogue has been a successful way to

address difference (Bennett, 1997). Audience involvement can be “reactive” from

pre-performance to post-performance. Before a show, people often share what they

have heard about the play, and when departing from the theater, the audience is in

more of a reaction mode. Qualitative interviews with audience members following a

production of WIT allowed me to explore the complex web of factors that contribute

to the doctor-patient relationship:

The theatrical can provide a methodology, an experience and the kinds of connections with others, either in production or reception, which make those confrontations into negotiations and which, at best, offer imaginations whereby we can see our own and others’ stories if not better, then at least somewhat differently. Spectatorship and intercultural theatre presents many perhaps unresolvable problems; yet it is the very appearance of these problems that holds out hope. (Bennett, 1997, p. 203)

Audience reaction to WIT was the springboard I used to launch the discussion

about the play’s portrayal of the doctor-patient dynamic, in relation to the audience

2 The limits and advantages of using a theatrical performance in a sense as a “case study” will be discussed further in the Chapter 3 of this document. 10

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. member’s own doctor-patient experience. In doing so, I can gain access to the

audience member’s perception of the “norm” of the doctor-patient relation. Herbert

Blau, in The Audience (1990), explains, “whatever the virtues of participation, the

virtue of theater remains in the activity of perception, where participation is kept at a

distance and - though it has come to be thought of as a vice - representation has its

rites” (p. 381).

By using WIT as the linchpin of a four-week course called The Physician’s

Identity, I was able to process WIT with a group of first-year medical students.

Theater and medical school: are they unlikely bedfellows or a perfect match? The

medical students were able to wrestle with the notion that the doctor-patient

relationship can affect healing. They were able to see the possibility (and hopefully

the value) of actively deconstructing the cultural identities assumed by doctor and

patient. Talking about issues when they are not yet personal, not yet ego infused, not

yet too intimate to discuss, seemed to widen the students’ view of healing and their

professional role within it.

As noted, WIT is being used in many medical schools in the United States, but

its larger “popular culture” appeal reflects the general societal interest in the doctor-

patient relationship. WIT was made into a HBO movie in 2001 starring Emma

Thompson and directed by Mike Nichols. The HBO film received national attention

by being featured in The New York Times and full-page advertisements appeared in

Time Magazine. It was nominated for 2001 Golden Globe awards in the categories of

“Outstanding Mini-Series or Television Movie” and “Actress in a Leading Role.” It

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. won the 2001 Emmy Award for the best “Made for TV Movie” and director Mike

Nichols won the Emmy in the category of “Outstanding Directing for a Mini-series.”

Within medical education WIT has been a vehicle to open up discussion of the

role of the doctor within the doctor-patient relationship. Yet, WIT has also furthered

the larger cultural consideration of the patient’s role in this dynamic as well. The

physician’s identity is not an easy role to explore in our changing world of medicine

and managed care, but neither is the patient’s. Even the legal definition of death no

longer draws a firm line, which further complicates discussion about death and the

needs of the dying person. These are critical topics that doctors, patients, and indeed

society-at-large needs to explore.

1.3 THE PROBLEM PLAYS OUT: REAL LIFE CONSEQUENCES

A March 4,2001, Columbus Dispatch front-page news article entitled, “Just

what did the doctor order?’ (Greenberg, Associated Press), speaks to the American

Medical Association’s estimate that 90 million Americans have problems

understanding medical information and acting upon it. This is what the AMA terms

“low health literacy” and cites its costs to the health care system - pushing $73 billion

a year in extra doctor visits and longer hospital stays. Doctors are frustrated that

patients may not understand their recommendations. In the same article, Dr. Herman

I. Aromowitz suggests that his colleagues have an ethical responsibility to ensure that

patients understand them, ‘Take away the fear of your white coat and stethoscope.

Let your patients know it’s OK not to understand and to ask questions."

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Adding validity to the doctor-patient communication problem, every patient

seems to have a “story” they want to tell about dealing with a physician with whom

they felt they could not communicate, yet felt a great need for this communication

(Frank, 1995). This frustrating Erlebnis (“lived experience,” a central concept in

Wilhelm Dilthey’s [1833-1911] theory of understanding) that often occurs between

doctor and patient may be rooted in the divergent identities of the two actors within

the relationship: the doctor and the patient. Doctor-patient communication is of

major importance in the delivery of effective health care (Cegala, 2000) and a divide

between the two actors (in terms of how they view each other) may impede

productive communication. If either the doctor or the patient does not feel that the

other party is communicating effectively, then the care of the patient is hindered and

the doctor-patient exchange becomes one of frustration.

This project will begin with an exploration o f the conditions that historically

and culturally influenced the construction of the doctor-patient relationship and

ensuing communication. Based on the construction o f‘the other,” how does the

patient perceive the doctor, and how does the doctor perceive the patient? How do

the constructed identities influence the communication between doctor and patient?

My primary research objective is to explore the ways in which the construction of

divergent doctor-patient identities has shaped the way in which health care has been

delivered. It is an assumption of the study that quality health care is dependent upon

effective communication within the doctor-patient relationship.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A related dimension of this study is the changing perceptions of wellness in

health care. In 1998, the Journal o f the American Medical Association reported that

40% of Americans were engaged in some form of alternative medical treatment

(Lundberg, 1998). Patients reportedly often withhold this information from their

physician. Twenty-seven billion dollars were spent for alternative care, most of it not

reimbursed by insurance. Americans are willing to buy what they want. They are

voicing their preferences with their dollars, and many facets of the health care

community are beginning to hear their voices. Are these patients seeking an

alternative view of “health” by stepping outside the Western paradigm of medicine,

or are they seeking a different relationship (and different communication) between

themselves and their alternative health care provider? Or, are they (at a more basic

level) imagining themselves differently from previous dominant constructions of

doctor and patient? Exploring the link between changing perceptions of wellness and

innovative understandings of the doctor-patient relationship may illuminate future

areas of research.

As our culture has been transformed by changing roles for women, minorities,

and all others classified as “subaltern,” the social expectations within the doctor-

patient relationship have also shifted. In the recent past the modus operandi of the

communication within the doctor-patient relationship was that the doctor told the

patient what was wrong and the patient was to follow the doctor’s instructions. Even

some recent studies conducted on the topic of “Doctor-Patient Communication,” use

“patient compliance” as the measure of success to gauge if the communicative

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. intervention was successful or not (Post, Miser, Cegala, &Welker, 2000). This

assumes that for the communication to be “successful” the patient must follow the

doctor’s recommendations. Lemer (1997) points out that “noncompliance” itself is a

socio-historical construction to describe deviant patients. Clinical research that uses

compliance as an outcome measure of successful communication reflects the

positivistic ethos that medical science will yield results if the patient would just

comply with the doctor’s orders. Within such a paradigm, health is understood as the

absence of illness, with the doctor’s job being one of getting the patient back to the

state of normality.

By inviting the philosophy of Michel Foucault to be in conversation with the

pragmatism of John Dewey, the concept of a fluid identity for both physician and

patient shows itself as a way to negotiate the doctor-patient divide in the 21s* century.

Medical school curriculums may need to include an examination of the constructed

“physician” with the cultural identity of “patient.” This could open up a discussion

within medical education in terms of new paradigms of communication that may be

considered useful for improving the doctor-patient relationship.3 Yet, Foucault’s

contribution to understanding the cultural construction of physician should include

John Dewey’s (1938) recognition to attend to the particulars that come together in

individual patients. Deweyian analysis, which affirms rather than discounts

difference, has been used in medicine in the field of medical ethics (Wolf, 1994).

Because the physician is trying to teach the patient about the illness and what to do

about it, my intent is to use the Deweyian approach by considering the doctor-patient

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. relation as similar to that of the teacher-student. Patients also teach the doctor about

how the disease is manifesting itself in their body. Both doctors and patients can

learn valuable lessons by being in relation. I close this inquiry with concrete

suggestions for medical school education, which may help medical students attend to

what a particular patient is asking of them.

Who might feel more liberated in this new scenario, patients or doctors?

Perhaps both doctors and patients want reciprocity and mutuality in the doctor-patient

relationship. It is clear that patients are not the only actors within this dyad. More

attention should be paid to the nature of this encounter as medical students prepare to

become the doctors of the 21st century. Post et al. (2000) emphasize that the clinical

interview (communication within the dyad) is probably the most common medical

“procedure” occurring between a doctor and patient. It is prudent, then, to explore

the factors shaping this exchange.

How may one explore the effects of othering without felling victim to the

process itself? That is, how can one ask others about the process of othering?

Qualitative research has been accused of othering even in its attempts not to be so, but

my project requires in-depth conversations with both patients and doctors to delve

into the “lived experiences” that a quantitative approach cannot do. Grounded in

Michel Foucault’s understanding of “practices of freedom” (Bemauer & Rasmussen,

1991), I will utilize the stories o f doctors and patients as actors who can influence the

circulation of power, thus transforming the gulf itself.

3 Specific suggestions will be given in Chapter S. 16

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I used Multiple Method Crystallization (Richardson, 2000) in this inquiry.

This approach included: (a) establishing the theoretical background of the social

construction of the doctor-patient relation, (b) interviewing doctors, patients, and

medical students, (c) teaching a class within a medical school, and (d) identifying the

expectations of college students utilizing a survey on the subject of doctor-patient

relationship.

Richardson (2000) stresses the importance o f the “whole” picture of any

research project, including the report itself. “Writing is also a way o f‘knowing’ - a

method of discovery and analysis” (p. 923). Her words rang true in this research

project as themes emerged about the differing constructions of identity that were not

evident during the interview stage of this examination. Richardson also claims that

qualitative research depends upon people actually reading it. Thus, the researcher

must engage the reader. Excerpts from WIT will be included throughout this research

report in an attempt to accomplish this.

An important dimension of this study (beyond exploring the social

construction of the doctor-patient relation) was the action research component.

Medical students were asked to question the importance of identity

construction/communication. Teaching a class in the Medical Humanities Program

within the Medical School provided this opportunity. Thus, I was able to evaluate the

value of my concrete suggestions for medical education.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.4 ASSUMPTIONS AND LIMITATIONS

All participants in this study saw the theatrical performance of WIT. Utilizing

a doctor-patient relationship represented on stage provided access to explore this

relationship: (a) interviews were restricted to persons who came to see the

performance, (b) tickets to a Broadway, or Broadway Tour performance of WIT were

costly, thus many of the audience members I interviewed were from an upper

educational and socio-economic group, and (c) cancer survivors, health care

providers, and persons interested in patient treatment were most likely to attend this

type of performance.

My interviews were with persons interested in discussing the topic of “doctor-

patient relationship/communication,” who already believed this to be an important

factor in healing. Those who considered this relationship to be unimportant may not

be inclined to respond to my flyer soliciting interviews. Most interviewees were in

the 35 to 60 age-range (except for the medical students whom I interviewed), and

held jobs in education or health care.

To include a wider population, I surveyed college students who were

required to attend WIT. My assumption was that not all of these students were

interested in doctor-patient relationship, nor deemed it a critical factor in healing.

These students saw the production of WIT for a nominal fee, and were students at a

public state university. Most of the students were from an 18 to 22 age-range. What

do these students expect from the doctor-patient relationship? Does it significantly

differ from the audience member whom I interviewed?

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Using a portrayed relationship to explore audience member’s own relationship

may at first appear to be a limitation. The media, critics, and interviewed doctors and

patients alike often characterized the doctor-patient relationship presented in WIT as

“a caricature,” “stereotypical,” and “unrealistic.” But this was an advantage for an

inquiry exploring what people actually experience and expect from the relationship.

WIT infuriated some people because it portrayed doctors “in caricature as insensitive

buffoons whose only interest is research.”4 While it was alluring to others that,

“Vivian tries her best to cooperate with the doctors who treat her purely as a research

subject. . . (yet) there are times that cry out for simplicity and basic demonstrations

of human kindness ”5 Whatever audience members thought of the constructed

relationship in WIT (the “case study” being explored), it gave them something to

which to compare their own construction o f the relationship.

1.5 EXPECTED CONTRIBUTIONS OF THE STUDY

The doctor-patient relationship portrayed in WIT elicited somatic response

from the audience. The response varied with the audience member, but each response

became a window into the audience member’s construction o f the relationship itself.

This provided an opportunity to talk to people about their own expectations and

desires. If doctors and patients have a better idea of what they want from their own

doctor-patient relationship, they will be more likely to encourage it to happen.

4 Gregory Eastwood, M.D., president of Upstate Medical University, as quoted in the Syracuse Herald American , 2/18/01, p. D-3.

5 As quoted from Stephen Oxman, Variety Magazine (Online), 1/28/01. 19

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Becoming aware of socially constructed roles calls into question the necessity and

desirability of assuming those restrictive roles. Calling into question the viability of

these roles is one contribution I hope to make.

A second contribution will be the suggestion of innovative approaches within

medical education to widen the students’ understanding of themselves as doctors and

as communicators.

1.6 OVERVIEW OF CHAPTERS

Chapter 2 will begin with a review of the relevant literature on the conceptual

frame of socially constructed identities and their influence on communication

processes. I will draw upon Foucault’s (1963, 1994) structures of perception relating

to medical practice as he deconstructs the use of power in discourse. Thomas Kuhn

(1970) is instrumental in considering Western science as one paradigm among others,

which enlarges the possibilities in considering the meaning of “health” and “health

care,” and the roles that we play within the dominant paradigms of these structures.

Sandra Harding (1998) emphasizes the integrity o f modern science within its

historical moment. Donna Haraway (1997) shows science to be “meaning-making,”

while it is the meaning that has had great impact on how the doctor and the patient

imagine themselves individually and as a construct.

The second topic of Chapter 2 concerns the professionalization of the

physician as distinguishing medical doctor from patient. The historical developments

within medical education that may have influenced the social construction of doctor-

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. patient identities will be detailed. Third, Chapter 2 will discuss medical discourse

within the larger cultural context of being a doctor or a patient and how this

influences the communicative process. Much has been written on medical discourse

within the doctor-patient relationship in the past 25 years (Waitzkin, 1991; Stoeckle,

1987; Mishler, 1984; Ley & Spelman, 1967; among others). My intention is to

closely review the more recent literature (Ong, deHaes, Hoos, & Lammes, 1995) to

examine if current work on doctor-patient communication may indicate a disparity in

communication based upon divergent constructed identities. I will survey some

theories suggesting ways to get beyond traditional medical discourse.

Chapter 3 will further the discussion of using theater as a methodology for

studying sensitive cultural concerns. To investigate the social construction of the

doctor-patient relationship, I utilized a mixed method approach. This inquiry

included the collection of four types of data: (a) qualitative interviews of interested

audience members, (b) a survey o f undergraduates required to see WIT, (c) evidence

of societal reaction to WIT (awards, newspaper reviews, letters to the editor,

educational initiatives circling around WIT) and, (d) ethnographic field notes 1

compiled while teaching The Physician’s Identity to medical students. This mix was

utilized in order to grasp the origins and potential for change within the doctor-patient

relation.

Chapter 4 presents the results and analysis of the data collected. Is the doctor-

patient relationship accurately considered a social construction? How does this

influence communication within the relationship? Chapter 5 summarizes the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. conclusions drawn from the study, considers current cultural influences on the

practice of medicine, and offers suggestions for further research on the doctor-patient

relation.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 2

FRAMING THE DOCTOR-PATIENT RELATION

2.1 SCIENCE AND THE SOCIALLY CONSTRUCTED IDENTITY OF DOCTOR- PATIENT

TECHNICIAN 1: Name.

VIVIAN: My name? Vivian Bearing.

TECHNICIAN 1: Huh?

VIVIAN: Bearing. B-E-A-R-I-N-G. Vivian. V-I-V-I-A-N.

TECHNICIAN 1: Doctor.

VIVIAN: Yes, I have a Ph.D.

TECHNICIAN 1: Tour doctor.

VIVIAN: Oh. Dr. Harvey Kelekian.

(WIT, p. 16)

Doctors have been educated in medical science, and unless a patient is a fellow

medical doctor, there is a clear distinction between doctor and patient. The medical

school training, completion of a residency program and the successful completion of

state certification boards all certify to the patient that this individual has an adequate

knowledge of the medical specialty practiced. The physician has studied the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. scientifically-based medical knowledge that the patient needs. The physician resides

inside science while the patient may not. This study focuses on the impact that these

divergent identities may have on the communication that transpires between doctor

and patient.

Any exchange between doctor and patient involves the embedded discourse of

medicine, with all of its central rules, values, concepts, and practices of discourse

(George, 1999). We do not consciously examine these but allow these to function as

dimly perceived conditions of the experience. Lupton (2000) calls for the necessity of

examining the social construction of ideas, knowledge, and individual experience o f

health and medicine in Western societies (p. 50). Her argument is that they are socio

cultural products that require examination. Individual experience is explored in this

research study via qualitative interviews, but many scholars have emphasized the

theoretical basis for claiming medicine to be a product o f social and cultural process.

Certainly not exhaustive, the intention of this literature review is to illustrate that there

is sound theoretical basis for explicating the cultural shaping of the doctor-patient

relation.

Modem medicine is considered a science, as it is based upon scientific method

and research. Feminist theorists, standpoint epistemologists, and others focus on the

context in which modem medicine came to be. Commonly, they base their theoretical

work on Thomas Kuhn (1970) whose history of science was groundbreaking in his

affirmation that science is a process embedded in culture. He was interested in the

community structure of science (p. 209) and called for further study concerning the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ways in which this influenced scientific “developments .” He wondered at the

pedagogy of scientific development differing from that of the arts, politics, literature,

and music. Kuhn pointed out that Western culture has no problem in seeing those

disciplines along the lines o f periodization with revolutionary breaks in style, taste and

structure. Is science fundamentally different than other disciplines? He asked this

question and understood his biggest contribution to be the question itself. “How could

history of science fail to be a source of phenomena to which theories about knowledge

may legitimately be asked to apply?” (p. 9).

Kuhn’s (1970) work began with his definition of normal science as research,

based on past scientific achievements operating as the foundation for further practice.

Normal science “is predicated on the assumption that the scientific community knows

what the world is like” (p. 5) and Kuhn points out that they spend much time

defending this assumption. Yet, anomalies arise that

subvert the existing tradition o f scientific practice - then begin the extraordinary investigations that lead the profession at last to a new set of commitments, a new basis for the practice of science... .They are tradition- shattering complements to the tradition-bound activity of normal science, (p. 6)

Kuhn calls these “scientific revolutions” as they end up changing the way scientific

work is done. He cites Copernicus, Newton, and Einstein as examples of scientists

that transformed the scientific imagination in such a way. Each necessitated the

scientific community to reject a time-honored theory in favor of another that was

incompatible with it. Kuhn expresses wonderment that different interpretations of the

same phenomena are lost when something becomes qualified as “science” (p. 17).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Kuhn (1970) is most famous for his comment on paradigms, or accepted

models/patterns that end up guiding a whole group’s research. Within a specific

paradigm, facts are determined, they are matched with theory, and the theory is

articulated. He goes on to describe normal science as the functional community

(scientists) operating according to a foundational paradigm:

One o f the things a scientific community acquires with a paradigm is a criterion for choosing problems that, while the paradigm is taken for granted, can be assumed to have solutions. To a great extent these are the only problems that the community will admit as scientific or encourage its members to undertake. Other problems, including many that previously had been standard, are rejected as metaphysical, as the concern of another discipline, or sometimes just too problematic to be worth the time. A paradigm can, for that matter, even insulate the community from those socially important problems that are not reducible to the puzzle form, because they cannot be stated in terms of the conceptual and instrumental tools the paradigm supplies, (p. 37)

A problem here may be that because the paradigm is foundational to the

scientific life, the scientist may not be called to question the paradigm itself:

“Scientists work from models acquired through education and through subsequent

exposure to the literature often without quite knowing or needing to know what

characteristics have given these models the status of community paradigms” (p. 46).

This affects what the scientist perceives as normal or anomaly, as “anomaly appears

only against the background provided by the paradigm” (p. 65). The scientist is

subject then to the paradigm not only as a map, but the paradigm becomes the

directions essential for map-making (p. 109). How to step outside the paradigm and

question its own assumptions?

“Though the world does not change with a change in paradigm, the scientist

afterward works in a different world” (p. 121). Or is the old world just seen anew by

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the scientist? Kuhn (1970) validates the role played by the individual scientist in the

scientific process, and points out that the quest for pure-observation language

presupposes a paradigm. He points out that scientific community’s acceptance of a

new paradigm usually is very slow, often taking a whole generation or more. This

also does not occur all at once in a community “rather than a single group conversion,

what occurs is an increasing shift in the distribution o f professional allegiances” (p.

158).

Did Kuhn recognize the role that scientific discourse holds in scientific

process? Comparing the “insider” nature o f both language and knowledge Kuhn says,

“Scientific knowledge, like language, is intrinsically the common property of a group

or nothing else at all. To understand it we shall need to know the special

characteristics of the groups that create and use it” (p. 210). Certainly, in his

suggestion to study the community structure o f science came a call to study how it

functions as a community. As this study will indicate, patients often construct

themselves as “patient” as being outside o f the medical discourse.

What is discourse? It is a pattern of ways in thinking that end up constituting

our view of reality. Fairclough (1992) views discourse as a form of social practice,

action as well as representation. Lupton (2000) illuminates: “Cultural analysts,

adopting a poststructuralist perspective, argue that there is an inescapable relationship

between power, knowledge, discourse and what counts as ‘truth’” (p. 51). This

poststructuralist perspective applied to the medical profession has been most

influenced by Michel Foucault and feminist theorists.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In The Birth o f a Clinic, Foucault (1963,1994) exposes the structures of

perception relating to medical practice. He sees the “normalization” of the conception

of “health” as the absence of disease, as the influential discourse in the individual

perception o f‘‘illness,” and how it is dealt with on an institutional/societal/individual

level. In the clinic, the body of the patient becomes subject to the medical gaze. This

gaze had/has such power because it appealed to the rationalist approach to containing

disorder. The gaze could appear to be culturally neutral, but Foucault wanted to

expose the cultural foregrounding of objectivity/rationalism that informed the gaze.

Lupton comments,

The medical gaze is a product of a dominant discourse in scientific medicine that champions the importance of expert medical practitioners using visual cues to assess and monitor patient’s bodies. This approach to diagnosing and treating the ill is the result of changes that took place in the late eighteenth and early nineteenth centuries, in which scientific medicine, reliant on systematic measurement and identification of visible signs of disease and comparison emerged, (p. 55)

Foucault’s main project is to question how the self is related to the practices of

self. I am interested in looking at how “self' in the doctor-patient relation is defined

by the perception of the “other” in the dyad. Looking at the dyad through the lens of

Foucaultian deconstruction could be illuminating, in that becoming “archeologists” o f

the connections between knowledge and power, one becomes aware that the “truths”

of medical science are imbedded in the socio-historical frameworks within which they

operate. George (1999) points to the treatment of a South American disease in the

1800s called drapetomania that caused slaves to flee their masters as an example of

how “disease” can be a culturally constructed concept.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. By bringing to light the historical and material conditions of a specific

discourse, the possibilities for alternative ways to act and speak may be made easier.

Doctors and patients may not realize the part he or she plays in furthering the medical

discourse as they currently experience it. Examination o f the assumptions beneath a

discourse can expose “practices of freedom” (Bemauer & Rasmussen, 1991) that did

not seem possible prior to examination.

The role that the patient plays in this didactic relationship is crucial in

supporting and/or revolutionizing the constructed relationship. The doctor has

medical knowledge that the patient needs, but this alone does not determine the way

the power circulates. The way the doctor and patient imagine themselves and each

other may impact the relationship. “The power relationship for Foucault is to a degree

a function of freedom: people have to be somewhat aware of alternative possibilities

they want to pursue if they are to feel themselves blocked or manipulated” (Greene,

1995). Today’s patient may not imagine him- or herself as a medical “case”

presenting disease but more as a person who is in need o f medical attention. Moyers

(1993) interviewing physician David Felton notes, “The very word ‘patient’ has a

passive connotation, whereas the word ‘person’ suggests someone who is an active

agent in his or her own life” (p. 225). Felton responds that patients today have a

choice to exert their own power in healing,

Yes, I guess the medical profession has become very used to thinking in terms of doing something to a passive recipient. But patients have to be very active participants in their own health. A message has gotten across with regard to diet, exercise, smoking, drug abuse, and so forth — but the message can be extended beyond just those immediate issues at hand. Patients have a vital role

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to play in their own healing and in many other circumstances, such as autoimmune diseases, or infections, or things of that nature, (p. 225)

Moyers interviewed health professionals that are willing to imagine the patient as a

person and not solely as a “case.” These interviews with physicians such as Felton

could be considered a “practice of freedom” by inviting the patient to acknowledge his

or her personal power.

Foucault's examination of the history of punishment points out the center stage

held by the construct of power in any discourse. His overview of “institutions”

(prisons, hospitals, schools, etc.) highlights the aim to control/correct that is held by

the nature of any institution. Through establishing rhythms, imposing occupations,

and regulating cycles of repetition (i.e., specializations, board certifications for

physicians) the aims of the institution (in this case, Western medicine) are carried out.

Foucault calls us to examine the multiple networks of diverse elements that exercise

the power of institutions toward normalization. The challenge is that we are already

“normalized” by a whole societal set of values (gender, economy, and ideology) when

we come to examination. Foucault points us to the idea that behind any concept of

health is the notion of “normality” and this dictates our view o f health and disease.

It was also Foucault (1982) who considered relations to be a conglomeration of

material effects and materials acts. The disease paradigm of health that emerged in

modem times could be considered a material effect of the scientific advancements that

followed the understood linear progression of Western sc ience-as-culture quest for

knowledge. Without the disease paradigm of health occupying the dominant mode of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. thought concerning health, the patient would have not have become such an object of

examination. This mode of thought, constructed by the Western medical model

transformed the person of a patient, into the patient as objective “case.”

This does not deny that patients want and need the privileged scientific

knowledge that the physician obtained in medical school. Foucault values the verified

truth that science has to offer. What needs to be negotiated is the way in which such

knowledge is expressed, withheld, mystified, and so forth, depending on how the

physician chooses to use or tool the knowledge. Foucault explains the power involved

in the control of knowledge,

There is nothing “scientistic” in this (that is, a dogmatic belief in the value of scientific knowledge), but neither is it a skeptical or relativistic refusal of all verified truth. What is questioned is the way in which knowledge circulates and functions, its relations to power. In short, the regime du savoir. (p. 212)

Laboratory test results provide a series of readings from which the physician

can profile the patient as presenting a particular pathology, and the doctor has been

trained to consider various therapeutic interventions. The doctor, through the use of

technologies (stethoscopes, x-rays, etc.) is permitted to medically gaze into the

patient’s body, getting an objective construction of what is going on inside the

patient’s body. In today’s medical world, evidence-based medicine then provides the

best odds for the choice of treatment. Within such a paradigm then, the specialist (the

physician most inside medicine) is the physician o f choice.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Perhaps it was the construction of patient as a “case” rather than as a person

that encouraged the discursive formulation of minute medical specialties. Ashis

Nandy (1995), writing on “Modem Medicine and Its Nonmodem Critics: A Study in

Discourse” certainly holds this view:

It is possible to argue that the entire range of specializations in modem medicine is the direct outcome of such a perception of the patient. Specialists are increasingly regarded not as a tangential development or deviation from the primary agent o f medicine in action, the general practitioner. The general practitioner is seen a residual category - that which is left behind after the specialists and the specialization are taken out o f the field. In the medical utopia, therefore, there is no place for the G.P. He or she is there today as a stopgap measure. For truly scientific and fully developed medicine is viewed as a definitionaUy the sum of medical specializations, (p. 57)

Two practical problems arise from the increased specializations in medicine.

The gap between the player inside science (the physician) and the receiver outside of

science (the patient) oftentimes widens. The gap is experienced by the individual,

often played out in the realm of interaction where the effects of power are often felt.

The scientific language used by physician specialists is often so complicated that the

patient may not clearly understand what the treatment choices really are.

Both Kuhn's concept of science as a “paradigm” and Foucault’s understanding

of social construction can be heard in Sandra Harding (1998) as she queries the

relationship between European expansion and the development of modem sciences in

Europe. She recognizes the inexplicable tie between scientific process and social

process and calls into question an assumed value-neutrality of the Western medical

model, as it is itself a construct of science. She recognizes the idea that all knowledge

claims are partial, Western scientific knowledge qualifying as one form o f

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. epistemology. Harding emphasizes the integrity of modem science within its

historical moment. Ehrenreich and English (1993) claim that medicine was never

neutral “science” but that it directly reflected the class and patriarchal nature of

society. Donna Haraway (1997) furthers this approach by looking at the trap created

by denying knowledge partiality, and closing one’s eyes to the influence of the way

scientists see and shape the world.

Haraway uses the example of the immune system being thought of as a bodily

expression of national defense by scientists, and military personnel’s understanding

national defense as the state’s immune system, to explicate science-as-culture. She

shows science to be “meaning-making,” and this meaning has had great impact on

how the physician and the patient image themselves individually, and as a construct.

Feminist theorists focus on the situated nature o f medical “science” while

Foucault tries to deconstruct the idea of “normal” as the medical world functions with

all the circulations of medical knowledge and power. Margaret Edson simply invites

us to experience the circulation of this power and knowledge from the inside out, in a

particular situation. The audience member is exposed to both doctor and patient who

are at once subject to the medical discourse and all it entails. Both doctor and patient

become subject to the socially constructed roles that they occupy. There are no

innocent bystanders in this play. Vivian, Dr. Bearing, was used to participating in a

discourse that similarly associates knowledge with power: academia. Thrown out of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. that discourse into another one (medicine), the circulation of power changes and she is

a “case” within the medical discourse that may provide her the chance to return to

“normal”

WIT stories her realization that it is her personhood, and not simply Vivian’s

“case” o f cancer that is being addressed in her treatment. Dr. Kelekian clarifies that as

a case study Vivian is valuable:

KELEKIAN: This treatment is the strongest thing we have to offer you. And, as research, it will make a significant contribution to our knowledge.

VIVIAN: Knowledge, yes.

(tfTT, p. 11)

2.2 PHYSICIAN AS PROFESSIONAL

The “professionalization” o f medicine is intimately tied to the scientific,

medical discourse from which it came. Perhaps this is most clearly evidenced in

medical education. Cobum and Willis (2000) trace the development of medicine’s

rigorous scientific training that gave medicine its authority, to today’s changed world

in which medical knowledge is more accessible. They look at today’s medicine as it

has been transformed such that,

most health care is provided ‘impersonally’ by paid experts within a mass market for care. In the duration of less than a century, medical work has changed from individual healers within a “cottage industry” to a highly complex health-care division o f labour surrounded by huge industry, (p. 378)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. They consider the medical profession to be “losing the almost hegemonic control it

once had, not only over the context of health care, but even over the content of

medical work” (p. 379).

Where did medicine come by the social and cultural authority that Cobum and

Willis detail? They felt that it had to do with obtaining a medical education. “The

control, by a relatively small, homogenous community, over a body o f knowledge

applied to health care, a vital aspect of human societies, was, many felt, an important,

perhaps crucial underpinning of medical power” (p. 383).

Medical education was the path needed to obtain this authority. Yet, who had

access to becoming a physician was generally established by a report published in the

first decade of the 20th century. Bledstein (1978) explains that it was the Flexner

Report (1910) that largely determined what became defined as “medical education.”

The Carnegie Foundation fended a study to be conducted by Abraham Flexner, whose

results were published in 1910. The goal o f this study was to raise the educational

standards of medical education to approximate the rigorous scientific studies of

German medical schools. The beginnings o f this scientific model of medical

education was happening at Johns Hopkins University Medical School, but the intent

of the report was to raise the standards of all medical schools in America to such a

leveL

In fact, Harvard Medical School’s Elliot Mishler (1981) reports “The Flexner

Report was a seminal document in medical education, leading to changes in the

number and nature o f medical schools, their curricula, and the research and clinical

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. roles of American physicians” (p. 227). He points out that the Flexner Report

institutionalized medicine based on positivistic science and the paradigm of the body

as a machine, and as a consequence “wholistie [sic] medicine declined” (p. 228).

At the time of the Flexner Report, there were many American schools

providing “medical training.” Many of these schools trained women and minorities,

as these people o f ahem or sub-altera status fulfilled the function o f “healer” within

their own communities. In 1910, midwives trained by either the apprentice model or

by the other schools providing medical training delivered 50% of all babies. The

concern of the Carnegie Foundation was the lack of standardized medical training (or

care) in line with the scientific, medical discoveries happening in Europe.

Flexner’s report accomplished the standardization by detailing the

inconsistencies of medical training. Schools providing medical education in America

would meet the scientific standards of the day or be eliminated. The new medical

schools became preoccupied with standardization, regulation, and control. An impact

of the Flexner Report was that many schools were closed (p. 232). The dissolved

schools did not meet the newly established standards. These were largely the schools

that allowed women and minorities access to an education in medical training.

Flexner (1910) recommended keeping open two “Negro” medical schools, Howard

and Meharry, rather than “the inadequate maintenance o f a larger number of schools..

. A well taught Negro sanitarian will be immensely useful; an essentially untrained

Negro wearing an M.D. degree is dangerous” (pp. 180-181).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A consequence of the Flexner Report was that it changed the fabric of who

became a doctor and it also opened the door for specialization in physician training.

As science tended toward specialization, medical science followed suit. Access to

medical education after 1910 was to a large degree limited to those students who could

fulfill the rigors of a scientific education, those who could afford it, and they were

usually white and male. Medical education was in no uncertain terms tied to furthering

the scientific construct from which it was bom. Mishler claims, “The Flexner Report

redefined the nature o f medicine as a profession and institutionalized a machine model

of the body in medical education and practice” (p. 232).

Where was the patient in this development? The obligation of the person who

sought help from one educated in this way, was to trust the professional that had been

trained in the theocracy of science. The medical doctor not only had “made it” in

terms of middle class aspiration of success, he was the closest thing to a “local”

scientist with whom most people would ever come into contact. The medical doctor

also had the commitment of unswerving service to humanity. The scientifically

trained, medical professional was also above self-interest, so it would not make sense

to question him, on many levels. The doctor was the external authority that could help

the patient return to the normalized perception of “health.” Patients came to

understand their own role in relation to such a professional, defining him- or herself in

relation to the professional “other.”

During the 20th century though, there were varied interpretations of what

medical professionalism referred to for the individual physician. Abraham Flexner’s

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. (1910) definition did specify altruism as an essential component of medical

professionalism, but Ritchie (1988) pointed out that this came to be used as a

justification of long working hours for medical residents. Ritchie stressed that

overworking residents cannot be ethically justified, nor is it essential to medicine’s

being a profession (p. 449). Ritchie argued that Flexner meant that the altruism of the

physician refers to the profession as a whole, making society’s goals its own, not that

the individual physician is required to act altruistically, except when it involved

fulfilling an actual or implied obligation.

Even the most recent medical literature reflects varied definitions of

professionalism, with some physicians calling for restoration of professional values,

while others claim it needs to be invented. Herbert Swick, M.D. (2000) claims that in

spite of all the attention that professionalism has received in recent years that there is

no common understanding of what is meant by the term. He points out that “perhaps

professionalism is like pornography: easy to recognize but difficult to define” (p.

612). He advocates a normative definition of medical professionalism. Swick

considers a profession to be a way of life with a moral value, a calling, and not simply

an occupation. As the specialized body of medical knowledge expanded, expert

knowledge, and not one's commitment to be a “social-trustee” became more closely

associated with professionalism for the physician.

Swick feels that medical professionalism must be grounded in the physician’s

work, with patients, the patient’s families, and with other physicians. He emphasizes,

“At the core of medical practice is the need to create and nurture a healing dyadic

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. relationship between physician and patient” (p. 613). Other elements (the social

vision of medicine, etc.) reflect broader responsibilities. He makes the point that

professionalism must be considered on two levels: individual and collective. And,

given our current industrial model of health care, practicing professionalism can be the

factor maintaining the distinction between medicine as a profession and as a

commodity (p. 616).

Other physicians, for example Cruess, Cruess, and Johnson (2000), understand

traditional professionalism as knowledge-based activities that require long periods of

education that entail service for the common good (p. 156). They reflect that while the

role of the healer has remained fairly constant, an understanding o f the concept

medical professionalism depends on the expectations o f both society and medicine.

They point out that because knowledge is used to serve others, professions are labeled

as altruistic and value laden. Self-regulation then is expected to assure quality. They

consider the medical profession to be in a time of challenge with the public, to be in a

time requiring renewal as the public may question the medical profession’s success

with self-regulation.

Rothman (2000) calls for an examination o f the internal factors o f medical

professionalism. He cites Talcott Parsons as being responsible for the foundation of

medical professionalism of the 1920s and 1930s, which focused on technical expertise

and self-regulation. Rothman says technical expertise was solved by board

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. certification but that the profession is replete with failure in the area of self-regulation.

According to him, “To the extent that self regulation is the focus, professionalism

today has to be invented, not restored” (p. 1284).

Flexner’s vision of the medical professional held for a vast majority of the 20th

century. This altruistic vision, furthered by Talcott Parsons’ focus on technical

expertise and self-regulation, was in keeping with the medical education of the day.

And medical doctors were produced that could fill such a role.

2.3 DOCTOR-PATIENT ROLES WITHIN MEDICAL DISCOURSE AND THE COMMUNICATIVE PROCESS

Were there other cultural factors that encouraged the mindset of the doctor as

the actor and the patient as reactor? Thomas Hobbes (1588-1679) may have

intuitively, yet unwittingly, predestined the construct between physician-patient in his

description of the materialistic world:

As when one body by putting forwards another body generates motion in it; it is called the AGENT; and the body in which motion is so generated, is called the PATIENT; so fire that warms the hand is the AGENT, and the hand which is wanned is the PATIENT. That accident which is generated in the patient is called the EFFECT, (p. 33)

Seventeenth-century language, referring to matter in motion is a theory that

seems to foreshadow the physician-patient relationship as it came to be viewed 400

years later. Hobbes was detailing his philosophy of cause and effect and not the

physician-patient construct - yet the language is Euro-centrically situated in a world,

which would come to revere male-dominated science. It is critical to question the

impact of such language on the emergence of “modem medicine,” and how the patient

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. conies to be imagined in this construct. Hobbes' foreshadowing language became part

of the practice o f the lack o f agency on the part o f the patient framing the physician-

patient relationship. Medical education, as it developed, was a narrative of teaching

an “agent" (medical student), about scientifically based “effects” (medical treatments),

that could heal the “patient.”

Much attention in the literature has been given to the communication exchange

between doctor and patient. (Waitzkin, 1991; Stoeckle, 1987; Mishler, 1984; Ley &

Spelman, 1967; among others). It was Elliot Mishler (1981) who began the

investigations affirming health and illness as social as well as biological facts.

Following Kuhn, he emphasizes that the biomedical model upon which medical

education is based, is “treated as the representation or picture of reality rather than

understood as a representation” (p. 1). Similar to feminist theory, Mishler questions

the scientific neutrality of medicine, and like Foucault, he calls into question the

definition of disease as an aberration from normal biological functioning.

In terms of physician identity-formation Mishler states,

Physicans see themselves as bioscientists. Their self image as practitioner reflects a view of medicine as a discipline that has adopted not only the rationality o f the scientific method but the concomitant values of the scientist, namely, objectivity and neutrality.. . . physicians tend to see the scientist as an idealized role model for themselves, (p. 15)

He describes medicine as a “subculture, with its own institutionalized beliefs, values,

and practices” (p. 15), whereas, it “is a special type of social institution dominated by

physicians as a particular profession” (p. 16).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Mishler claims that most studies on the physician-patient relationship realty

reflect distortions of understanding due to a difference between “doctor talk” and

“patient talk” (p. 109). He considers this to be the result of socialization of physicians

and patients: “Besides facts and competencies, specific values and attitudes are

associated with the social role o f the physician. These values and attitudes have

pervasive, often hidden, effects on the feelings, thoughts, and behaviors o f the future

doctor (p. 121). This social learning is not delivered in a formal way, but throughout

the physician’s training, from the basic science courses through the clinical rotations.

“Doctors learn this role long before medical school, and through a variety of

experiences, patients also learn the rules governing the ‘patient’ role. These learned

roles serve as significant determinants of physician-patient relationships” (p. 125).

Mishler suggested that the social setting and the internalized expectations of the

participants impact the relationship.

Mishler recognized that a critique mounted from a constructivist position

would be troubling to health professionals because it questions the basic assumptions

of medical practice - the biomedical model (p. 165). His suggestion was that clinical

practice be restored to its social context.

In an attempt to examine the impact of social role on doctor-patient

communication, Mishler (1984) examined the presence of physician responsiveness to

patients’ attempts to construct meaningful accounts of their problems. Frustrated that

earlier studies on the medical interview stripped away the social context of meaning,

Mishler attempted to attend to this phenomenon. His frustration was based upon the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. orientation of previous studies in which “It is assumed that there is an ‘objective’

phenomenon to be found” whereas Mishler was convinced that, “the illness

‘discovered’ through the interview is constructed, not found. A diagnosis is a way of

interpreting and organizing observations” (p. 11).

Mishler (1984) concludes that that disruptions in dialogue between doctor and

patient result from the voice of the lifeworld interrupting the dominant voice of

medicine. His conclusion is that, “discourse is revealed as a dialectic between the

voices of the lifeworld and of medicine: it involves conflict and struggle between two

different domains o f meaning” (p. 121). That while the patients talk about the meaning

of illness in their lives, “the physician’s effort to impose a technocratic consciousness,

to dominate the voice o f the lifeworld by the voice o f medicine, seriously impairs and

distorts essential requirements for mutual dialogue and human interaction” (p. 127).

Most important for this study is Mishler’s claim that the voices o f medicine and the

lifeworld “were found to represent different frameworks of logic and meaning

expressed in the talk of patients and physicians” (p. 189).

Ong et al. (1995) have reviewed the proliferation of literature during the last

two decades on descriptive and experimental research concerning the communication

process during the medical interview. Their conclusion from this endeavor is that the

insight gained from all the research is limited. “This is probably due to the feet that

among inter-personal relationships, the doctor-patient relation is one of the most

complex ones” (p. 903).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Ong et al. (1995) found one study that investigated the role perceptions play in

the doctor-patient relation and how these perceptions related to patient satisfaction.

They found that doctors who viewed their relationship as a “partnership” rather than

being authoritarian with their patients had more satisfied patients (Anderson &

Zimmerman, 1993). But most research that has been conducted on doctor-patient

communication focuses on interaction analysis systems.

Generally, the data reflect the trend of the medical encounter moving from

paternalism, to shared decision making between doctor and patient, to the model of

patient-centered interview techniques. This progression of orientations could be

viewed as expressions of three different models of the doctor-patient relationship

envisioned by Szasz and Hollender (1987). Paternalism reflects the Activity-Passivity

Model, shared decision making reflects the Guidance-Cooperation Model, and patient-

centered interviewing fits into a Mutual Participation Model. These trends reflect the

shifting doctor-patient relation over the course of the 20* century.

Although many interaction analysis systems have been developed and used to

analyze the medical encounter, Ong et al. (1995) advocate for the medical interview

that integrates the patient-centered and physician-centered approaches. Essentially,

Ong et al. envision the patient leading the communication in areas in which they are

expert (experience of the symptoms, etc.) while the doctor leads the communication in

the areas of physician expertise (such as details of typical disease progression). They

also question the outcome measures that are currently used for assessing the doctor-

patient relationship such as patient satisfaction, patient compliance, recall of medical

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. information, and so forth. “If the ultimate aim o f medical care is to produce optimal

health outcomes, then ideally, effective doctor-patient communication should lead to

better health of patients. Patient satisfaction, compliance and other widely-used

outcomes, do not necessarily address the patients' health status” (p. 912).

Ong et al. (1995) note the continuing dominance of the scientific standpoint:

“Despite the growing interest for a more biopsychosocial model of medicine, the

former is still considered as ‘science,' whereas the latter is regarded more or less an

‘art'” (p. 911). Measures of the patients' health status are the least used in studies

concerning the doctor-patient relationship (p. 914). Compliance with doctor’s

instructions is still used today to judge the success/failure of doctor-patient interaction

(Post et al. 2000), in spite of Lemer’s (1997) argument that “noncompliance” is itself a

socio-historical construction. Lemer emphasized that non-compliant patients are seen

as deviant to the positivistic ethos of evidence-based medicine and that the term

“compliance” reflects a way to legitimize physician control. He suggests that the

physician affirm the narrative knowledge offered by the patient in order to understand

the person of the patient. In his examination of “compliance” Lemer highlights that

“by examining the historical construction of language, we remind ourselves how a

social agenda may be concealed within scientific terminology” (p. 1429).

The greatest contribution of Ong et aL’s (1995) review of the literature was

their conclusion after looking at current research on doctor-patient communication, “In

all likelihood, the way the doctor-patient relationship is seen can have consequences

for the actual content of the communication” (p. 914). There are many varied and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. complex measures of doctor-patient communication, but in the end, they conclude that

the way the relationship is understood may be the determining factor in studies

conducted on the subject.

Supporting Ong et al.’s (1995) summation is a study by Tannen and Wallat

(1999) who examined the interaction between a pediatrician and the patient’s mother.

They observed a wide difference in the schemas between the mother and the doctor,

which led to a confused, lengthy, and uncomfortable medical interview. They

considered the mother’s schema for health to be a comprehensive one from which the

mother felt compelled to share relevant information, while the physician was narrowly

focused on the medical issues of the child. They attributed the difficult

communication to stem from the “mismatch” of the mother and the doctor’s schema

(p. 363). The patient’s mother felt that the narrative of non-medical facts was relevant

to the child’s medical situation, while the physician did not.

Frank (1995) and Young (1999) are two theorists that have addressed the

important role played by the “wounded storyteller” in the experience of illness. Frank

focuses on narrative as a means for the patient to recover his or her voice in making

sense of illness. He considers the loss of the person’s cognitive map framed by one’s

“normal” state o f health as a loss of coherence in life. And, as in feminist thought,

Frank affirms that when one person learns to make sense anew out of life with illness,

that others in a similar situation may also be able to find their voices. His view is that

the narrative can play an important role in the healing process.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In agreement with Frank, Young (1999) regards narrative discourse as a means

of regaining personhood from the objectifying discourse of medicine that made the

person into a patient. Young understands the reconstruction of self to be central to the

health of the person. She advocates that the doctor needs this vital information (how

the patient makes sense of the world) in order to discover how the patient frames his

or her own personhood.

2.4 MOVING BEYOND EXCLUSIVE MEDICAL DISCOURSE

An interesting approach may be to take the standpoint of Fairclough (1992)

who is convinced that discourse can be used not only to study social change but also to

encourage it along. He attempts to develop a language analysis that could function as

a discursive practice encouraging social change. In talking about changing the social

identities of doctors and patients, he suggests that changes in this constructed

relationship could be discursively realized through shifting away from the traditional

medical interview to the model of a conversational consultation. Fairclough’s is a

textually-oriented discourse analysis while Foucault’s is more abstract. But

Fairclough recognizes the interpersonal function of discourse as having both

“relational" and “identity” functions, stressing that discourse can change the

construction of social identity.

Fairclough (1992) focuses on the construction of “self’ in discourse and more

particularly on the ways in which discourse contributes to the processes of social

change, in which the social identities or “selves" associated with specific domains and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. institutions are redefined and reconstituted (p. 137). He examines who exhibits

interaction control (e.g., topic control, a pre-set agenda) in a traditional medical

interview compared to an alternative medicine interview. Fairclough observed a

contrast between the physicians’ narrow focus on medical detail as opposed to the

interconnected topics present in the alternative medicine interview. Fairclough

indicates that this reflects a larger phenomenon. “Different varieties o f medical

interview do not simply coexist: they enter into relations of contestation and struggle,

as part of the more general struggle over the nature of medical practice” (p. 148). He

characterizes the alternative medical interview as “transparently linked to values such

as treating the patient as a person rather than just a case” (p. 148), while

Doctors in standard medical practice manifest what is called a scientific ethos (modem medicine prides itself on being “medical science”) which is variously realized in the ways in which they touch and look at patients when they examine them, the way in which they filter patients’ contributions in terms of topic, and the niceties of interpersonal meaning... which would suggest an orientation to the patient as a person rather than a scientific orientation to the patient as a case. (p. 143)

Like Mischler (1984) before him, Fairclough summed up the traditional medical

interview as the doctor using the “voice” of medicine while the patient mixes this with

ordinary experience, as the two voices interrupt each other.

If Fairclough is right, that discursively adapting one’s language can shift

reality, then what might such a model look like? This model would have to be

culturally current to recent changes in society (e.g., the emergent alternative medical

practices becoming mainstream, Internet use for both information gathering and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. communication, time constraints o f the medical interview imposed by health

maintenance organizations, etc.) and allow for the impact of these changes on the roles

of doctor-patient.

Educational philosopher John Dewey (1859-1952) gave us an image o f a

dynamic, dialogical, and transactional learning relation that can exist between student

and teacher. Are there similarities between doctor-patient and the student-teacher

relationship? The teacher has knowledge that the student needs, just like the doctor

has medical knowledge that the patient needs. Dewey stresses that the teacher must

consider the starting place or context of the student in order to hilly engage the

student. The teacher also needs to know something about the person of the student, to

make the content of the lesson meaningful. Some would argue (Frank, 1995; Young,

1999; among others) that the physician needs to know the patient as person, and not

just a “case” for the physician to be able to be able to communicate with the patient, to

fully engage the patient. (It would be possible to argue this also from a medical

“compliance” strategy but this would undercut the patient as person). The “educative”

dialogue that Dewey advocates transforms both the teacher and the learner. Would

such an approach change the medical interview for both physician and patient?

Dewey (1929) was convinced that all dialogue that occurs in experience could

be seen as educational if both teacher-student (or perhaps doctor-patient) are

changed/effected by the interaction (or even imagine themselves to be so). For

Dewey, the transaction that occurs in “true” education is more than interaction. The

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. experience of dialogue, in which both players are participatory in the co-construction

of the transactional process, is not a personal, private experience. It transforms both

parties involved.

Perhaps a new frame, a fluid picture of the doctor-patient relation that is co

constructed by the individuals within a particular patient-doctor relation, is a model

that could be applied to the practice of medicine today. Doctors, patients, and medical

students would all need to be exposed to a re-imagining of the relationship.

Envisioning the doctor-patient exchange to be one in which both parties are engaged

and authentic education is possible would allow for medical knowledge to be offered

to the whole person of the patient. Dewey comments,

The profit of education is the ability it gives to discriminate, to make distinctions that penetrate below the surface. One may not be able to lay hold of the realities beneath the froth and foam, but at least one who is educated does not take the latter to be the realities; one knows that there is a difference between sounds and sense, between what is emphatic and what is distinctive, between what is conspicuous and what is important, (p. 776)

The philosophy of John Dewey has been used in medicine before, but in the

area of medical ethics. Susan Wolf (1994) has been actively lobbying for applying

ethical principles as “tools of action” in health care decision-making. Dewey’s

theories are utilized in medical ethics theorizing, as he presented an ethical sensibility

that affirmed rather than discounted difference.

Dewey’s conception of dialogue (in which both persons change/grow) had

been furthered in current educational thought by Nick Burbules (1993). Burbules

applied a “gaming imagery” to the give and take within dialogue. He argues that true

transactional dialogue can happen between players of an uneven knowledge base. The

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. doctor-patient relation is certainly uneven: The physician has medical knowledge and

the patient has the personal knowledge o f his or her own life context. A valid

assumption may be that a transactional sharing of such information could enhance

medical care.

Pragmatist Gert Biesta (1995) illuminates how Dewey could be utilized to

enlarge the imagination concerning doctor-patient relations. Biesta advocates for

using Dewey’s pragmatic pedagogy as a ‘Theoretical frame” for education, rather than

as a recipe for educational praxis. He argues that if Dewey’s theoretical work was

used to imagine the educational process itself, then the co-constructive, participatory

potential of the process might become a reality. Biesta employs Dewey’s learning

theory at the level o f “paradigm” or “educational theory” rather than arguing about the

uses/misuses of pragmatic pedagogy at the micro (praxis) level. It could be argued

that Dewey (1938) was advocating the articulation of his theory that Biesta provides.

The greatest contribution that pragmatic education can make to envisioning the

process o f education itself is for the over-arching image it can provide. How can an

overarching educational theory impact the practice of medicine, or impact how the

doctor and patient construct each other? If the doctor-patient relation is regarded as an

educational relationship, then the interaction between the two parties becomes a

central focus.

Medical reform may be most powerful at the level of medical practice, the

interaction between physician and patient. The current approach advocated in both

medical literature (Smith, 2002) and beginning in medical education, is the patient-

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. centered interview approach. Research conducted by Post et al. (2000), on the

medical interview (the most commonly performed “medical” procedure), illustrates

that a “patient-centered” interview style is related to (a) better health for the patients,

(b) an increased level of satisfaction for doctor and patient, and (c) an overall decrease

in health care costs. This “patient-centered” interview style stresses building rapport,

taking the patient’s lead, questioning, active listening, and picking up on somatic cues.

This sounds very similar to Dewey’s understanding of what could happen in a

participatory transaction between teacher and student.

Dewey’s portrait of the dynamic, teacher-student relation could be applied to

the doctor-patient relation as a way to transform it. Dewey’s portrait could be viewed

as a counter discourse (Foucault, 1982) interrupting the traditional construction of the

doctor-patient relationship. This new story (Frank, 1995; Young, 1999) may be a re-

imagining that is a practice of freedom (Foucault, 1982) liberating for doctor and

patient alike.

Central to authentic education, whether it’s between teacher-student or doctor-

patient, is the ability to communicate. As people from different cultures often

experience difficulty communicating across difference, doctors and patients

experience a similar difficulty. The physician is a medical professional that embodies

the paradigm of scientifically objective data. But, the patient may want to

communicate with the physician in a narrative fashion, discussing aspects of his or her

life that may not appear to be relevant to the specific medical issue. How to

communicate across these seemingly disparate frames?

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Thomas Kasulis (2002) has formulated a cultural philosophy of difference that

is directly applicable to the communication challenges of the doctor-patient relation.

Kasulis’ theory is a useful heuristic in understanding why communication differences

exist between cultures and sub-cultures, and it offers an approach to listening that

enables negotiation of communicative difficulties. A basic premise of his model is

that the way individuals imagine their relationship to self, other, and the world,

influences the way they construct reality and then talk about it. What is foreground to

one culture may be background in another (p. 20). Kasulis characterizes the two

dialogical modes of relationship as “intimacy” and “integrity,” sometimes using the

examples of Japanese and American culture as foregrounding opposite modes of

relationship. His philosophical discussion is a valuable lens through which to

understand the frustrating interactions that often transpire between doctor and patient.

Physicians, by their training and licensure, are required to be proficient in

objective, research-oriented medical science. The training of physician foregrounds

the characteristics of Kasulis’ “integrity” orientation. He details the values

emphasized in the integrity orientation:

1. Objectivity as public verifiability. 2. External over internal relations. 3. Knowledge as ideally empty o f affect. 4. The intellectual and psychological as distinct from the somatic. 5. Knowledge as reflective and self-conscious on its own grounds, (p. 25)

Based on the research approach to medical science, physicians are trained to regard

disease as a separate entity. Their whole education and training emphasizes objective,

publicly verifiable knowledge of medical science.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Individual patients may or may not approach health, or a specific illness, in an

integrity-dominant way. In this sense physicians and patients may be from different

sub-cultures. If a patient foregrounds the orientation Kasulis terms “intimacy,” the

patient may emphasize connections, focusing on the interconnectedness of his or her

personhood and health/illness. Kasulis lists five fundamental characteristics to the

intimacy orientation that are in almost direct opposition to the to the emphases in

integrity:

1. Intimacy is objective, but personal rather than public. 2. In an intimate relation, self and other belong together in a way that does not sharply distinguish the two. 3. Intimate knowledge has an affective dimension. 4. Intimacy is somatic as well as psychological. 5. Intimacy’s ground is not generally self-conscious, reflective, or self- illuminating. (p. 24)

A patient may relate to his or her specific disease in an “intimate” way, experiencing

the illness in a personal, affective, certainly somatic manner. Physicians are trained to

approach “disease” in the “integrity” orientation that foregrounds rational, positivistic

data. If the patient and the doctor use different categorical schemes to understand the

disease, then perhaps they are akin to sub-cultures trying to communicate across

difference. The research conducted by Tannen and Wallat (1999) illustrated this very

problem: where the doctor and the patient’s mother seem to be talking two different

languages, that result is frustration for both parties. Kasulis provides a way to

negotiate across such difference.

Kasulis emphasizes that the foregrounded orientation determines the rhetorical

discourse that is used within a culture to explain, value, and persuade. For example,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. physicians often use objective, rational rhetoric in explaining disease etiology, such as

“Research shows that smoking causes lung cancer.” In contrast to this, a patient may

have a need to process the elements in his or her experience that made it difficult to

stop smoking in the past, in spite of the well-publicized research finding. Both are

important bits of information if the goal is for the patient to stop smoking. If the

patient does not express his or her experience that impeded smoking cessation in the

past, then it might be difficult for the physician to understand what might persuade the

patient to make a healthier lifestyle choice now.

If physicians were taught to listen for the orientation that the patient is

foregrounding, the physician may have an increased understanding of how best to

communicate with the patient. Becoming “bilingual” as such, being able to listen and

respond to the patient within the patient’s foregrounded orientation may be a way to

negotiate the communication disparity. Medical discourse encourages integrity-

dominant exchange, yet not every patient foregrounds an objective rational approach

to health. In dealing with medical professions, the patient often has to use integrity-

dominant discourse in order to communicate with the physician. Patients need to be

bilingual in dealing with doctors, but perhaps doctors could benefit by learning to

become bilingual with patients. If the patient foregrounds the integrity orientation,

then using integrity-dominant talk (e.g., using phrases such as “statistically your

chances of reoccurrence are...”) makes sense to the patient, while if the patient seems

to emphasize the intimacy orientation, the physician may need to emphasize and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. explain the disease using intimacy-dominant discourse for the patient to actually

“hear” what the doctor has to say. In a situation that individuals and groups need to

communicate with others that may not share the same dominant orientation.

Kasulis suggests becoming culturally bi-orientational, similar to the way

people can become bilingual (p. 156). He clarifies,

That is: if we acculturate ourselves to both orientations, both may become second nature to us. If this happens, we would be able to move fluidly between them depending on whom we are with. Intimacy and integrity are different enough that we may never be successful in balancing the two - as with languages, one may be my “native” cultural orientation and the other my “second” orientation. Still, the better we can adjust the way we analyze and communicate, the more successful we will be in establishing fruitful, pragmatic, and effective relations with a diversity of others. There is something we will have to give up, however - namely, the idea that there is only one legitimate take on reality, (p. 157)

2.5 CONCLUSION

In this chapter I utilized the theoretical framework of Thomas Kuhn (1970) to

introduce the notion that science is not accustomed to regarding itself as one paradigm

among others. I illustrated how medical science and medical education is situated

within the scientific paradigm that regards health as the absence of disease, tapping

into Michel Foucault’s (1963,1994) observation that the medical gaze discursively

constitutes “patient” as one needing to return to “normal.” Feminist theorists locate

the intertwined values o f scientific and social process, with a discussion o f medical

professionalism reflecting the cultural values set out in the Flexner Report (1910). My

intent was to provide evidence that the doctor-patient relation reflects cultural values

of the time.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The communicative process that happens in this relation has been a topic of

much research and seems to reflect the changing image o f physician over the last 50

years, from a paternalism model to a guidance-cooperation model, to today’s mutual

participation model. Elliot Mishler (1981,1984) was the forerunner in regarding

investigations on doctor-patient exchange as reflective of the social relationship.

A paradigmatic shift is suggested regarding the doctor-patient relation. The

argument is made that this relation could be improved if it were understood as

Dewey’s (1929) conception of transactional learning possible in the teacher-student

relation. Fairclough’s (1992) claim that discourse can be used to encourage social

change was introduced to set the stage for Thomas Kasulis’ (2002) theory of cultural

relationship that holds possibility in transforming the common frustrating

communicative process in the doctor-patient relation.

Certainly, the literature review was not exhaustive but intended to provide the

background information on research conducted on the doctor-patient relation. Chapter

3 will detail the methodology used in this study to investigate the doctor-patient

relation.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 3

DESIGN AND METHODOLOGY

3.1 PILOT STUDY

The anticipated methodology for this project was a discourse analysis of

communication between doctor and patient. A pilot study was conducted to explore

the viability of an observational discourse analysis. One intention was to attend to the

presence/absence of Kasulis’ (2002) intimacy/integrity dominant discourse during a

medical office visit. The expectation was that the patient would principally use

“intimacy” rhetoric in describing the illness and that the physician would primarily

employ “integrity-dominant” discourse. A second intention was to evaluate if the

medical interview fit Mischler’s (1984) description of “doctor talk” being interrupted

by the patient’s “lifeworld talk” was characteristic of a medical interview.

Access was gained to a family practice medical group in Dayton, Ohio. I was

permitted to individually observe three family practice physicians in their office visits

with a variety o f patients in the “naturalistic” clinical setting for health care delivery

(in terms of doctor-patient communication). The observational techniques outlined

by Adler and Adler (1994) that employ systematic and purposive observation (p. 337)

were used. I was interested in the presentation of what Adler and Adler term the

structured-ness of human interaction. This work focuses on the idea that social reality

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and social process is jointly constructed by self and other through the forms o f

"sociation residing in the interconnections developed among people. The dyad, not

the individual, is their unit o f analysis” (p. 383). It was difficult to remain the

“peripheral-member-researcher” (p. 379), because during an office visit the patient

would often try to include me in the verbal exchange. This substantiated an

“observer-effect” (p. 382) that the interaction was different due to my presence.

Notes were taken during each medical encounter detailing the communication

exchange between doctor and patient.

The day concluded with an interview o f each participating doctor (n = 3).

Interviews were conducted to understand the factors at play from the physician side

of the doctor-patient dyad. I explored the physician’s opinion of his communication

skills, and the type of patients he enjoyed or dreaded working with, attempting to

understand his perceived role as “physician.”

The pilot study fueled my desire to explore the possibility that it is the

physicians’ construction of “who they are as a physician” (and what that means to

them) that largely determines their mode of communication with their patients. There

were extreme differences between the communication styles of the three doctors. I

also observed a huge disparity between how the three individual physicians thought

of themselves as “doctor” and how they constructed “the patient.” This seemed to be

the largest determining variable for how the individual doctor communicated with

patients.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A striking example illustrating this point was the difference between the three

doctors’ approaches to the ways in that they gave, or tacitly did not give, the patient

authority to allow me access to observe each office visit. Two of the doctors had

their nurses privately make the request for my presence during the office visit with

each patient. These two doctors instructed their nurses to ask the patient’s permission

before the patient saw me, so there would be no tacit pressure to allow me access. In

contrast, the third doctor asked the patient’s permission with me already in the room,

closing the examination room door, as he made his request that I observe the office

visit. It was, therefore, made clear to these patients that the doctor had already

decided that I would be allowed to observe the office visit.

The first two doctors had some patients who told the nurse that they were

uncomfortable with a third party present. However, I was allowed access to each and

every patient’s office visit with the third doctor. I was extremely uncomfortable with

the third doctor’s behavior. Following my interview with him, I concluded this to be

a reflection of his personal construct of who holds the authority in a medical office,

he or the patient. This reflected a pattern I had not expected to witness. The intention

of the pilot study had been to observe and analyze the communication between doctor

and patient. I concluded that there were differing constructions of the identity of the

doctor and the patient, even among physicians sharing the same office. Upon

examination, the interviews with the three doctors displayed very different

constructions o f how they perceived themselves as “doctor.” I wondered if identity

construction was the most influential factor in determining doctor-patient interaction.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. This pilot study influenced my desire to investigate if patients may also have

differing constructions of themselves, and of their doctors, that influences how they

communicate within the doctor-patient relation. How to gain access to patients?

What forum would be appropriate to encourage both doctors and patients to voice

their true opinions (hopes, desires, frustrations) about the doctor-patient relation

without threatening an actual doctor-patient relation between real individuals?

Janesick (2000) provides qualitative researchers with a fluid view of the

research design process. Influenced by John Dewey (1934), she approaches research

design from an artistic, metaphoric perspective. Comparing research design to

choreography, it needs to be rigorous and “do justice to the complexity of the social

setting under study” (p. 379). Choreography is the art of designing dance and

Janesick convincingly argues that this is an appropriate metaphor for adapting the

research design when needed. In the 1990s, Janesick had advocated for

interdisciplinary triangulation (p. 391) but now advocates Richardson’s (2000) idea of

crystallization as a better lens through which to view research design. “Crystals

grow, change, alter, but are not amorphous.. . . What we see depends on our angle of

repose. Not triangulation, crystallization” (p. 934).

Struggling with a way to investigate how doctors and patients understand

themselves and the other, I saw Margaret Edson’s staged production of WIT off-

Broadway in New York City. The audience leaving the theater after the show was

totally silent. I wanted to know what they thought of the doctor-patient relation

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. embodied in WIT. The silence o f the audience - what did it mean? The interviews

with doctors had revealed varied constructions of their professional selves. But I

needed access to the patient’s conceptions of the doctor-patient relation.

WIT theatrically presents a doctor-patient relationship that for many people is

difficult to witness. The design crafted for this project utilizes audience reaction to

the doctor-patient relations in WIT, as compared to their own doctor-patient

relationships.

Evolving in such a manner, this project exemplifies grounded theory

methodology (Strauss & Corbin, 1994) as the research design was grounded in data

taken from the pilot study that was systematically gathered and analyzed. ‘In this

methodology, theory may be generated initially from the data, or, if existing

(grounded) theories seem appropriate to the area of investigation, then these may be

elaborated and modified as incoming data are meticulously played against them” (p.

273). The anticipated discourse analysis was abandoned as a methodology, adopting

instead a mixed method (including both qualitative and quantitative data collection)

grounded in the conclusions drawn from the pilot study: identity construction of

doctor-patient may precede and influence the communication.

Strauss and Corbin point out that topics within the realm o f medical sociology

often use grounded methodology, as the first two grounded research studies were

about dying in hospitals. And a forerunner to these was Becker, Geer, Hughes, and

Strauss’ (1961) study on student culture in medical schooL Using a grounded

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. approach, which refers to a way of thinking about and conceptualizing data in

developing a substantive theory (Strauss & Corbin, 1994) is a theoretically valid way

to explore the factors that influence doctor-patient communication.

3.2 THE USE OF THEATER AS A CASE STUDY

Case study is not a methodological choice but a choice of what is to be studied. By whatever methods, we choose to study the case. We could study it analytically or holistically, entirety by repeated measures or hermeneutically, organically or culturally and by mixed methods-but we concentrate, for the time being, on the case. (Stake, 2000, p.435)

WIT provided the “case study” addressed in this project. The doctor-patient

relationships portrayed in WIT were the subject o f study to which audience members

were asked to respond. Ironically, a topic of this project involves a distinction

between regarding the patient as a medical “case” rather than as a person. Vivian, Dr.

Bearing, is taught as a “case” to medical students as part of the Grand Rounds led by

Vivian’s physician, Dr. Kelekian, and the resident fellow “Jason”:

KELEKIAN: Dr. Bearing.

VIVIAN: Dr. Kelekian.

KELEKIAN: Jason.

(Jason moves to the front o f the group.)

JASON: Professor Bearing. How are you feeling today?

VIVIAN: Fine.

JASON: That’s great. That’s just great. (He takes a sheet and carefully covers her legs and groin, then pulls up her gown to reveal her entire abdomen. He is barely audible, but his gestures are clear.)

VIVIAN: “Grand Rounds.” The

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. term is theirs. Not “Grand” in the JASON: Very late traditional sense o f sweeping or detection. Staged as a four magnificent. Not “Rounds” as in upon admission. a musical canon, or a round o f Hexamethophosphacil with applause (though either would be Vinplatin to potentiate. refreshing at this point). Here, Hex at 300 mg. per meter “Rounds” seems to signify squared, Vinat 100. Today darting around the main issue... is cycle two, day three. which I suppose would be the Both cycles at the fu ll dose. struggle for life . . . with heated ( The FELLOWS are discussions o f side effects, other impressed.) complaints, additional treatments. The primary site is—here {He puts his finger on the spot on her abdomen, Grand Rounds is not Grand behind the left ovary. Opera. But compared to tying Metastases are suspected in here, it is positively dramatic. the peritoneal cavity—here. And—here. {He touches those spots.) Full o f subservience, hierarchy, gratuitous displays, sublimated Full lymphatic involvement. rivalries—I feel right at home. It {He moves his hands over is just like a graduate seminar. her entire body.)

With one important difference: At the time of first-look in Grand Rounds, they read me surgery, a significant part like a book. Once I did the of the tumor was de-bulked, teaching, now I am taught. mostly in this area— here. {He points to each organ, This is much easier. I just hold poking her abdomen.) Left, still and look cancerous. It right ovaries. Fallopian requires less acting every time. tubes. Uterus. All out.

Excellent command o f details. Evidence of primary-site shrinkage. Shrinking in metastatic tumors has not been documented. Primary mass frankly palpable in pelvic exam, frankly, all through here— here. {Some FELLOWS reach and press where he is pointing.)

KELEKIAN: Excellent command of details. {WIT, pp. 35-37) 64

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. An advantage of using Vivian's experience as a “case study” of doctor-patient

relations is that the research participants are the observers of the case they are asked to

analyze. They do not have a personal stake in how Vivian and her doctors interact; it

is a portrayed relationship. They could be “partkipant-observers” (Adler & Adler,

1994) of a doctor-patient relationship, allowing for reflection upon the relationship.

The interaction only becomes personal if the audience member is bothered by the

interaction for some reason, and if so, why is the portrayed relation bothersome? Are

the portrayed relationships in WIT surface stereotypes or did they reflect fundamental

imbalances commonly present in health care delivery?

Although WIT has been characterized as a critique of health care professionals

treatment of patients, it is not unusual for theater to be utilized as a tool to discuss

difficult cultural topics. Examples include Peter Shaffer’s play Equus (1974)

characterized as "‘nothing short of a far reaching interrogation of the mental health care

profession” (George, 1999, p. 232) and Bill T. Jones' dance company’s 1994

production of STILL/HERE, a multimedia work about death and dying that ignited

controversy among journalists and cultural critics. Some critics called STILL/HERE

“victim art” while others noted that it was simply part of life, that it captured the story

o f our times (Edwards, 2001).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Salverson (1996) speaks to theater’s potential for advocacy, healing, harm, or

an environment where difficult histories might be witnessed (p. 181). She comments

on the power held by both the messenger (the storyteller) and the audience in theater

that tells what she refers to as “risky stories.” To bring the story of the messenger

into the “story line of their [the audience] history compels the listeners to radically

uproot who they understand themselves to be, and, with the question of how they will

respond, introduces a fundamental challenge to what they intend to become” (p. 182).

Salverson views theater as potentially pedagogical,

Popular theater is a public and distinctly pedagogical enterprise, with its aims historically rooted in the efforts of poor and marginalized people throughout the world to stage and realize alternatives to their current lives A climate o f witnessing thus involves not only listening to someone’s story, but allowing our attitudes and behaviors to be changed by it. (p. 183)

Did audience members consider the patient or the doctors, or both, to be the

“marginalized” characters in WIT! The doctor-patient relation portrayed in WIT was

the “case study” that audience members were asked to analyze, reflect upon, and

compare to their own doctor-patient relationships.

3.3 QUALITATIVE INTERVIEWS WITH AUDIENCE MEMBERS

Soliciting audience members interested in participating in this research

project, flyers were placed in the theater lobbies showing WIT. (See Appendix A, p.

176 for the flyer.) An announcement was included in WTTs program (or Playbill)

recruiting audience members. (See Appendix A, p. 177 for the program

announcement.) This included theaters in Cincinnati, Columbus, and Dayton, from

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. May 2000 to May 2001. The flyers were collected weekly so that the audience

members willing to participate were interviewed during the week following their

experience of being an audience member. This was done in an attempt to have the

details of the “case study,” the doctor-patient relationships portrayed in WIT, fresh in

their experience.

While most interviewed research participants were self-selected via response

to the flyer, some audience members called with names o f friends and relatives who

saw WIT in various other U.S. cities that wanted to participate in this study. These

audience members were then contacted and interviewed.

Semi-structured interviews were conducted based upon the work of Glesne

(1999) who views the interview process as a co-constructed interaction:

The intent o f such interviewing is to capture the unseen that was, is, will be, or should be; how respondents think or feel about something; and how they explain or account for something. Such a broad-scale approach is directed to understanding phenomena in their fullest possible complexity. The elaborated responses you hear provide the affective and cognitive underpinnings of your respondents’ perceptions, (p. 93)

The interview schedule of questions was developed and modified during the

course o f the research project, but the framework o f the protocol remained fairly

constant. My purpose was to explore how the audience member perceived the doctor-

patient relationships portrayed in WIT and their own doctor-patient relationships. The

interview schedule of questions was adapted appropriately to the participant’s

standpoint: Doctor, patient, or medical student. (See Appendix A, pp. 178-179 for

the schedule o f questions used with patients, pp. 180-181 for the schedule used with

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. doctors, and pp. 182-183 for the questions posed to medical students.) The interviews

explored if the role one occupied (doctor, patient, or medical student) influenced the

construction of the doctor-patient relationship and its communicative mode.

The majority of interviews were conducted on the telephone at the researchers

expense, ranging from 20 to 95 minutes in duration. The average interview lasted 40

minutes. During the course of the interview, an analytic approach was taken, zeroing

in on the participants perception of the doctor-patient relation. Glesne (1999)

emphasized that an interview differs from conversation in that the purpose is to obtain

“good data,” data that provide information about the topic of study (p. 84). The

interviews were semi-structured, following the outlined schedule of questions.

Detours were taken when necessary, affirming the train of thought of the interviewee;

it was important to grasp the participant’s intended meaning. Often, the interviews

seemed therapeutic for the participant (p. 85), as if they felt that their participation in

the research project allowed them to voice their thoughts on this important topic.

Sixty-eight interviews were conducted over a period of a year. A thank you

note for participation in the research was sent to all persons interviewed. (See

Appendix A, p. 184 for a sample letter.) Analytic files were kept throughout the

project to record the researcher’s thoughts and emerging themes that were common

among the interviews. Following Glesne’s suggestion, data analysis began

simultaneously with the data collection (p. 130), allowing the study to take shape as it

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. proceeded. This also enabled Richardson’s (2000) image of the crystallization of the

project to happen, to grow, as the project was choreographed (Janesick, 2000) during

the year that the interviews were conducted.

The interview transcripts were organized according to age and gender after it

became obvious that certain themes were emerging according to age and gender

differences. Although no attempt was made to interview participants from a gender

and age mix, the self-selected participants were distributed along gender and age

categories. Three times as many female patients agreed to be interviewed, as opposed

to males. The distribution of the interviews conducted, by role, gender, and age were

as follows:

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Patients N= 39 Role

Male Gender Female N= II N= 28

<30 30-50 50+ <30 30-50 50+ Age N= 2 N=4 N=5 N= 2 N= 10 N= 16

Doctors Role N= 14

Male Female Gender N= 7 N= 7

<30 30-50 50+ <30 30-50 50+ Age N= 2 N= 3 N=2 N= 0 N= 6 N= 1

Med Student N= 15 Role

Male Gender Female N= 8 N= 7

<30 30-50 50+ <30 30-50 50+ Age N= 6 N= 1 N=0 N= 6 N= 0 N= I

Figure 3.1: Interview distribution by role, gender, and age 70

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Although conducting 68 interviews was a large task, the “fat data” (p. 134), or

information-rich data obtained was well worth the time and energy. Were there

connections between patients’ constructions of the doctor-patient relationship? Were

there further similarities between female patients who fit into the over SO years o f age

category? Did female doctors construct the doctor-patient relation differently than

their male counterparts in the same-age category?

Exploration and interpretation of the complex data obtained in these

interviews required the use of the NUD*IST 5 computer software for qualitative data

analysis. This package is designed to aid in the management and analysis o f non-

numerical and unstructured data of qualitative research. The emerging ideas were

categorized as “codes” and “sub-codes” in order to make sense of the data, and will

be presented in Chapter 4.

3.4 SURVEY OF COLLEGE STUDENTS

In keeping with Janesick’s (2000) metaphor for research as choreography, a

turn was added to the dance of research, and a quantitative piece of data collection

was added. It provided the opportunity to survey a large number of younger adults,

exploring if their answers differed from the interviewed audience members that

tended to be 30 to 60 years o f age. Do undergraduates differ from older cohorts in

their expectations of doctor-patient relations? If so, what does this indicate? In the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. interviews there were various viewpoints expressed concerning the “teach-ability” of

communication skills. Do undergraduates consider communication skills to be

teachable?

Using an instrument grounded in prior data allowed for verification of

anticipated correlations. Gender difference on certain questions was expected, as was

a difference in answers for students who expected to become health care providers.

The questions were also able to “flesh out” sub-topics of the doctor-patient relation.

An example is that many interviewees spoke of the doctor “treating me as a person”

as being the most important factor in the doctor-patient relation. Was it the amount of

time a doctor spent that determined this? Did the young adults view the patient as

instrumental in the relation? Being able to quantify the responses in the form of a

Likert Scale, which reflects degree of an attitude towards a topic (Ary, Jacobs, &

Razahieh, 1996), was helpful in exploring the degree to which a respondent agreed or

disagreed with a statement.

The survey questions were generated from themes that re-emerged time and

again in the interviews. The strongest theme expressed in the interviews circled

around the question of who or what determines the doctor-patient relation: the doctor,

the patient, being treated like a “person,” or managed care? The survey questions

were based upon recurrent themes that surfaced in the qualitative interviews enacting

Strauss and Corbin’s (1994) recommendation of using qualitative and quantitative

methods of data collection in tandem if it helps in understanding the phenomena

being studied.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3.4.1 QUANTITATIVE SURVEYS

The Ohio State University Theater Department obtained the rights to produce

the Central Ohio premier of WIT, and did so Spring 2001. It played at the Roy

Bowen Theater, May 2-19,2001, featuring Equity Guest Artist Sue Ott Rowlands and

was directed by Theater Department Chairperson, Lesley Ferris. It received a very

favorable review in the Columbus Dispatch, May 3, 2001.

All students enrolled in the undergraduate course Theater 100 in Spring 2001

(n = 1002) were required to attend a performance o f WIT. Participation in this study

was not a requirement of the class. When the teaching assistants (T.A.s) for Theater

100 were approached concerning their willingness to give out a research survey on

WIT, they responded favorably, given one modification. On the second page of the

quantitative survey, there were open-ended sentences that the students were invited to

complete. The T.A.S requested that a distinction be added between the doctor-patient

relationship that the students imagined themselves having in the future, and the

doctor-patient relationship that they hoped to have. The T.A.s felt certain that there

would be a difference between these two responses, as they said their own responses

would differ between these distinctly different questions. They said that they

imagined themselves in a relationship that was less than what they hoped for. The

instrument used in the study reflected their desire for the including this distinction.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. All 1,002 students enrolled in Theater 100 received the survey used as the

instrument in this study. (See Appendix B, pp. 186-187) Fifty-seven percent of the

students responded. All students were 18 years of age or older. Results are presented

in Chapter 4.

3.4.2 OPEN-ENDED QUESTIONNAIRE

Richardson’s (2000) suggestion to “crystallize” one’s data was heeded in this

section of the project. Richardson proposed the central imaginary for “validity” as

the crystal that “combines symmetry and substance with an infinite variety of shapes,

substances, transmutations, muhidementionalities, and angles of approach.” (p. 934).

To only survey college students with a quantitative instrument would not have

provided a thorough representation of the students’ expectations concerning the

relationship in question. The open-ended questions on the second page of the survey

provided this opportunity. The open-ended questions provided information that made

sense o f some of the proportional responses collected on the quantitative instrument.

Results are presented in Chapter 4.

3.5 IMPACT OF WIT ON CULTURE

Hodder (1994) comments on the social embeddedness of any text. “There is

no ‘original’ or ‘true’ meaning of text outside historical contexts” (p. 394). Margaret

Edson’s (1993,1999) WIT was written, received, and acclaimed in a historical

context of an aging population. As more and more Americans experience sickness

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and loss o f health, there seems to be an increased cultural interest in the experience of

health care delivery. How does it feel to be on the receiving end of health care? Was

the reflective nature of this play and the feet that many Americans may soon see

themselves in the character of Vivian, Dr. Bearing, correlated with the success of this

1999 Pulitzer Prize-winner? Regardless of the answer to such questions, WIT was

both nationally and internationally a success.

The success of WIT is the “material culture” evidence that WIT struck a chord

in many arenas. And, in affirmation o f Hodder’s statement that “material items are

continually being reinterpreted in new contexts” (p. 398), WIT was adapted for

television as an HBO movie (by the same name) that was nominated for the 2001

Golden Globe Award for “Best Television Movie” and “Best Actress.” It won the

2001 Emmy Award for the best “Made for TV Movie” and director Mike Nichols

won the Emmy in the category of “Outstanding Directing for a Mini-series.” WIT s

popular culture success, in both its theater and film versions, is evidence that the

themes being discussed within this play are at the forefront o f people’s minds.

Included is the theme o f grappling with the doctor-patient relation. A National Public

Radio summation witnesses to the level of attention given WIT:

HBO WIT PREMIER DRAWS CAPITOL HILL CROWD

Response from Capitol Hill to HBO's premier of WIT at Union Station on 3/21/01 was enthusiastic. The event, sponsored by Last Acts and Partnership for Caring in conjunction with HBO, drew Members o f Congress and dozens of Hill staff. Among the members in attendance were Representatives Benjamin Gilman (R-NY), Connie Morelia (R-MD), Joseph Pitts (R-PA), and Jan Schakowski (D-IL). Attendance for the film, based on the Pulitzer Prize-

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. winning play by Margaret Edson and starring Emma Thompson, was so high that it was screened twice instead of only once, as was originally planned.6

In addition to its popular appeal, WIT had pedagogical value, recognized and

used to enact what Salverson (19%) has referred to as the value of “risky stories”:

Through such aesthetic forms, the story and the act of trauma are marked in such a way as to be visible and yet, at the same time, not utterly pinned down. The form then speaks of trauma, but remains open to possibilities of resistance; to different ways both trauma and agency are and can be known. Risky stories in popular theater must be able to be told in public spaces and understood as events situated within history, remembering that the artists who solicit and shape such stories need to listen not only for damage, but also for hope and resistance, (p. 188)

The pedagogical value of WIT for medical education was recognized by an

innovative training program called “The WIT Educational Initiative” (Steckert, 2000).

This training program combines theater and medical education in order to address a major policy issue - the personal experience of dying and the quality of medical care given at the end o f life. The project has received broad support from the play’s author Margaret Edson, its award-winning lead Kathleen Chalfant, major U.S. graduate medical education and medical school organizations including the Accreditation Council for Graduate Medical Education, and a national group of experts in palliative care education and practice, (p. 1)

The WIT Educational Initiative arranged with medical schools and residency

programs to lead discussion following a production o f WIT. They created a Program

Handbook and a Small Group Facilitator Guide attempting to facilitate post

performance discussion of important themes of the play. Themes included the

patient’s experience o f illness, physician-patient communication, core competencies

in palliative care, spiritual growth near the end o f life and medical ethics issues.

6 http://freshair.npr.org/dayFA.cfindisplay=day&todayDate=03%2F21 %2F2001 76

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A Pulitzer Prize-winner for Drama (1999), Golden Globe Nominee for Best

Television Movie and Best Actress (2001), an Emmy Award for Best Made for TV

Movie (2001), and being utilized as a pedagogical tool in medical education are all

examples of the impact that WIT, by Margaret Edson, has had in contemporary

American culture. They are all “material traces” (Hodder, 1994) that the issues

highlighted by the theatrical, or television adaptation o f WIT, are part o f public

dialogue.

3.6 ACTION RESEARCH - TEACHING A MEDICAL SCHOOL CLASS

How does a medical student come to the identity he or she will assume in the

role as “physician”? As a first-year medical student, how does one envision this

future role? A researcher bias of this study was the belief that one’s identity

construction (either doctor or patient) is a critical factor influencing doctor-patient

communication. Is it possible to teach medical students to become “bilingual”

communicators in Kasulis’ terms (2002) as a way to shift the way they see their role

in the doctor-patient relation? Do medical students view this as a helpful way to

frame their future doctor-patient communication?

The fourth and final segment of this study utilized the theory and practice of

Ernest Stringer’s (1999) approach to educational research termed “action research” in

order to explore these questions. Action research refers to investigative skills that

engage in systematic approaches to inquiry in order to “formulate effective and

sustainable solutions to the deep-rooted problems that diminish the quality of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. professional life” (p. 3). Another bias that grew out of the grounded nature of this

inquiry was the belief that the professional relationship between doctor and patient

could be enhanced by viewing it as a transactional learning experience. This will be

further developed in Chapter 5 o f this document, but it important that the reader of

this research understand that the researcher believed this to be possible in teaching the

medical school class.

A brief overview of Stringer’s approach to research is that although it is a

systematic and rigorous investigation, it is “action" oriented in the sense that it

enables people to understand the nature of problematic phenomena. “It can also

incorporate actions that attempt to resolve the problem being investigated” (p. 5). The

researcher, who also was the instructor for the medical school class entitled The

Physician’s Identity, believes in the power of pedagogy as a means to influence

societal change. A basic assumption of an action research project is that the project

intends to make a difference in the lives of the people with whom the research is

engaged. In this portion of the study, those persons were first-year medical students

who either chose or were enrolled in the class by default (e.g., the class they really

wanted to take was already full). Most of the students (10 out of 12 students)

expressed that this specific class was his or her first choice for the elective Spring

mini-module.

The role of the researcher in action research is not that of an expert but is to be

a catalyst (p. 25). The essence of the work in action research is process, enabling

people to develop their own analysis o f the issue being explored. In keeping with the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. grounded theory methodology (Straus & Corbin, 1994) of the overall project, the

researcher attempted to make transparent the way in which the medical school class

grew out of the qualitative interviews with doctors, patients and other medical

students. In addition to this, the researcher explained that by being a participant-

observer (Adler & Adler, 1994) of the discussions concerning the construction of

their own identities as physicians, valuable data on the subject could be gained. Data

would be gathered while interacting with the research participants (p. 378) in the form

of ethnographic field notes.

As instructor of the class, the action research nature of the class was outlined

for the students on the first day, allowing for any student to drop the class if they did

not want to be part of the action research project. (See Appendix C, p. 189.) All 12

students choose to participate in the study.

The class was four weeks in length, meeting once a week for two hours. The

syllabus (see Appendix C, pp. 190-192) was structured to elicit the medical student’s

construction o f identity as physician and to introduce them to Kasulis’ Theory of

Cultural Relationship (2002) as a tool available to them. An aim of this class was that

the medical student would begin to consciously reflect upon their future identity as

physician.

Only 1 o f the 12 students occasionally referred to, and seemed bothered by,

the research nature of the class. The researcher-instructor took field notes during

each of the classes in ethnographic style, checking with the medical students each

week concerning the accuracy of the previous class observations. The same student

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. who expressed distaste at being a research participant considered these “member

checks” (Janesick, 2000, p. 393) that were necessary for the participants to be

represented accurately, as an expression o f weakness. This particular medical student

said, “You are the researcher, don't ask us if that is what we meant to say, you just

need to tell us what it means.” I explained to the student the concept of “member

checking” as a way to crosscheck qualitative research. (See Appendix C., p. 193 for

example of member check.) I also discussed his implied, “Just tell me what the truth

is” approach as possibly related to his acquired view of education, probably including

medical education. It was a fortuitous opportunity to expose the medical students to

various available paradigms through which research is currently framed. Stringer

(1999) explains.

In the past, it has been accepted that “experts,” or those who are authorized by credentials that signal their access to scientific knowledge, should provide answers to social problems. Researchers are becoming increasingly aware of the limitations of this perspective, however. Scientific knowledge is partial, incomplete, and reductionist (i.e., it reduces phenomena to minute components) and is often of limited practical use. (p. 192)

Focusing on the task o f building links and formulating complementary coalitions (p.

146), the class responded positively and proceeded as planned.

There were four salient activities that sparked discussion during the month

long session. The first day of the class the medical students were asked to introduce

themselves by completing the sentence, “If I hadn’t chosen to become a doctor, I

probably would have become ______.” As the students

introduced themselves and began to get to know each other, the discussion was

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. intentionally shifted to have them consider, if for them, a large part of becoming a

doctor was becoming a “professional,” the actual day-to-day work that a he or she

will engage in, or something else entirety.

The next activity involved each student drawing himself or herself as a

physician. Then the pictures were exchanged among students so that the artist did not

comment on his or her own portrayal o f him- or herself as physician. Each student

was then asked to describe the physician as portrayed in the drawing they held. What

was included or excluded? What were the defining features of the portrayal? (See

Appendix C, p. 194-195 for examples o f drawings.)

As a class we attended an evening production of WIT. The students were

required to attend the 20-minute lecture following the play given by a John Donne

scholar, intended to clarify some of the references in the play to this H^-century

poet. Post-performance discussion of the play occurred at the class meeting the

following week.

Lastly, the medical students were exposed to Kasulis’ (2002) concept of

cultural orientation and bilingual communication across difference. Following the

lecture by Kasulis detailing his theory and its possible implications for the doctor-

patient relationship, the students were given scenarios to role-play. Each student was

assigned the role of either doctor or patient and was given a detailed explanation of

the way they were to communicate within the doctor-patient dyad. (See Appendix C,

pp. 196-197 for samples o f the role-play.) This provided the medical students with an

experience of “communicating across difference” and with an opportunity to

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. negotiate solutions to this frustration evidenced via the role-plays. They were able to

“get inside the communication problem” often experienced in the doctor-patient

relation. Chapter 4 will detail the results and analysis o f these four activities.

3.7 SUMMATION

Janesick’s (2000) metaphor of the dance of qualitative research continued to

spiral with additional turns during the year of this research project. It began with

interviewing audience members reacting to the doctor-patient relation portrayed in

WIT. It continued with a survey of undergraduates who saw WIT in order to gauge

their expectations and desires o f the same relation. The music playing behind the

dance was the music of the overwhelming popular acclaim afforded WIT. The dance

ended with a classroom experience where medical students were invited to unveil

(even to themselves) their emerging understanding of what it means to be a doctor.

Chapter 4 attempts to “unpack” this large mass of data allowing for a

synthesized analysis of the data results in Chapter 5.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 4

DATA RESULTS AND ANALYSIS

4.1 QUALITATIVE INTERVIEWS OF AUDIENCE MEMBERS

The semi-structured in-depth interviews conducted with audience members of

WIT were done in an attempt to reconstruct how they construct meaning. The open-

ended questions allowed participants to “tell their own stories” (Glesne, 1999, p.

197). In doing so, audience members accounted for their reaction to WIT, revealing

the way they construct doctor-patient identity. The play WIT was the common thread

that all participants experienced. Playwright Margaret Edson values the somatic

aspect of live theater as she comments,

To me the thing that's the most interesting is the whole idea that there are live people in the audience and live people on the stage. I'm not interested in a play that pretends that's not the case It's a play about love and knowledge. And it's about a person who has built up a lot o f skills during her life who finds herself in a new situation where those skills and those great capacities don't serve her very well. So she has to disarm, and then she has to become a student. She has to become someone who learns new things. ... we feel if there were an intermission, people would leave and we want them to stay till the end.”7

Themes that emerged out of the interviews provided a glimpse of participant’s

construction of the doctor-patient relationship on and off stage. Why was it so

7 As quoted in an interview with Margaret Edson, by Theron Albis, “In the Spotlight,” Stage & Screen.com. http://www.stagenscreen.cofn/mybookclub/showbiz/bookclubs/sns/Special/Authors/ Margaret_Edson.htm 83

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. difficult for many audience members to watch Vivian (a name derived from the Latin

word for “alive”) being treated as if she were a medical case as opposed to a person?

If it were only a staged relationship that had no relevance to the audience member’s

life, would it have had such strong impact? Analysis of the qualitative interview data

suggests that Margaret Edson was correct in her characterization of WIT as live

theater. Clearly the patients, doctors, and medical students interviewed expressed

varied but strong responses.

4.1.1 PATIENTS

A majority o f the “patient” audience members who became participants in this

study (by this I mean all participants who were not physicians or medical students)

expressed a desire to “explain what their own doctors do right,” as they hoped

physicians might read this study since they believe it qualifies as “research.” Many

of the patient participants were educators and held a firm belief that the doctor-patient

relation is in a time of cultural transition. They wanted to embrace the opportunity to

voice the desirable factors in doctor-patient relationship from a patient’s perspective.

Across gender and age categories of the patient participants, WIT was viewed

as a vehicle for both doctors and patients to examine their role and responsibility in

the doctor-patient relation. A 60-year-old professor crystallized this overall feeling:

WIT allows each person in the audience to examine with honesty his/her self- knowledge as it involves the human lack of ultimate control, the tendency to be in denial o f death, the need to acknowledge interdependencies, the difficulties experienced by both sides o f the patient-physician relationship, the necessity of full communication, to FEEL fully respected particularly in “compromised” situations.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. All of the patients who had extensive experience with medical personnel

(because they had dealt with a serious illness in their own life) felt WIT was a more

realistic, and less stereotypical representation o f patient experience o f medical care.

Overall these patient participants were more critical o f the medical profession than

the interviewees with less experience. A woman in her late 20s, who was also a

cancer survivor, reflected the attitude that WIT was

an important piece o f work. It seems to me that the most important element of WIT holds up a mirror to the face of the medical profession and how they affect patient’s lives.. . . The role of Jason was horrifically true to life on so many levels Doctors who embrace all that patients can do for themselves are the ones who really help their patients. So often doctors believe they are the ones in control and the patient can only do what they prescribe, but the best relationships are the ones where doctors inform their patients what they are doing, why, and the risks, and then discuss with the patient all that the patient can do.

The responsibility o f Vivian, as the patient, to express her own needs did not

go unheeded by audience members:

You know what's interesting? Never once in that play did that woman ever say, “I have emotional needs here.” As a matter o f feet, it was totally to the contrary. As an outsider we were looking in and saying, “Oh my God, that doctor's not responding well to her.” Her needs were never expressed.

One of these patients, who expressed the necessity of self-advocacy of

patients, illustrated in a vignette o f his own health care experience his willingness

(and perceived importance) of the patient to speak up:

I've had some doctors that have been very good; some that not only attended to my body but also my person. There was one doctor that I actually stopped in the middle o f a test and introduced myself saying, “I am Kevin C. Who are you?’ I needed to let him know my name so they would identify me as a person.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Most patients were committed to the idea that they needed to be an active

participant in their health care relationships. One patient went on to say that this is

the way she identifies a “good doctor” - one who desires an active patient participant:

I think that the patients’ willingness to be an active participant in their treatment is the biggest determining factor. That patients who will do the research, get themselves up to speed on what they have and what the current thought is on treatment, will know the kinds of questions to ask, will understand the various options available to them. Those patients bring to the doctor-patient relationship a sense o f partnership. In my experience, patients who don’t do that simply invite the doctors to sort of take charge and a doctor’s not going to insist that a patient be an equal partner - they’ll fill the void that a patient leaves by not doing their own homework, so to speak. I think that the good doctors would certainly prefer a patient to be educated and aware but I tell you what, it’s up to the patient to decide that they’re going to do that.

A mother o f a seriously ill teenager spoke to the conflicted feeling of wanting

to participate in one’s health care, yet at the same time had a desire for the physician

to have all the answers:

I think the hard thing is - and I don't know if I'd want them to - if they admit they don't know, if they admit they really don't know - do we want to hear that as patients or not? We want answers and we expect them to have answers.

She recognized the messy nature of the doctor-patient relation, making it difficult for

both players in the dyad to know how to proceed.

Many, if not all of the patients, though, validated the belief that the

relationship between doctor-patient is a location of empowerment that affects healing.

Some patients desired a physician who would strongly recommend a particular

treatment, while other patients appreciated making treatment decisions themselves,

after the doctor presented the treatment options and risks. Patients considered the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. most valuable trait in a doctor to be the doctor’s ability to distinguish the patient’s

desires. And the avenue for being able to distinguish patient desires centered on the

doctor being willing and able to get to know the patient as a person. Patients talked

about medical encounters in a positive manner when the doctor and patient

expectations were congruent. Patients who wanted an “all authoritarian” approach in

their physician were happy when the doctor was totally “in charge.” Patients who

envisioned themselves being an active participant in their health care were pleased

with doctors who desired that in their patients. Most patients, though, desired a

physician who regarded them as a person, such that the physician would be able to

adjust to the nuances of the whole person, able to distinguish between the ebb and

flow of patient needs.

If a patient perceived that the doctor regarded he or she as “a herniated disc”

or “the ruptured gall bladder,” the doctor-patient relation represented feelings of

alienation rather than relation. Most patients commented that they especially look for

a personal relationship with their primary care physician. Although most patients

expressed this desire, they qualified this desire by saying it is probably just something

that is uniquely important to them. A representative example:

I would say for me, and I don't know how much o f this has to do with just my own personality and my own personal needs, medical knowledge is very important on the part of a doctor, but I would say in fairness equally important is my relationship with that doctor; feeling that doctor has a concern for me as an individual, knows me somewhat as a person, not just from a medical history standpoint, but from a personal history standpoint.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Virtually all patients interviewed desired a personal relationship with the

doctor who they viewed as coordinating their care. They expected less of a

relationship with specialists. Comments about specialty doctors include:

I think it is harder with specialists because your time is more cut and dry.. . . I find that surgeons, of all the specialty areas, are the worst at having M.D.-itis. . . . my guess is that the folks who are at the very top of the line are the most respected and get into a power trip. It could have to do with specialty, but more likely, it’s where they are in the echelon.

My general feeling is that specialists (e.g., surgeons, neurologists, orthopods, etc.) tend to be more ‘mechanical’ in their approach to patients. I see internists, family practitioners and pediatricians as being more empathic and sensitive to patient needs The most regressive specialties, as far as I'm concerned, the most iron-clad, conservative, hold onto, the aloofness, and patient-as-object people, seem to be found more in the specialties like orthopedics and some of the heart specialties.

WTTs attention to the importance of role played by the patient in the doctor-

patient relation did not go unnoticed by the patient interviewees. Patients saw WIT as

a story about patients and about doctors, not exclusively as a story about doctors’

treatment o f patients. WIT reinforced that patients need to be advocates for their own

health care. If Dewey’s (1934) definition of “art as experience” is that the art impacts

the participant’s future actions, then WIT seems to have qualified as art for many

patient audience members. An overwhelming number of patients spoke to the

importance o f being able to change doctors if they weren’t getting what they needed

from a particular physician in terms of relationship. Primarily, their voiced

frustration seemed to circle around not being heard or validated as an individual:

If the patient is willing to change doctors if they’re not being satisfied with the treatment options being presented, then again I think that sets a particular tone for the relationship. The willingness to change if they’re not satisfied sets one

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. relationship. A patient who is just never going to change and is going to sort of give over all sense of control into the hands of a particular doctor, that sets an entirely different relationship.

One patient expressed frustration that her doctor didn’t listen to her

description that a particular medication had unacceptable side effects for her. Her

description o f the scenario highlights the need for individualized care and the

responsibility of the patient to obtain what they need:

The doctor said, “Well, Sue, many o f my patients have done very well on this combination.” It's like, “Who cares? This is me we're talking to.” I then spent a few minutes going back over my history of eating problems and how it had been a big issue in my life. It wasn't an issue anymore. I hated that the medication was causing it to be a big issue again. He said, “Well, Sue, you can't gain weight by breathing air. You have to cut back on what you're eating.” I could have killed him. That was the last straw and I went looking for another doctor.

Similar situations necessitating the search for a new physician were described

by a patient who was told by the doctor that debilitating migraines were (ironically)

“all in her head” when a causal agent couldn’t be located. A woman described her

seizure medication requiring titration during her menstrual period. Her illustration

reflects the frustration in not being heard:

I kept saying, “Something is wrong. Do you think it has to do with, for example, hormones?’ He says, “No. Your condition has nothing to do with hormones or your period.” But every time, he told me no, that it had nothing to do with hormones or the time of the month or anything. I said, “Well, my seizures have increased during that time.” He said, “They have no effect on each other.” For several years I had been very sick and he couldn't regulate my medicine. So finally I went to another doctor. This doctor, on the other hand, had a totally different tone. They were both male doctors, both in the same practice, although the first doctor left for Colorado. I said to the new doctor, “What do you think about this possibly relating, heightened during different times of the month.” And he said, “Oh, absolutely.” Well, he was able to regulate the medicine in accordance with my periods and I haven't had as many seizures and we've been able to connect.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A recurrent theme that surfaced time and again in the patient interviews was

the desire to be listened to as an individual, as a person, and not to be seen as a

medical case. This supports Fairclough’s (1992) suggestion that patients desire such

a transformation. When patient participants did have the experience of being treated

as an individual, they emphasized that their positive experience was an anomaly:

We’re all breast cancer survivors in this group and some of the things I’ve heard about the treatment of other members of our group by doctors and their staff it’s just - 1 was so lucky - People will tell you some horror stories and they will be true and that is really sad. I wanted to report to you a positive. But I know from being part of this group that my experience was the exception and not the rule.

Yet the majority, (28 of the 39) patients interviewed, did have a positive

experience of being treated like a person by their doctor. The factors that made them

feel this way included the doctor respecting them as individuals who had some

knowledge of their body, listening to the patients’ level of understanding of the

medical terminology, and the doctor’s ability to craft the communication to the level

of the patient’s understanding. They emphasized that, “Physicians should be aware

that medical terms, treatments, medicines, procedures, etc. are all unfamiliar and

often incomprehensible to patients.” And that in WIT, “The effort of the doctor to be

clear was compromised by his unawareness of how much technical language he

used.” Clearly, patients expressed a need that doctors speak to their level of

understanding as a starting point of a positive doctor-patient relation.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The two patients who participated in medical research studies emphasized the

need to highlight the patient’s value as a person first, never as a research participant

first. They emphasized,

WIT portrays the inhumanity of doctors who are more concerned about carrying out research than their patient’s feelings and well-being. It raises the question of the balance between the need for research in order to advance science, and the accompanying need to be constantly aware that research subjects are real people with real needs and feelings.

But more than one patient participant articulated the difficulty in teaching

medical students about discrete disease while at the same time training them to regard

everyone as a person first. She says,

It's been proven in many studies that happiness and acknowledgment brings a healthier person. . . but often you're looked at as an organ or a herniated disk or whatever it may be. It's not a person with a disease, it's a disease first and then the person I think you need to teach it, incorporate it in eveiy class they take in medical school. It doesn't have to be Personal Relations 101. It just needs to be taught as you're dealing with someone who has cancer, not your dealing with a cancer which is invading this person's body. It's hard. I'm sure they're having trouble figuring out how to do it best.

An interviewed nurse claimed the most difficult part of being in the audience

o f WIT was watching the team of doctors come in and talk over Vivian as a case,

ignoring her personhood. But she remained hopeful that good physician instructors

could guide residents in this task:

The young residents are so wrapped up in what they need to be learning or what they need to get out of the experience that they lose sight of the patient. Part of that is just inherent in being new. Part of that you cannot escape until you get truly comfortable with what you are doing and then you can maybe clue in more on the patients. I guess a truly great teacher would somehow maybe try to help those students focus more on the patient as they’re learning. A doctor-teacher. It’s just kind of difficult to grasp all that at once.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Interviews with patients indicated that the social expectations of the doctor-

patient relation may have changed over the last few decades. Patients see their own

role as more proactive and their expectations of the doctor’s role may have changed.

A 62-year-old male executive explains,

When I was younger, you didn't really - talk back is not the word I want - challenge your doctor very much. That whole dynamic has changed with other changes in health care and some doctors who grew up in that culture are probably finding it very difficult to be doctors today. Because the patients have changed somewhat, and if the doctor has not changed, he is relating to his patients in a very different way than most people expect today, I think. It may be that the younger doctors coming up, since they're coming into an entirely different culture, they may relate differently. But it's certainly very difficult today for a doctor in his SOs or early 60s.

The main discussion concerning the change in the doctor-patient relation, then

and now, focused on unequal power relations. Some patients focused on the necessity

of the patient becoming empowered, while others concentrated on the one in power

respecting the person in the less powerful role:

Anyone who's in a position of relatively less power such as patient is to a physician, or a student is to a teacher, a child is to a parent, is at the mercy, in a sense, of the person with the power. Therefore if there's going to be any kind of treatment which is humane and healthy there has to be a perception on the part of the person who has the power, on a relatively permanent basis or a temporary basis, of respect. There has to be an attitude of respect and valuing of the person who is in the position of relatively less power. Hie teacher who is condescending, the doctor who is patronizing, the parent who is tyrannizing or taking advantage of, we're all familiar with these relations.

Even the language some of the patients used to describe their role as patient

distinguished them from the traditional doctor-patient relation of the early- to

mid-20lh century.

I do prefer to use the word client because I do think it speaks more of being a consumer - that clients need to feel empowered. I think that empowerment

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. comes from two things: one is self-esteem and the second is knowledge about one’s own body. In fact, I do a lot of full-day workshops on empowerment for older adults and those are my two main thrusts: coping skills and empowerment, how you get to be a more empowered person, and secondly knowledge. The more people could know about their own bodies, the more they can really interact well - and I do think going prepared to an appointment with a health partner is important so that people take a list with them of items they want to ask and secondly take another person along to be another listener. I think those are ways of reaching for empowerment I'm 52,1 think that people my age, we know that we are consumers of the medical industry so we have to write down questions. When I go and first meet with a doctor, I interview him...

As the patients spoke about becoming empowered health consumers, they

emphasized that doctors should aid them in becoming more knowledgeable about

their health problem. Patients are looking to doctors to guide them as to where to

look for information and support in dealing with health. These words seem to

describe a service provider of information or where to obtain it:

Today, doctors have more to offer patients in terms of where to obtain health information. There are support groups for every kind of physical and mental health problem. There is a plethora of information available on the Internet and through a multitude of organizations that deal with every kind of health problem. Hospitals today are much more open to allowing the general public use their medical libraries, that used to be open only to staff. Many people are more aware today that they have to be responsible for educating themselves about their health problems. Doctors need to educate and reassure their patients that others share their concerns and health problems. They also need to have current information available in the way of easy-to-read pamphlets that list educational resources and local numbers (agencies, organizations, support groups, etc.), so that a patient can immediately call someone after they leave the office to discuss their concerns. Many doctors do this.

A professor summed up the new vision of the relationship between doctor-

patient that so many of the interviewees tried to articulate. She describes,

The best analogy for the best type of doctor-patient relation is an Olympic ice skater. You have a coach who has training and experience and can see from the outside what’s going on with you, what’s wrong with your spin and so

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. forth. But you’re on the inside of it and you bring your own capabilities to the table and you bring your own sense of how this can work best in your body to the table. But it’s a partnership that says, “Look, we know the form needs to be perfect and how are we going to get there?” From the outside looking in, what’s wrong? How do we fix it? And from the inside doing it, what can I contribute and how can I make it work? I think it’s a real partnership. The ultimate goal is wellness.

A changed perception of wellness from the disease paradigm of health was

often mentioned in the interviews with patients. Many patients sought medical

doctors who focused on preventative care, or who were willing to coordinate health

care with the inclusion of alternative and naturopath practitioners. A problem that

three patients encountered though, was that other physicians did not regard medical

doctors specializing in preventative care as “real doctors,” thus coordination of care

was an issue. A 79-year-old woman revealed her own oscillating feelings concerning

her own preventative holistic medical doctor:

He doesn't act like God. He doesn't pretend that he knows everything or act like he thinks he ought to know everything. He lets us take more of our own responsibility and actually asks that we assume more responsibility. At first that's kind of startling because you think, “I want you to tell me what to do!” But then you realize that's why you went to this kind of a person.

Her reflective candor appears an honest statement of the difficult stance betwixt and

between the scientific medical understanding of the disease paradigm of health with

its medical, scientific authority, and the desire for a more integrative notion of health

as a process in which patient is an active, empowered participant in health and any

discussions concerning it.

Analysis o f patient interviews reflected some gender and age differences, but

certainly less than anticipated. The notion of information gathering as a comfort was

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. much stronger in the interviews with male patients. Many male patients indicated

that their conception of a “good doctor” was a good information provider, without the

patient having to generate his own questions. A doctor that gave all information

without the male patient having to pursue information was valued: “I expect the

physician to tell me what the real prognosis is, the real short- and long-term of this,

what to expect in terms of how I would recover and what the time frame is.” For

most males, their description of a “bad doctor” (as they put it) was one that was not

forthcoming with information. One such scenario was described:

We had to ask him for all the information, rather than him give it to us I thought he was kind o f passive in his approach to suggesting what we might do. This thing came out o f the blue. First was the analysis that it was likely to be prostate. Then the biopsy that said not only was it prostate but it was very aggressive. He was not forthcoming with information. I felt like every question that I asked he gave me a minimalist answer.

Interestingly, males also desired a particular type of information concerning

illness, namely, its effects upon daily life. Younger men usually brought up that

doctors need to view themselves as teachers. A 22-year-old male emphasizes both of

these expectations,

I am hoping the doctor will be concerned with how this ailment affects my everyday life . . . it’s very important that a doctor realizes his or her role as an educator of sorts. The patient needs to leam about their illness and it is important for the doctor to use this role to comfort the patient.

Information, especially concerning the effect of the illness on the man’s daily life,

was comforting to male patients.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Regarding the “teach-ability” o f good communication skills, the man over age

50 emphasized that although education may be able to improve one’s communication

skills, there was doubt expressed that education could instill these skills. They

considered these skills to be acquired early in life from one’s upbringing.

Distinctive themes that emerged from interviews with females centered on the

idea that it was white men who traditionally were the doctors (they were the ones that

had access to the scientific medical education) and that the communication style

characterizing the doctor-patient relation common during the 20* century simply

reflected this fact. Many women noted that feminist ideas have helped open up the

professions to various styles of communication, but that this is a cultural process that

develops over time. A 65-year-old clinical counselor states,

One of the problems with the medical profession, as with all the rest o f the world as far as I'm concerned, is that women have not had a voice. Women are not accustomed to being teachers enough and men are not accustomed to listening to women. They tune out, they interrupt, they disregard. The insights and the points of view that women represent are not available to men because they really have a screen, a filter, they've heard their fathers disregard their mothers, some o f them from the time they were at birth. This is still happening . . . But the main point is I think the women's movement has opened up the other half of the human race, the values that women have, the outlook that women have, is primarily responsible for the humanizing o f all these professions.

As women are given the opportunity to participate in the profession of

medicine, the general feeling from the women interviewed was that medicine would

be transformed. A mother of a sick child commented that she was struck by the

group of residents she saw hovering over her daughter’s bed,

To see the face of the new medical personnel blew my mind. It was entirely - we're not talking white men anymore - it was all, not all ages, but a fair

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. amount were retuming-to-med-schoo 1-type people - different colors - and of course a hospital like Children's would attract people like that. But it was very interesting. The breadth of people moving into medicine and probably a lot of those communicate very differently.

Women did not express a sense that men caused the communication difficulties often

experienced in the doctor-patient relation, but that the relation will undoubtedly

change due to the current presence of women being educated to become doctors.

4.1.2 DOCTORS

Most doctors also felt that the pedagogical purpose of WIT was for health

professionals to look in the mirror and ask, “Is this what we look like to the patient?'

The researcher was aware that doctors who had very negative reactions to WIT

probably would never agree to be interviewed for a research project on the social

construction of the doctor-patient relationship. A young male intern felt, “a lot of

physicians might take offense to the play, but that is because they do not understand

the perspective of it.” He considered WIT to be a story of the patient’s perspective of

her own death.

Another physician, a 40-year-old male, understood the weight o f WIT to be

the message that human relationship is the most powerful tool medicine has to offer:

You know as well as I do that written words or information and data probably would never change anyone compared to what a human relationship has the potential to change people. It has much more weight than data and information.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Doctors understood the pain that Vivian experienced when she was treated

like a case, craving to be recognized as a person. A female physician noted, “At

some point Vivian says, ‘They’re taking care of - I’m a cancer, I’m not a person.

They’re not asking about my life, they’re asking about my side effects.’”

A hospice doctor felt that WU allowed the audience to experience things that

“you may not have experienced. But in a way it prepares you for things you might

come to experience.” Another doctor commented,

WIT has gotten so many people’s attention. It speaks to some basic truths for both patients and for doctors. It helps then to explain something that's missing.. . . The purpose was to help doctors look at themselves. And for patients to realize that doctors are human as well. Patients need people and she didn't have any so she needed the doctors to be people. Especially when people are dying they need human contact.

The interviewed doctors were conscious that WIT was also a discussion of

mortality: “It touched on the issue of facing our mortality from BOTH the patient and

physician perspective.” And another physician recounts, “I think it reminds us of our

vulnerability as a human being. We could be Vivian and I think it reminds us o f our

vulnerability toward death. It reminds us to live life.”

All the physicians noted that the reason other doctors may not enjoy being an

audience member of WIT was due to the way that doctors were presented in the play.

A physician, a medical school professor from New York, lamented,

I dealt with a lot of doctors seeing this; they only, only saw doctor-bashing. They failed to see that this was as Vivian had lived her own life, that this was

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. a juxtaposition, that that was the great irony of the play. They failed to appreciate, so it was realty interesting because it depended on what set of blinkered vision you approach this play, that determined what you saw.

Yet, the same professor truly valued the opportunity to provide her doctors-in-training

with a provocative learning experience:

I’d have to give Edson a round of applause because she created something that is very controversial It provokes people, it provokes doctors to think about what they think of themselves, it provokes patients. People don’t like Vivian a lot because she’s not so likable. She integrated great literature in there. I found so many layers o f meaning here that I’m still digesting it.

In true Deweyian transactional learning, this gifted physician educator notes

that in trying to teach her medical students WIT, she was the one taught. She walked

away from the experience of teaching WIT with the realization that it provided a

glimpse o f who doctors are at times:

I’d like to think I’m not one of them. I wouldn’t say it’s neither realistic or unrealistic; I think it is a glimpse and I think it’s a glimpse o f something that’s a part of all of us whether we like it or not. But it may be a larger part of some people than others. So, I don’t think it’s true or untrue; I think it’s part and I think it can range from a tiny part to a large part. But at least it brings attention to that and it serves to make us aware and more sensitive to our behavior.

One young emergency room physician I spoke to affirmed the truth of

insensitivity that easily slips into the day to day of medical work:

When people are having procedures done, doctors and nurses will talk just like a mechanic who’s talking to his friend when he’s working on his car. “Hey did you see the game last night, blah, blah, blah” and sometimes forget the patient’s there. Is it right? No. Does it happen? Yeah. It’s because it’s our job. And just like you talk to your friends at work while you’re doing your work, we talk to other people when we’re doing CPR and doing code. We’ll be in the middle o f a cardiac arrest and a patient’s crashing and yes, you’re doing the best you can to help the person and yes, you’re doing whatever. But sometimes you can turn and make a comment and feel like appropriately bringing humor to the situation because we have to deal with the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. stress as w ell. . . sometimes people are forgetting where they are, if you bring them back and say, “Okay, look, this patient’s sick and we need to help her out and tell her that she’s doing okay an stuff like that.” People are brought back down to earth and they’re like yeah, they remember that this is serious.

The same young physician was the only doctor with whom I spoke who was at all

critical of patients being participants in their own health care. He spoke about how he

emphasized different parts of the patient’s medical facts depending on whether or not

he thought a patient ought to have surgery. Although he did not directly state it, the

underlying theme of his interview was that he regretted not being able to be a

physician o f the past:

In the old days you’d have, “Yeah, doc, whatever.” And the doctor was in charge. And now we’re moving more toward patient autonomy and they want to be more participants, be decision makers in their care. It’s fine, but I’ve had trouble with patients being able to make the simplest decision. I am enabling the patient and I’m giving them their autonomy and they say, “Well, what do you think I should do?”

The other interviewed doctors contrasted sharply with this young doctor’s

sense of the doctor’s role. All of the other doctors spoke of seeing themselves as

teachers or health advisors with their patients. Many of the doctors spoke of viewing

themselves as an educator so that their patients could become independent of them.

A young resident’s response is representative,

My role is to educate patients on lifestyle modification and disease prevention, and then treat disease once found so it impacts the least amount on their lives. Most importantly I feel I am an advisor to the patients, to whom I can relay the most important medical info and up-to-date technologies available to the patients in order that they may make the most informed and best decision for themselves.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. An infectious disease doctor gives a similar answer but teaches his patients to

increase the likelihood that they are compliant:

Care is a two-way street. As an example, I care for HIV positive patients. They are all educated about their disease/care. The ones who do best, and with whom I/we have the best relationship, are those who fulfill their half of the contract. Once we get the therapeutic aspects of the relationship out of the way, we can interact as people I teach and advise. I hope that they will become educated and thence a compliant patient who will reach maximum therapeutic benefit.

Like the interviews with patients, an emergent theme in the interviews with

doctors was the importance of the congruence of expectations between doctor and

patient. A family practice physician says, “I guess the perfect conversation is one in

which both the patient and doctor’s expectations of the encounter are met.” He goes

on to say that dissatisfaction results when the patients don’t feel they were part of the

encounter if they envision themselves as part o f the process. He offers the example of

one of his partners:

I got a partner and I’m not saying he’s a bad doc, but he comes to his conclusions really quick. It’s based on experience, knowledge, and understanding. Now, it can lead to a very dissatisfying experience for a patient. But it keeps my partner on task and he feels better about his day.

This primary care physician feels his partner is not being prudent. He explains that

there is a certain "service expectation” today in medicine that is necessary to practice

"good medicine.” It isn’t the amount of time spent with a patient that is important but

the perception by the patient of the time spent with the physician. This increases the

likelihood of a good relationship with a patient, which in turn decreases the likelihood

of getting sued. He is saddened that lower malpractice insurance is given as a reason

for doctors to be encouraged to develop good relationships with their patients.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. What is the service expectation? I don’t think the service expectation is as much on the clinical side as much as it is on the psychological side. You hear all the time, I’m not sure it’s 100% anymore, that doctors that have great relationships don’t get sued. Even if they royally screw up, they don’t get sued, because it all comes down to the relationship.

This same doctor was convinced that a strong relationship needs a physician that is

willing to respond to the lead of the patient. Some patients value time efficiency

while others value empathy.

I do think there’s a generation of patients now that appreciate speed and efficiency. There’s a value on that. And they’d rather know that you’re on time, you’re efficient. Again it’s a perception o f their expectations of that encounter.

A woman who has been a doctor for 50 years claims that the most important

role that she occupied was to be empathic.

I think it was important for me to know enough to practice good medicine but the way I treated patients was for more important. As an oncologist, and I did oncology as well as hematology, I took care of a lot of dying patients. I'm sure the way in which I took care of those patients was for more important than what I did. Almost anybody can do what you do in this day and age, but it's how you do it.

A common response among the doctors was that they considered mutual

listening and mutual assessment of goals to be critical factors in doctor-patient

relationship. How to best accomplish this? A young primary care resident shares his

view:

Successful doctor-patient communication is dependent on the ability of the doctor to shut up. The most important skill that can be taught or learned for medical student/residents is the ability to listen. For me that was/is hard because I am an interrupter. Patients feel more satisfied if they are able to say all that they wish. Also, physicians, hopefully, eventually learn that the

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. patients usually know what is wrong with their own bodies.. . . Every patient and physician realize that everyone has a different take on life itself and must respect that choice/lifestyle.

He suggests a way around this conflict by following the patient’s lead:

At times these can be conflicting concepts, yet once again the issue comes down to the physician listening to the patient and her desires.. . . You must have the ability to adjust your style to a particular patient. One must also be adept at using non-medical terms and easy-to-understand concepts, without appearing condescending. It is definitely an art, but not that difficult if you listen and ignore your own biases.

An experienced female emergency room doctor agreed but spoke to the

difficulty o f being bilingual:

The medical language, I think, is a huge culprit. We speak a different language much like lawyers do and that language is used amongst ourselves. And I have no doubt that that has continued to keep barriers between ourselves and the patients.. . . There’s a whole, I believe subtle, probably even unrecognized conspiracy of language so that you have to always realize I go from clinical language to layperson language. It’s like going from French to English. You’re doing that potentially minute by minute and that’s not easy.

The majority (11 o f 14) doctors admitted that they enjoyed working with

patients whom they could diagnosis easily, and help solve the problem. It was much

more difficult when the doctor couldn’t “fix” the problem, when it was unclear what

the physical problem was, or if the patient came in with a list of 25 health issues. All

the doctors mentioned the difficulty in dealing with patients who abuse drugs as the

doctors expressed feeling manipulated, and not knowing what to believe, thus it is

difficult to “take the lead from the patient.”

The way doctors talked about patients researching their health issues on the

Internet followed the common theme: “There is a lot of misinformation out there. It

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. is difficult to separate the wheat from the chaff.” Virtually all doctors interviewed

considered the Internet helpful in its “conversation starting function” between doctor-

patient, as opposed to an authoritative source o f medical information.

One gender difference that showed itself was that male doctors mentioned the

value of patient compliance more than female doctors. As one doctor insists,

The patient must be pro-active and compliant with their health care. (Keeping appointments, tests, keeping record of their past history and medications so that other physicians know their status, and resources are not wasted through doctor shopping, repeat tests, etc.)

An oncologist proudly admits, “In general, my people are compliant. In general,

stupid people are less compliant/’

Male doctors also found it irritating for patients to already have their minds

made up, before seeking help from a physician. The middle-aged male doctors

brought up the issues of managed care and malpractice insurance more than any other

age or gender grouping of physicians.

Women doctors were overall more verbal about their need to connect with

patients on a personal level:

I think it’s important to try find some little aspect of the person that doesn’t have to do with the illness: where they’re from, what they did, what they liked in their life, or do they have animals. Something where you have a common ground where you can have an exchange that isn’t strictly about the illness.

Although it was evident from the interviews that the male doctors also did this,

female doctors emphasized it.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Two of the seven female doctor participants stressed the inequities in

medicine for women. An emergency room doctor was frustrated:

There's a major issue about women in medicine.. . . Part-time work will let you get better in your clinical skills but you cant get prorated partnerships or academic promotions.. . . That the whole thing needs to be questioned, it just keeps the control of the profession with men.

The female professor of medicine who has practiced for 50 years was not at

all surprised that many male physicians saw WIT as physician-battering. When she

used WIT in her own classroom she found:

There were several people, mainly men, who saw this as doctor-battering, physician-battering. This was brought out. Several people said this. More men than women. I think this was because women are used to being criticized. I think women are much more used to being criticized, for attitude. ... It's for more critical to the male ego not to be criticized. Women, I think, are fairly used to it or have, in entering medical school, made certain adjustments. It's a rare woman that I see who's likely to be sure she's right if someone says she isn't.

Dr. S. has seen first-hand the ways in which the experience of medicine has

changed for women over the years. She describes her experience in medical school

54 years ago:

It was about 5% women, I think, across the country, when I started medical school. But medical school was not the big problem for the women. We were very isolated; it was isolation, being not part of the group. We were peripheral. We had all the learning opportunities but we were peripheral people. You just don't sit around and play poker with the boys, this kind of stuff. You were held in a different milieu, a different viewpoint. I think all o f us felt very isolated.

She is very pleased that men and women today more evenly attend medical schools.

Although she did not indicate how this would transform medicine, she made it clear

that she thought it would.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4.1.3 MEDICAL STUDENTS

Of the 15 medical students interviewed, 8 were male and 7 were female. This

reflects the general gender enrollment of medical schools in the United States today

(Dworkin, 2001). The one theme that all 15 medical students agreed upon was that

communication couldn’t be taught in the academic arena. They were referring

directly to the academics of medical education. They all stressed that the way for

future doctors to learn good communication skills is by emulating experienced

doctors who exhibit such skills. One medical student claimed that watching and

reflecting upon a senior doctor’s skill is the best pedagogy, “I pick up on what aspects

of communication/bedside manner/general personality I like and don’t like when I

spend time with physicians. Hopefully I can emulate what I like and never do what I

didn’t like.” The same medical student told me that he thinks of good communication

between doctor-patient as critical to good health care. He used a fundraising principle

as the best analogy for positive doctor-patient relationship, “In fundraising they say

you really have to get to know someone to ask them for money. Likewise, you really

have to get to know someone to provide adequate emotional and physical care.”

Although she doesn’t think it can be taught, another medical student pointed

out the current effort to address this issue:

There are some doctors who cannot communicate with their patients on human level while others are very empathetic. Nowadays, I think medical schools and residency programs are trying to reduce the distance there has traditionally been in the doctor-patient relationship. WIT seemed to acknowledge this in the feet that the fellow had a clinical requirement in his

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. program. The feet that the fellow had abysmal personal skills could have been a statement about the lack of success of these new requirements or about the type of person attracted to medicine or academic medicine.

Compliance was a major concern for 11 of the IS medical students, but it

generally was regarded in this way: “A patient I look forward to working with would

be compliant (meaning that he or she would follow the treatment plans we had agreed

upon) and would bring up any questions and concerns to me about how the treatment

seems to be going.” Another comment a student made concerning compliance:

I can foresee that patient non-compliance might be a problem for me. I will get so frustrated and upset if I have patients who choose not to help themselves that I might not be able to hide it. Thus, my ideal patient would be someone eager to be well, and eager to follow medical instructions with positivity and enthusiasm. I hope that our interactions can be something like me taking on the role of coach/supporter who provides my patients with the tools they need to get better. But ultimately it will be the patients themselves who have the biggest role in their healing.

One development that the medical students all agreed upon was that they

looked forward to using the Internet with patients as an educational tool. One

medical student considered use of the Internet as a sign that patients were being

proactive in their health care:

I think the Internet will actually benefit my practice. I’d rather have a patient come into my office at least having tried to understand their own problem or disorder, even if they have received feulty information, than have them come in completely oblivious. Even if they have the information wrong, at least it shows some responsibility being taken for their own treatment. They’re not just looking to the doctor for a magical treatment.

When asked how the medical student envisioned his or her future role as a

physician, most often the term that the students used was teacher/educator while the

second most common image generated was that they envisioned themselves as a

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. compassionate healer. Overall, the medical students seemed to embrace the image

that just as a teacher does not know all the answers, neither does a doctor. “The

doctor is sometimes nervous and unsure; in their profession, competition makes doubt

seem like a weakness, rather than something to be explored.” One student gave a

representative summation o f how most interviewed medical students regarded their

future role:

I think the doctor-patient relationship is unique. On some levels it’s like a parent-child relationship, where the doctor must be a caring parent, observant of their child’s feelings and emotions, loving to that child, and concerned with the well-being of that child. On the other hand, such an analogy would place the patient as subjective to the doctor, and that would negate the patient’s role and responsibility in their own care. Really, the doctor-patient relationship is unique in the sense that it is a careful balance of give and take, of responsibility and of caring and compassion. There are probably very few relationships that combine these aspects in the same way, while containing so much importance in the lives o f the individual members.

There were two exceptions to such thinking. One student states, “The doctor

is someone to be respected and deferred to . . . the doctor-patient relation is kind of

like a priest-worshipper relationship; the doctor is educating the patient and helping

them achieve something ‘holy’ in a sense, i.e., a healthy being,” while another student

makes his desired role clear in describing his perfect image of a doctor-patient

interaction:

The patient would be a middle-aged man or woman who has complete faith in physicians. He or she would be assertive in his/her description of the problem, leaving no details out. He would be responsive to all suggestions

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and would not try to second-guess me. Also, they would follow whatever treatments that I felt was appropriate. I would talk with him in a respectful, but authoritative manner. There would be mutual respect on both ends.

He goes onto express his anger concerning the lack of respect for doctors today,

I do not think that physicians get the respect that they deserve. They are in training (very hard training) for at least eight years or more after college. They are taking the best years of their lives and devoting them to studying so that some day they can help people who need it. Their friends are buying cars and houses and moving on with their lives while docs are still in school. Then, docs take tremendous responsibility every day they go to work. (It is probably stressful to feel that someone’s life is in your hands.) Not to mention that doctors put their health at risk often. People have the nerve to disrespect doctors! This drives me crazy. I feel that doctors should be treated with a little more respect than they are.

It will probably not be surprising to readers that the above-mentioned medical student

did not appreciate the portrayal of doctors in WIT, “They made doctors out to be

rather heartless and simple, which is the farthest thing from the truth.”

Yet, he was not the only male student who felt this injustice. Gender

differences became evident when the interview questions related to the medical

students’ reactions to WIT. A joint M.D.-Ph.D. student whose career goal is to be a

researcher in pain control felt angry at the portrayal of medical researchers, “The

stereotypes were too extreme — I realize that is was for effect, but as a future

researcher I was still angry at the heartless portrayal.” Another male medical student

felt that WIT was like a presentation o f all the “bad” scenarios that could happen with

a doctor:

I appreciated the message but didn’t like the play as much - at least how health care was portrayed. It was like someone cut out all the clippings of all the bad experiences they read about patients in health care having and made a story out of them.. . . I took offense to the way doctors were portrayed but I

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. guess I don’t want to be viewed like that after giving up half my life in education, making sacrifices to my family, and taking less money than I could make in other arenas.

Another male student also felt the portrayal did doctors a disservice in light of

his sacrifices, “How could anyone who gives their life to the well-being of society be

portrayed so negatively? It really bothered me.”

Female medical students were more concerned that WIT would encourage the

public to be hostile against doctors,

It's difficult when you're seeing WIT - here's a generalization o f physicians being portrayed to the public and it’s so negative. You feel humiliated and you want to stand up and scream, “But no. I'm not like that and it doesn't have to be like that!” I think that it instilled in me a lot of fear that it's breeding hostility. One o f the things that I fear when dealing with my patients is that my patient comes in as already hostile, already anticipating that they're going to be treated in a certain manner. It's an extra hurdle for me.

A fourth-year female medical student observed that WIT revealed the reality

that it does make the doctor’s job easier when dealing with a dying patient to regard

the patient as a “case”: “There was a sense there of, even the sense of a certain level

of, this is going to sound terrible but, of objectifying the patient as a case study,

because it makes some of your job easier. . . especially when the patient is dying.”

She went on to say though that seeing the dying process from the patient’s

perspective and witnessing the experience of being regarded as a case study was an

“invaluable lesson” for her as a medical student. She strongly affirmed the value of

seeing WIT.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A first-year female medical student was disturbed with some of her peers’

reaction to the experience o f WIT:

I was a little disturbed that my peers didn’t have the same reaction to WIT as I did. Some of them even said it was a waste of time and a blatant exaggeration. That made me kind of concerned because even if it was exaggerated, it made quite a point in my head.

She reflects upon her experience of WIT:

I thought the play was a scathing indictment on the medical field. But this is not to say that I am resentful or anything like that. Quite the opposite actually. I think this play should be required for all those in medicine. It really makes you think about the effect the comments you make and the actions you take can have on your patients. I thought it was wonderful, but I must admit that it made me squirm in my seat more than once.

She speaks of the difficulty she experienced as an audience member:

The scene where the young resident interviews Vivian formally was the hardest for me to watch. I hated that resident! He perfectly embodied all the negative images/stereotypes I have in my head about arrogant physicians and the utter lack of concern and/or compassion they can show. He literally made me cringe sometimes when he spoke because it made me uncomfortable that some people are going to have that image of doctors, and most importantly, that there are doctors like that out there. The interview was especially disturbing because some of the cliches and phrases the intern used were things we are actually taught to say! I guess it is all going to be about the delivery, but nonetheless, I was disturbed greatly.

Overall, women medical students seemed to feel less attacked professionally

than the male medical students by the portrayal of doctors in WIT. They were more

concerned that WIT was presenting a skewed image of all physicians, and they were

adamant to not be included in such an image. Yet it was a male medical student least

offended by WIT who generated a statement that the women interviewed generally

expressed:

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. WIT was written from the perspective of the patient, and intended to show an exaggerated view o f the harsh realities of medicine and the doctor-patient relationship. Vivian’s doctors in the play were after the beast of cancer more than they were there to treat the needs of the patient. They were warriors of science and, in the midst of the battle, lost sight o f the true goal of their efforts. However, I don’t believe every doctor is like this. There may be some, but that is to be expected given the circumstances. For the most part though, I have enough faith left in my profession to believe that we still have not lost the entirety o f the goal for which we are striving.

4.2. SURVEY OF COLLEGE STUDENT AUDIENCE MEMBERS:

The survey given to college students to explore their expectations and

personal conceptions regarding the doctor-patient relationship appears as Appendix

B, pp. 186-187. The second page of the survey (that required exclusively open-ended

responses) will be addressed in section 4.2.2 of this chapter.

4.2.1 QUANTITATIVE DATA ANALYSIS

A 57% survey response rate was achieved from the Theater 100 students who

were required to attend WIT. Female responses comprised 49.3% of the responses,

while male responses accounted for 50.6%. This gender breakdown allowed the

inference that the data obtained were representative of a college age population.

Enrollment for Spring quarter 2001 undergraduates at the O.S.U. Columbus campus

was 51.4% male, 48.4% female.8

Histograms showing the distribution of responses for each question are as

follows:

8 Student Enrollment Reporting & Research Services (SERRS), Office of the University Registrar, The Ohio State University

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. §

ll 3 Q1 Question 1: The doctor-patient relationship portrayed in WIT was a realistic one. l=Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.1: Distribution of responses to question 1

3 02 Question 2: I want to become a health care provider in the future. l=Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.2: Distribution of responses to question 2

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i ! fs C* 8

8 I O tL

1 2 3 4 5 q3 Question 3: I expect to have the doctor-patient relationship that I desire. l=Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.3: Distribution of responses to question 3

§1

1 2 3 4 5 <*• Question 4: The patient largely determines the nature of the doctor-patient relationship. 1 =Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.4: Distribution of responses to question 4

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§ a

8 8 I 1 2 3 4 S 05 Question 5: The doctor largely determines the nature of the doctor-patient relationship. l=Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.5: Distribution of responses to question 5

Question 6: Managed care/insurance reimbursement largely determines the nature of the doctor-patient relationship. l=Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.6: Distribution of responses to question 6

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1 2 3 4 5 q7 Question 7: Theater such as WIT can play a role in societal change. I =Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.7: Distribution o f responses to question 7

1 2 3 4 5 qB Question 8: It is possible to teach people to become better listeners and communicators. l=Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.8: Distribution of responses to question 8

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Question 9: Time-constraints on the doctor largely determine the nature of the doctor-patient relationship. 1= Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.9 Distribution of responses to question 9

1 2 3 4 5 qlO

Question 10: My doctor’s interest in getting to know me “as a person” largely affects the nature of the doctor-patient relationship. 1 =Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.10: Distribution of responses to question 10

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q11

Question 11: The relationship between the patient and the disease is different than the one between the doctor and the disease. l=Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.11: Distribution o f responses to question 11

sr* - 8 mCM t Is

I ■

Q12 Question 12: A member of my immediate family has been faced with a serious illness. 1 =Strongly Agree 2=Agree 3=Unsure 4=Disagree 5=Strongly Disagree

Figure 4.12: Distribution o f responses to question 12

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Frequency tables were calculated for each question along with / tests and other

inferential procedures (Appendix D). The data reflect the following proportions:

1. Sixty-four percent of the students agreed/strongly agreed that the portrayal in WIT

was realistic, with the exact 95% confidence interval for this point estimate

0.5998,0.6830. This was true for all students, even those planning on becoming

health care providers.

2. Seventy-three percent of the students responded they expected to have the doctor-

patient relationship they desired. This proportion increased to 93% if the

respondent planned on becoming a health care provider. (See discussion of this

result below.)

3. Eighty-seven percent responded that they believed it was possible to teach people

to become better listeners and communications. This was the strongest message

given by the college students.

4. Which factors (the doctor, the patient, HMOs, time constraints on the doctor, or

the doctor’s interest in getting to know the patient as a person) did the students

identify as “largely determining the nature of the doctor-patient relationship”?

- 84% responded “my doctor’s interest in getting to know me as a person” • 74% responded “the doctor” ■ 68% responded “time constraints on the doctor” • 34% responded “the patient” ■ 25% responded “managed care/insurance reimbursement”

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A visual representation of the factors identified as determining the nature of the

doctor-patient relationship:

my doctor's thethe doctor doctor doctor's time thethe patient managed interest in me as carefinsurance aperson reimbursement

Figure 4.13 Factors determining the nature of the doctor-patient relationship as perceived by college students

The more sensitive analysis included information on the following questions

of interest:

To what extent did gender impact the responses? A research expectation was

that there would be significant gender differences. Overall, the data did not

substantiate this expectation. As the frequency tables with distribution by gender

(Appendix D, pp. 199-201) and the / test (Appendix D, p. 203) show, there were few

significant gender differences reflected in any of the responses. The question

concerning who planned on becoming a health care provider reflected the largest

gender difference. On this question, the test for equality of variances indicates a

significant difference in the two variances (Ff = 1.75, p < 0.0001), so the t statistic for

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. unequal variances (Satterthwaite) was used. Based on the Satterthwahe statistic,

there is a significant difference in gender for question 2 (/ = -4.61, p < 0.0001), or in

other words, gender impacted the number of respondents who agreed/strongly agreed

that they planned on becoming healthcare providers.

In response to this question, 24% of female respondents indicated that they

planned on becoming health care providers, as opposed to 9% of males that indicated

this intention. But because there was no distinction made between the desire to

become a physician versus another type of health care provider, question 2 on the

survey did not provide the data necessary to draw conclusions about students who

already considered themselves preparing for the profession of physician. Only when

a student indicated in one of the open-ended responses that he or she was a pre

medicine major, was the assumption made that this respondent indeed was preparing

to become a doctor.

To what extent did the student’s intention to become a health care provider

impact his or her responses to the other survey questions? The expectation was that

the students planning on becoming health care providers may respond differently than

students who were not planning on entering the medical field. The data did not

substantiate this expectation, except on question 3. When future health care workers

(students who chose #1 or #2 on the Likert scale) were asked if they expected to have

the doctor-patient relationship that they desired, 93% either agreed or strongly agreed.

This was different than the 73% o f the overall population that expected to have the

relationship that they desired. Based on the Satterthwaite statistic, there is a

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I

significant difference in responses for future health care workers (/ = -6.87, p <

0.0001). Planning on becoming a health care provider was a significant indicator that

the student expected to obtain the relationship they desired. (See Appendix D, p.204).

To what extent did the students’ experiences with serious illness within their

family impact their responses? A difference in responses due to the students’

experience of illness within their immediate family was expected. Again, this was

not supported by the data on most questions. An exception was question 11 that

stated that the relationship between the patient and the disease was different than the

one between the doctor and the disease. The / test procedure showed a t value =

•2.68, p < 0.0075. The students who had experienced illness within their own family

answered question 11 significantly differently than students who had not experienced

illness within their family. (See Appendix D, p.205.) The whole sample reflected

86% agreement/strong agreement that there is a difference between the doctor and

patient’s relationship to the disease. When students had experienced a serious illness

in their family, the proportion o f agreement/strong agreement rose to 89%.

4.2.2 SURVEY OF COLLEGE STUDENTS: OPEN-ENDED QUESTIONS

The vast majority of students used the male pronoun “he” when referring to a

doctor in their responses to the open-ended question section of the survey. This may

reflect that the majority of the college students primarily have had male doctors, but

current enrollment figures for American medical schools reflect an equal enrollment

of men and women (Dworkin, 2001).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Another finding that was not present in the quantitative section was that many

students feel negatively about even being asked to imagine themselves as a patient in

a health care setting. Examples of common responses;

Question 3. When I imagine myself as a future patient in a health care setting, I feel:

“Like I want to die before that happens.”

“Petrified. No one is there to help you with any feelings or questions you may have. Even the doctors do not describe it in a way you can understand.”

“Scared that I won’t have a good relationship with my doctor. I want him/her to treat me and my disease separately.”

“Lost.”

“Like I have to let the physicians know how I expect to be treated. Yet I shouldn’t have to tell the physician how I want to be treated.”

There was a marked difference in responses between the students who

revealed that their major in college was pre-med and the rest of the student responses.

The pre-med students had a different frame of reference concerning the doctor-patient

relationship compared to their peers. The responses o f the pre-med students were

more hopeful concerning future medical care. And they were clearly negative toward

the way doctors were portrayed in WIT. In response to the same question about their

feelings when they imagine themselves in a health care setting, the pre-med students

replied:

“Hopeful that I will encounter doctors who are interested in treating me as a person both emotionally and physically.”

‘Tine. Actually I was upset with the way they portrayed doctors.”

“That the doctors will be doing their best to help me.”

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. “My feeling is that the doctor will be kind and caring and enthusiastic about helping me in any way she or he can.”

“Since I am in pre-med, I imagine myself as the doctor. But if I was the patient, I imagine myself only going for a check-up.”

“I hope to be a good doctor who the patients will respect and admire.”

“If I’m the doctor, I would want to listen to my patients because they not only need medical advice, they need comfort and support. Since I hope to be a doctor, I think I would be open to anything that a patient would say.”

Reflecting an unease with the portrayal of the doctor-patient relationship in WIT:

“I feel the relationship between Vivian and Jason is not that common...I hope.”

“The way they showed doctors was so WRONG that it made me dislike the play. I hated WIT”

The majority o f students surveyed did not intend on becoming doctors. The

responses emphasized the central role played by good communication skills in a

successful doctor-patient relationship. For example:

“I hope my doctor will explain things very easily to me.. .1 don’t understand all the correct language so I would want things to be broken down.”

“Good. I feel as if I can talk freely with my doctors, but uncomfortable when they start using big words I don’t understand.”

The most common qualitative remarks that supported the results of the

quantitative survey circled around the importance to students of their doctor getting to

know them as a person. This variable “getting to know them as a person” focused on

the communication skills of the physician. The students stressed the importance of

the doctor making this effort:

“I would hope it (the relationship) would be a good one, that is built on trust. Where I listen to what he says and he listens to what I say.”

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. “The ‘classic’ relationship - we know each other well and he/she tries their damnest to do what’s best for me.”

“I hope that the doctor would use plain words and not medical terms so that I can understand my condition. Since the doctor is healing me, I would hope he would genuinely get to know me a little.”

“I would like to have a relationship with my doctor whereas he/she would know about my family and vice versa - not specifics necessarily, just general info. That makes for a more comfortable situation.”

“My doctor will know my name before he checks my charts. I will make sure he knows me as a person.”

Three themes stood out in the responses: (a) students feel comforted by the

medical technology available to them, (b) medical care is a service that they are

paying for, and thus deserve a certain level of attention, (c) students are concerned

about the doctor’s lack of time available to spend with them as a patient. Medical

technology was not mentioned in the wording on either page of the printed survey, as

it was not a focus of the study. The student responses showed that college-age

students are very comforted by the advances that they perceive as being available to

them. They note feeling,

“Comfortable with the new technology that they will use to cure me.”

“Good, knowing all the technology that is out there.”

Responses often reflected an attitude of “I should get what I am paying for.”

They oftentimes referred to the obligation of doctors to fulfill their duty o f delivering

a specific service, namely medical care:

“If I want something, or want more time/advice/etc. from the doctor, I will tell him. After all, I am paying him to take care o f me.”

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. “I feel that for as much as you pay for health care - kindness should be mandatory”

“It’s important that health care providers still maintain a personal outlook with each patient because they are being paid for their profession and care - regardless of who pays it (welfare, tax dollars, health insurance, etc.)”

“I imagine my relationship to be much the same as Vivian. Doctors tend to always be ‘too busy’ to sit and even talk to you about your ailment. I HOPE that this is not the way I am treated. I pay doctors unsightly bills, and the least they could do is stop and talk for a second.”

The last quote mirrored many other comments noted in response to question 6 asking

the students to describe the doctor-patient relationship they imagine having in the

future. Lack of time spent with the patient was the central concern:

“My image is similar to the play...busy doctors while I wait around forever.”

“I think many doctors care about their patients, they just don’t have the time to meet emotional needs.”

“I imagine going to the doctor and waiting for hours just to go in and spend 5 minutes with the doctor.”

The data did not substantiate the Theater 100 T.A.'s expectation that there

would be a difference between the imagined and the hoped for relationship.

In response to the open-ended phrase, “Overall my impressions of WIT were

______” many of the students recognized and commented on the

pedagogical value of WIT:

“It made me feel sick to my stomach the way the doctor-patient relationship was. I thought that it was a good tool to teach people about the relationship in health care. It was an informing play that made me think.”

“It was an important play about lapsed health care and the need for reform.”

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. “WIT hit the nail on the head. Everyone studying in the medical field should not only see it, but be required to play one of the characters.”

That last quote implies the importance o f embodied experience in the learning

process.

4.3 EVIDENCE OF WITS IMPACT WITHIN CULTURE

Did WIT impact culture, or was WIT a reflection of cultural issues begging a

forum? Playwright Margaret Edson wrote a play inspired by her experience as a clerk

on an oncology/AIDS unit of a research hospital. When asked why, she always

responds by saying that the experience haunted her. “Because I wanted to see it and I

thought someone has to write it.”9 Write it she did, and walked away with a Pulitzer

Prize for Drama for her effort. The play started at South Coast Repertory Theater in

Costa Mesa, CA, in 1995, moved to the Long Wharf Theater in New Haven, CT, in

1997, then to the off-off-Broadway location o f the MCC Theater in 1998, playing 450

performances at the off-Broadway Union Square Theater starting in 1999. From

there, the off-Broadway show went on national tour. WIT has been performed at

numerous locations in cities all over the United States and abroad.

The majority of the reviews written about WIT were glowing; some reviewers

even commenting on the weight of the praise, “Through no fault of its author,

Margaret Edson’s WIT has acquired a burdensome load of praise, from the Pulitzer

9 As quoted in “In Kindergarten with Author of Hit Play ‘ W7T,” by Amy Gamerman, Wall Street Journal, p. 28, 11/12/98.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Prize on down.”10 Other awards include the Drama Desk, Dramatists Guild, Drama

Desk of New York, New York Drama Critics Circle, Outer Critics Circle, Lucille

Lortel Fellowship of Southern Writers, Berilla Kerr Foundation, Susan Blackburn

Prize (finalist), and Los Angeles Drama Critics.

Media reviews of WIT included comments such as, “WIT will take your breath

away.. .. it is provocative and thought-provoking; almost everyone who has seen it

wants to talk about it. Edson’s play surfaces so many kinds of issues—the

impersonal medical system; the value of medical research; the spiritual meaning of

life and death; dealing with pain; the comfort o f human touch; the aura of hope;

coping with morality.. . ”' 1 The nearly unanimous acclaim by critics seemed to

emphasize that WIT, “ underscores the importance of personal relationships in health

care and in life. It will challenge everyone who sees it, upsetting some, but enriching

a ll.. . .When WIT played in other cities, audience members wanted to continue

discussing the play after it ended - this was even true in New York City, not the

coziest of places.”12

Most reviews across the nation noted the silence of the audience after WIT,

followed by a desire to talk about it. This researcher found this to be true. Audience

members (especially patients and medical students; doctors less so) were more than

willing to talk about WIT. Getting participants to volunteer for this study was not the

10 As quoted in “Theater Review,” by Michael Phillips, The Los Angeles Times, p. F-l, 1/28/00. 11 As quoted in “Edson’s Powerful Play Tackles Troubling Issues” by Suzanne Connelly, The Post- Standard, Syracuse, NY, 2/17/01.

12 As quoted in “Syracuse Stage Opens Dialogue About Cancer” by Caroline Chen, The Daily Orange, Syracuse, NY, p. 8, 2/15/01. 128

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. problem; conducting all the interviews of the number o f volunteers was the challenge.

Five research participants contacted me with names o f friends and relatives whom

they wanted me to interview. I received numerous letters, e-mails, and ideas for

books that research participants wanted me to read in order to enhance my work on

doctor-patient relations. This occurred weeks, and sometimes months after I had

interviewed them. (See Appendix E, p. 207, for an example). Culturally, Americans

are interested in the themes relating to patient care. Our population is aging and the

prospect of being a patient in a health care setting is a topic that many people now

consider in the context o f self.

WIT encouraged useful dialogue, not only as data for this research project, but

within the medical community. A physician, writing for the Science Desk o f The

New York Times, wrote an essay entitled, “When the Patient, Not the Doctor,

Becomes the Hero” (12/18/98) about her depressed feelings concerning the

representation of doctors by the end of WIT. Abigail Zuger, M.D., claims that it is

less and less true that WIT represents the reality o f being a patient in a teaching

hospital. She advocates for a representation in art of what doctors do, and have to

deal with, considering it shameful that such representation has been omitted. Why

has such a representation been omitted? This may be a comment in and of itself.

Newspaper articles on WIT often mentioned that it provided a starting point

for discussion. One such dialogue appeared on “The Readers Page” of the Syracuse

Herald American between two physicians. Gregory Eastwood, M.D., president of

Upstate Medical University authored, “Caricatures in WIT unfair to doctors” (p. D-3,

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2/18/01) and received a response entitled, “WTT is about people, Not about doctors”

(p. D-3, 3/4/01), from physician Janet Scully, M.D. Dr. Eastwood claimed that WIT

was a trivialization of a serious and sensitive subject that exceeded the artistic

abilities of Ms. Edson. “In my 35 years in the medical profession, I have never

observed a single one of my teachers, colleagues, or students behave in that manner..

. ” Dr. Eastwood seems to have missed that WIT was an artistic observation from the

perspective, and experience, of the patient. Reflecting the truth, he probably has

never observed doctors in such a way. Dr. Scully’s response to Dr. Eastwood

respectfully disagreed with his criticism, saying, “I would hope that those who are

charged with the responsibility of teaching medical students will not become

defensive after seeing WIT, but ask, where is the grain of truth and what can we as

physicians do better?” Dr. Scully was encouraged that WIT invited discussion on

issues that need to be addressed, and provided a perspective that she claimed, as a

doctor, she needed to hear: the perspective of the patient.

Success for WIT did not end with the off-Broadway production going on

national tour. WIT was adapted for television by HBO. WIT, the HBO adaptation of

Edson’s play, won the Emmy for Best Made for TV Movie, and director Mike

Nichols won an Emmy Award for best directing of a Made for TV movie. In a Wall

Street Journal article, “TV: As She Lay Dying,” reviewer Barbara Phillips (3/19/01)

describes the research fellow treating Vivian: “He has no use for the souls who

inhabit the cancer-riddled bodies that so fascinate him... it is only Susie [the nurse]

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. who has no intellectual conundrums and sees Prof. Bearing as a human being, not a

research subject, who is willing and able to level with her patient about the futility of

her case.”

Artistic acclaim is embedded in cultural experience and value. The qualitative

interviews conducted in this study were conducted in an attempt to explore individual

audience member’s experience and construction of the doctor-patient relation. But

there was evidence of a powerful larger group reaction to this piece of work, both in

theater and television formats. Why was WIT regarded as valuable within culture?

Was it because the discussion it evoked was critical for people’s individual and

collective lives? Was it because WIT sparked discussion of patient treatment by

medical professions, yet transcended that topic, by simply including it in the context

of kindness, considering it a pre-requisite for any work, including medical care?

Regardless of the answers to these questions, WIT, as theater, and as a television

adaptation (which made it more widely accessible), was a success, in this culture as

we face the 21st century with all the medical and technological advances available to

us as patients.

Medical school educators came to see the potential for using WIT as a

pedagogical tool for their students. As mentioned in Chapter 3, The WIT Education

Initiative is an educational attempt, bridging art and medical science, encouraging a

humanistic approach to health care delivery. It addresses a major policy issue, “the

personal experience o f dying and the quality o f medical care given at the end o f life”

(Steckert, 2000, p. 1). This initiative developed collateral educational activities

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. (including pre- and post-performance discussions for medical students and residents),

in order to enhance the training process by increasing physician understanding of the

interpersonal dimensions of medical practice. Over SO medical schools have

participated in this training effort.

Dr. Ruth Hart, a emergency medicine doctor for 17 years and medical school

professor spoke to the value of using theater to teach empathy to medical personnel:

“Nothing carries the immediacy and emotional bang for the buck as theater. No

classroom technique can equal theater as a tool for teaching empathy. Theater’s

impact is long-lasting.”13 Many productions o f WIT were followed by “talk-back”

sessions in which the actors, hospital personnel, and local medical professions had a

panel discussion relating to issues raised in the play. Discussion often centered on

death, cancer treatment, and the relationship between physicians and patients. The

Journal o f the American Medical Association included a comment (Friedrich, 1999)

that these talk-back sessions were

one useful way o f helping concerned individuals and medical professionals air their concerns and ideas about improving patient care. The play challenges the medical community not only to offer cancer patients cutting-edge therapies, but to do so with compassion and humanity, (p. 1611)

4.4 MEDICAL STUDENTS CONSIDER THE IDENTITY OF PHYSICIAN

I taught the class, The Physician’s Identity, with the intention of increasing the

likelihood that the medical students would begin to consciously reflect upon their

future role as physician. All activities in the class tried to make clear the connection

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. between how one envisions his or her own role, and the impact it has on the

communicative mode used. Toward the end o f the month-long course, I shared with

them studies I had read in review of the literature on doctor-patient relationship.

For the first activity of the class, I asked each student to complete the

sentence, “If I hadn’t chosen to become a doctor, I probably would have become

______.” The responses included the following: lawyer (n = 2), architect,

sales/marketing executive, archeologist, business, engineering, teaching/research, Air

Force, psychologist, director of a camp for kids with cancer, and pro basketball fen.

With the exception of the last response (which was the last non-serious response I

was given during the course), all the medical students saw themselves as being some

type o f’‘professional.” When I inquired as to whether becoming a professional was a

factor in their choice of medicine, there was overall agreement amongst the students

that this was a significant factor. When I pointed out that only 25% of them indicated

that as a second choice they would pick another traditional “helping profession” they

agreed that this was an accurate description of their interests. Being a professional

was an important aspect to their choice in becoming a doctor.

The second activity involved each medical student drawing a picture of

himself or herself as physician. This activity helped “loosen the class up” and the

students seemed highly interested in how their classmates viewed themselves in the

role of physician. There was great variance in these depictions.

u From “Stage Is Thoughtful in Presentation of WIT" by J. Coley, Post Standard, Syracuse, NY, 2/21/01. 133

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Requesting that the medical students draw themselves as doctor provided a

non-verbal source of information about their own construction of professional

identity. Students exchanged drawings and described what the picture revealed about

their classmate’s vision of themselves as doctor. The students expressed surprise at

the variety o f images. (See Appendix C, pp. 194-195 for samples o f the drawings.)

Those students who drew themselves as interacting with their patients seemed

surprised that not all medical students included patients in their drawings. The

frequency o f items common to the drawings is shown below:

0 0 e ' i so

stethoscope white coat or scrubs interaction with patents

Figure 4.14: Frequency of items pictured in drawings distinguishing oneself as a physician (as drawn by first-year medical students)

When the medical students were asked to “picture themselves as physicians,”

I was looking for indicators of which factors they most commonly associate with

being a physician. The expectation was that the students would draw themselves with

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. a white coat distinguishing them from their patients. But the greater majority of

students pictured themselves with a stethoscope, an IV cart or some other type of

medical technology that the students identified with being a doctor in today’s

technological medical world. Although a majority still pictured themselves in the

white coat/scrubs, clearly they connect being a doctor with the overriding presence of

technology. It seemed that the machines that could aid them in their diagnostic work

took center stage, whereas interaction with patients only appeared in half of the

medical student’s drawings.

In terms of gender difference, two of the six male medical students drew

themselves as a doctor interacting with patients, while the remaining four did not. For

the female medical students the proportions were reversed: four o f the six female

medical students drew themselves as interacting with patients, while two did not.

This gender difference among medical students is congruent with the finding based

upon interviews with practicing physicians. Female doctors were more verbal about

the need to connect with their patients as compared to the male doctors. Although the

sample in this study is not large enough to be able to generalize a gender difference, it

indicates a need for further study on gender differences within medicine, specifically

in terms of physician identity.

Discussion concerning the drawn images clarified that the students primarily

viewed technology as a comfort in minimizing human error in diagnosis. The lack of

patients in half of the medical students’ drawings may speak to the secondary

placement of the patient as an entity in their first year of medical school educatioa

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Of the medical students that did have patients in their drawings, all but one had the

doctor drawn bigger in size compared to the patients. Only one picture was drawn

with an image o f a divine being giving the power to heal to the doctor, which he then

divvied out to his patients. I noted some shocked faces around the table as that

particular picture was described. My sense was that the medical students were

discussing for the first time the way that they saw themselves as a doctor, and that

there was much individual variance in the images portrayed.

The third activity, also intended to get the students talking about themselves

as doctors, involved seeing WIT together as a group. Although clearly required to do

so, none o f the medical students stayed after the performance o f WIT to hear the

scholar on John Donne speak about the role of poetry in WIT. I questioned if the

medical students would have stayed for the post-performance discussion had a

physician given it.

Discussion about the play did not occur until five days after experiencing it.

Some of the male students were adamant that WIT was “doctor-bashing," but was

“okay as a play.” Other students who took WIT as “food for thought” tried to explain

the use o f exaggeration in making a point in order for it to be heard. To open

productive discussion on the valuable themes in WIT that might be helpful to medical

students, I asked each student to answer the question, “What was WIT really about?’

Responses were as follows:

“It was about how to be human.”

“It was about a disease that affects a woman."

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. “It was about how to live your life as a human being.”

“It was a glimpse into someone’s life, self-discovery, and depth. It was a tragedy.”

“It was about challenging the audience to give kindness to people, whether it be your students or patients. It was not only about sickness and death.”

“It is about capitalizing on the time that we have left.”

“The point is, what people choose to focus on is up to us. WIT had points about life/death/god. It was about how to recognize life-the importance of human contact.”

“It was hard to watch because she (the medical student) had just lost her grandpa and he looked just like Vivian; he had had a baldhead. WIT was about the well being of the human soul. It asks us if we are aware o f the treasures of life around us. It ends with the question, ‘Are you?’”

“It was about the subject of the human soul.”

Three of the students couldn’t articulate their perception of the play’s message.

Other comments that were made during this discussion included,

“Margaret Edson used too many stereotypes.”

“I saw that play once and I never want to see it again because I find it terrifying that it might be true.”

“The patient needs to find their support elsewhere.”

"WIT didn’t teach me anything but I did consider it to be art.”

Simply discussing WIT with a group of medical students, in order to get them

thinking about the choices available to them in terms of the doctor they are studying

to become, was a successful first attempt at “action research.” The students who did

not consider WIT to be “doctor-bashing” were able to articulate why not in front of

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. their peers. The point was made that one's vision of oneself as a physician matters,

and all the students heard this message through discussion of the portrayed doctor-

patient relationships in WIT.

The last piece of the action-research component of this study was to introduce,

and to have the students experience, Kasulis’ (2002) concept of cultural orientation

and bilingual communication across difference. Dr. Kasulis introduced his theory

and its possible application to doctor-patient communication. The medical students

were then given scenarios to role-play in which one student was the doctor and one

student was the patient. Students were assigned a mode of communicating with the

other in order for them to experience the frustration that is commonly felt in

communicating across difference. (See Appendix C, pp. 196-197 for examples of the

role-play assignments.)

The students were enthusiastic and creative in the role-plays. After each

role-play the rest of the class gave pointers to the actor-actress medical students on

how they might have listened more closely to the mode of communication being used

by the patient, and how the doctor might have adapted his or her own communicative

mode to facilitate effective communication. I shared with the students that one

medical student from another university that I had interviewed shared her frustration,

I don't know, it's difficult to find the balance of what patients want. Do they want someone who seems overly professional or do they want someone who's more down to earth? Sometimes you have to change your approach patient to patient.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Kasulis' model o f communicating across difference is a communicative

toolthat could aid medical students and doctors to listen for the mode of

communication that a particular patient is using. Did the medical students consider

introduction to Kasulis' theory and a role-played experience of the frustration

helpful?

Only one student strongly stated that it is impossible to understand the

difficulty of communicating medical information to patients without actually being a

doctor. The remaining students saw the value and implications that Kasulis’ model

could have within the doctor-patient relation. Concerning the theory itself the

students’ thoughts included:

“This theory is a very helpful way to think about the doctor-patient relationship because it stresses the individuality of the patient.”

“It was interesting in differentiating what individual patients want to hear.”

“This class has been one of the best of this year. Many think that just by telling a medical student to be compassionate or caring will do the trick, but when you learn the same point through examples, it is much more effective. That way, it is more concrete and you will remember longer.”

They also connected Kasulis' theory with ways in which WIT exemplified

poor communication across difference. One student summed it up:

The communication between Vivian and her health care providers was poor. The physicians foiled to read between Vivian’s words (e.g. when she wanted to discuss her fears concerning death with her physician). When Dr. Bearing is first informed about her cancer, the way she tries to rationalize it is the perfect example of the Integrity Model at work.

Overall, the medical students within the class, The Physician’s Identity, saw

the value and application o f tools that might be o f use to them in communicating with

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. patients. They did point out that this class, and its themes, would be better taught in

the last year of medical school when the students could directly apply these ideas, and

listen for different communicative modes between doctors and patients while doing

their clinical rotations. Their point was that introduction to a theory, followed by

role-plays, then listening for the ways in which residents and doctors communicate

with patients would allow for the most effective use of Kasulis’ theory to the practice

o f medicine.

4.5 SUMMARY OF DATA RESULTS AND ANALYSIS

Pulling together the data analysis from the interviews, the surveys given to

college students, societal reaction to WIT, and the ethnographic learnings of teaching

a medical school class is appropriately considered a crystallization of the research

(Richardson, 2000). Each method and source of data collection and analysis provided

a unique view of the doctor-patient relation, reflecting different angles of this

evolving construct.

4.5.1 QUALITATIVE INTERVIEWS WITH PATIENTS, DOCTORS, AND MEDICAL STUDENTS

Patients across gender and age categories viewed WIT as a tool encouraging

both patients and doctors to examine the role they play in this very important health

relationship. Patients clearly prefer doctors who have the ability to distinguish their

desires. They perceive this ability as coming from the doctor getting to know the

patient as a person, as opposed to viewing them as a medical case. Most patients

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. were clear that this ability is probably not something that can be taught in medical

school but could be improved upon if the basic orientation (viewing patients as

persons) was present in the student.

Another generalization that can be drawn from the patient interviews is that

there was an acknowledgment that the social expectations within the doctor-patient

relationship have changed over the past 30 to 40 years. Patients consider the

expectation of their own role to be more proactive than in the past, with the doctor

filling the role of the information provider (e.g., reading and interpreting the medical

tests). An emergent theme in the patient interviews was changed perception of

wellness. The exclusive disease paradigm of health seems to have been replaced by a

desire for medical doctors that are open to a holistic vision o f health that includes

preventative and alternative care, incorporated with an allopathic approach when

appropriate.

Gender differences among patient interviews were twofold. They include an

increased comfort experienced by men when the physician is forthcoming with

medical information, especially when this information includes the impact of the

health issue on daily functioning. Women patients often mentioned feminist

theorizing and the increased proportion o f women physicians as factors responsible

for the transformation within medicine that they see happening today.

The physicians interviewed for this study were conscious that most doctors

would view WIT as a play about poor doctor-patient relations, due to the portrayal of

doctors in WIT. The doctor participants for this study saw WIT as a story of much

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. greater complexity. Concerning their own medical practice, the doctor participants

viewed their role as a doctor to be a patient educator. Overall, the doctors viewed

medical information that patients brought in from an Internet source as a conversation

starter. Doctors stressed the importance of congruent expectations between doctor

and patient, in which the doctor needs to respond to the patient's lead. Drug or

alcohol abuse was regarded as a confounding factor in allowing the doctor to respond

to the lead of the patient.

A gender difference between male and female doctors was that men

physicians were more focused on compliance and were irritated if a patient knew

what they wanted to do about their health concerns before seeking help from the

doctor. Women doctors were more verbal about needing to connect with patients on

a personal level and about lingering gender inequities within actual medical practice.

The medical students all agreed that communication skills are best taught by

experienced doctors modeling those skills. Rather than viewing medical information

obtained over the Internet as a conversation starter (like the doctor participants), the

medical students viewed the Internet as an educational tool for both doctor and

patient. Teacher/educator was the most common term generated by the medical

students when asked to describe their future role as physician, followed closely by the

image o f a compassionate healer.

Concerning WIT, male medical students by-in-large focused on the negative

portrayal of doctors, while female medical students worried that WIT might

encourage hostility toward doctors, making their job more difficult. Women medical

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. students didn’t want non-medical persons to believe that all doctors were like the

doctors portrayed in WIT. But they emphasized the value of viewing a portrayed

doctor-patient relationship from the perspective of the patient.

4.5.2 SURVEYS GIVEN TO COLLEGE STUDENTS

The strongest response from college students was their belief that

communication skills can be taught. This contrasts to the qualitative interview

finding that most people (patients, doctors, and medical students) view

communication skills as something that can be improved upon as an adult, but that

one’s basic communication skills are acquired during childhood. Concerning the

factors that impact the doctor-patient relationship, college students believe that it is

the doctor, the doctor’s interest in getting to know them as a person, and time

constraints on the doctor that have the greatest impact. This researcher expected to

find more students attribute responsibility to the patient for the nature of this

relationship. Students clearly look to the doctor, with their time pressures and

individual commitment toward getting to know their patients, as the determining

factors in the doctor-patient relationship.

The fact that gender did not significantly impact most of the survey responses

indicates that gender does not influence what college students deem important in

terms of their future doctor-patient relationships. This information could be valuable

to physicians who make assumptions about the approach that their patients desire

based on gender.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The one gender difference that showed itself was that females were more

likely to say that they expected to have the doctor-patient relationship they desired. It

is critical to point out though, that many more females (15% more women than men)

responded that they intended on becoming health care workers; thus any correlation

between gender and expecting to have the relationship one desires, may be tied to that

variable rather than the gender variable. Seeing oneself inside the medical field is

probably in and of itself an empowering thought concerning getting what you want

from a doctor-patient relationship. The reflected gender difference could be largely a

function of more females wanting to work in the medical field, and then

proportionally having a higher expectation of achieving the doctor-patient

relationship that they desire.

The students who had experienced illness within their own family seemed to

recognize the impact that illness has on the sick person as a whole being. They

differed from the other college students on this item. Based on their own experience,

they were more likely to believe that there is a difference between the doctor’s and

the patient’s relationship to disease. Perhaps their firsthand experience with illness

(in their own family) enabled them to see the global impact that a serious illness can

have on someone’s life.

The open-ended questionnaire that the college students completed indicated

that students generally associated negative feelings with imagining themselves as a

patient in a health care setting. Students who indicated that their major area of study

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. was pre-med, markedly varied from that finding. They were much more hopeful

concerning themselves and future medical care. They were also clearly negative

about the portrayal o f doctors in WIT.

The most frequent remarks made in this survey focused on the importance to

students of their doctors getting to know them as a person. Within this context, the

students stressed the necessity of good communication skills of the physician.

Additionally, the student surveys reflected that they are comforted by the medical

technology available to them, they view medical care as a service to be rendered, and

that they are concerned that doctors today are limited by the amount of time available

to spend with them as a patient.

4.5.3 THE CULTURAL SUCCESS OF WIT

The numerous awards afforded WIT, in both theatrical and television versions,

speak to the timeliness of the messages and concerns voiced in WIT. WIT encouraged

dialogue in public and private spheres as people sorted out the issues raised in WIT,

the doctor-patient relationship being one of them. The pedagogical use of WIT by a

large proportion of medical schools reflects the belief that the doctor-patient

relationship heeds consideration by those studying to become physicians. It affirms

the importance of the interpersonal dimension of health care delivery.

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The intention behind the action research component of this study was

achieved: medical students reflected upon and discussed as a group how one views

oneself professionally impacts the communicative mode one uses. For many of the

medical students, it was clear that this was the first time they were asked to reflect

upon how they viewed themselves as doctor. The central role played by technology

as an integral part of being a doctor today was marked. Female medical students

were more likely than males to associate their role as doctor to involve patients.

4.6 LIMITATIONS OF THE STUDY

The qualitative interviews were conducted with patients, doctors, and medical

students who were interested in attending WIT, and, they were interested in

participating in this study exploring the doctor-patient relation. Being self-selected, it

is a valid assumption that most research participants held the belief that the doctor-

patient relation is an important topic, heeding examination.

The college students who were surveyed after seeing WIT did not choose to

attend WIT but were required to do so. Yet, in choosing to complete the survey, they

may represent college age students who are more interested in health care and societal

issues surrounding it.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The medical school class, The Physician's Identity, was conducted at a large

midwestem university with a dozen students who were mostly self-selected. It

represents a small beginning in the attempt to encourage medical students to examine

the construction and implications of their professional role.

Given these limitations, Chapter 5 will address implications and suggest

future areas of research exploration, based upon the findings of this study.

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CONCLUSIONS AND RECOMMENDATIONS

I thought I was helping him by listening. I never imagined that one day all he tokl me would be helping me. - May Sarton, As We Are Now

The patient (Vivian) asks the fellow Jason about his professional plans:

VIVIAN: What about you?

JASON: Me? Oh, I’ve got a couple of ideas, things I’m kicking around. Wait till I get a lab o f my own. If I can survive th is. . .fellowship.

VIVIAN: The part with the human beings.

JASON: Everybody’s got to go through it. All the great researchers. They want us to be able to converse intelligently with the clinicians. As though researchers were the impediments. The clinicians are such troglodytes. So smarmy. Like we have to hold hands to discuss creatinine clearance. Just cut the crap, I say.

VIVIAN: Are you going to be sorry when I - Do you ever miss people?

JASON: Everybody asks that. Especially girls.

VIVIAN: What do you tell them?

JASON: I tell them yes.

VIVIAN: Are they persuaded?

JASON: Some.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. VIVIAN: Some. I see. (With great difficulty) And what do you say when a patient is... apprehensive... frightened.

JASON: Of who?

VIVIAN: I just... Never mind. (WIT, p. 57-58)

5.1 SATISFACTION WITH THE DOCTOR-PATIENT RELATION

Data collected in this study suggest that patients (college age through older

persons) are most satisfied with doctor-patient relationships when they perceive their

doctor as being interested in them as a person and not solely as a medical case. In

reflections about positive scenarios, patients describe their doctor as being able to

discern their desires, that is, taking the lead from them and responding to their needs.

Patients desire a doctor who can explain medical terminology and function to their

level of understanding. Patients value the doctor’s recognition of individual

difference. And, they are most satisfied when there is a congruence of expectations

(between the doctor and the patient) concerning their roles. This study affirmed that

historically, we are in a time when not all doctors and patients view their roles in the

same way.

This social transformation of roles (away from the traditional relation in which

the doctor is understood to be the active agent while the patient plays the reactor)

seems to include a vision of the patient as more proactive, with the doctor managing

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a physician who is open to a shifted perception of wellness that focuses on a holistic

conception o f health.

Patients were not alone in emphasizing the importance of the individual doctor

and patient operating out of the same set of expectations. Doctors also recognized the

importance o f congruent expectations between doctor and patient. Most of the doctors

interviewed viewed their role as educator. Thus, educational theory (such as Dewey’s

transactional image of the student-teacher relation) may be an appropriate approach to

enriching the doctor-patient relation. John R. Burton, M.D., a physician addressing

his colleagues in a medical journal, writes of the wisdom that can be gained by doctors

regarding their patients as teachers:

During the 35 years I have been in clinical practice, I have learned greatly from my patients.... As a geriatrician whose patients’ average age is 84, the depth of insight and the experiences of my patient teachers have been truly remarkable. Every patient has taught me lessons about life and about clinical practice, an aspect of my professional activity that has been deeply rewarding and extraordinarily fiilfilling.(p.705)

Doctors interviewed for this study affirmed the need to look to the patient’s

lead to craft the communication between doctor-patient. They viewed this as a skill

that is acquired over time. Medical students were firm in their belief that positive

communication skills were best learned by watching experienced doctors use those

skills.

Concerning the ability to learn positive communication skills, college students

were more optimistic than any other group of participants in this study. Doctors,

patients, and medical students thought that those skills could be improved upon, but

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. difficult to teach to adults. An unexpected outcome of the study was that college

students viewed the doctor, rather than the patient, as having greater influence on the

doctor-patient relationship. This finding may indicate that the self-selected study

participants (many of whom were professional women aged 30 to 65) felt more

empowered as patients than society-at-large. College students seemed to view the

patient as a reactor to the actions of the doctor.

5.2 THE FUTURE OF THE DOCTOR-PATIENT RELATION

The focus of this dissertation has been the socially constructed nature of the

doctor-patient relationship. It was an underlying assumption of the study that the way

in which both players within the dyad imagine their role influences the relationship.

My suggestions for transforming this relationship circle around applying a Foucauhian

deconstruction to the relationship (an examination o f how and why it came to be) and

a re-imagining of the relationship through the dynamic student-teacher model

presented by educational philosopher John Dewey in the early 20lh century.

A starting point for such a transformation may be rooted in the finding that

doctors and medical students seem to view themselves increasingly as teachers in

relation to their patients. But the institution of medicine would need to support such a

vision in order for it to have a major impact on health care delivery. Adequate time

allowed for a relationship to develop, and an emphasis on the importance of the

doctor-patient relationship seem to be necessary pre-requisites for the transactional

relationship (envisioned by Dewey) to apply to the doctor-patient relation. Other

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. recent explorations of the relationship between self, social identity, and physical health

come to the same conclusion:

The patient and doctor constitute a central system in understanding the self health interconnection: here consumer and provider come into direct contact, and the success o f that interaction depends, in part, on how the doctor and patient define themselves and the other. Further, the patient-physician system is embedded in larger systems, perhaps the most important o f which is the health care system. (Ashmore & Contrada, 1999, p. 241)

If the health care environment precludes a doctor-patient relationship from

happening, does it make sense to utilize the doctor-patient relation as a means to

reform medicine? A recent study conducted on physician discontent implies that

transforming the doctor-patient relationship may not be enough. Magee and Hojat

(2001) investigated physician willingness to choose medicine again if given the

opportunity. They found that after adjusting for gender and age, that physician

discontent could be predicted by their negative perceptions of the health care

environment. Does a positive perception of the health care environment precede a

re-envisioning of the doctor-patient relation, or can the two be in tandem?

Understanding the difficulties within doctor-patient communication is only one path to

easing frustrations often experienced in health care delivery.

This researcher acknowledges the importance of the institutional factors

currently framing the doctor-patient relation, and that individual attempts differ in

scope from institutional reform. Foucault's notion of power and authority may need to

be used to deconstruct the social impact of the managed care time constraints put on

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research concerning the extent to which managed care actually effects time spent with

patients, and the quality of the time.

Can individual doctors transcend the demands of managed care? One doctor

interviewed was very strong in detailing the difficulty of such a notion:

I’ll tell you, I think our biggest problem in medicine is that it’s getting so time- constrained in reimbursements. It has to allow patients to keep the place open to pay all the bills and pay your employees and overhead supplies. You have to see more and more patients to be able to do that. Time is a big constraint on patients, on overtime, and everything. To be able to pay the bills and pay yourself and pay employees, you have to see more and more patients which means you probably have to take a little less time to do with each patient. That does affect patient happiness. It affects doctor happiness too, big time. We’d much rather be able to spend more time with people. It all has to do with quality reimbursement and managed care.

Yet others see it differently. Physician Ronald Dworkin (2001) examines the

dramatic loss of prestige undergone by the medical profession, “a profession that once

enjoyed tremendous power and influence in American society without even having to

exert itself' (p. 43). He says that most doctors blame managed care but he disagrees

with this oversimplified explanation. Medicine’s goal was to draw a distinction

between itself and other healing arts but, “in time, expert medical practice became

identified with precision, accuracy, and scientific knowledge - to the detriment of the

comforting and interpersonal skills that were once the hallmark of successful

doctoring” (p. 44). Dworkin attributes the doctors’ shift to being simply an engineer

of the body to have opened the door to managed care and evidence-based medicine,

practices that can be quantified.

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the widely held notion that managed care is responsible for a decrease in the amount

of time the doctor spends with a patient. The study examined 200,000 office visits

over 10 years and found an increase of time spent with patients of one to two minutes

depending on the survey source. David Mechanic, a Rutgers University sociologist

who led the study, maintained that doctors had always claimed they didn’t have

enough time with patients. Mechanic argues that with the rise o f managed care,

doctors now have someone to blame for something which always existed. Just as the

perception of time spent with a doctor matters more to a patient than actual time spent,

perhaps it is the perception of being rushed through patient visits that most negatively

affects physician satisfaction. This is another area of further research deserving

attention.

Dworkin also addressed the entry of women into the medical profession as

fundamentally altering the profession’s attitude toward medical practice. “In 1970,

13% of medical students and 8% of practicing physicians in the United States were

women. By 1999, those figures had risen to 50% and 22% respectively” (p. 45).

Dworkin claims that women physicians are not as likely to accept the professional

ideal o f being a physician as the defining element in one’s existence. He sees this

happening as younger male doctors are influenced by the goal of achieving the right

balance in life.

One can think o f a number of positive sides to this decline in the professional ideal - including a revision of the old, contemptuous attitude among doctors towards labor for profit.... I can recall as a college student how those of us

14 As printed in The Columbus Dispatch, 1/18/01, p. 1. 154

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. who were going into medicine looked down upon those who were going into business. We were more noble, while they were somehow degrading themselves. Among working doctors, this prejudice seems to be on the wane, (p. 46)

Speaking from within the medical profession, Dworkin’s analysis parallels the

opinions expressed by female audience members participating in this study. He even

comments on the rise in number of physicians who are open to alternative medicine.

Rather than trying to find scientific reasons why alternative treatments may work, he

comments on physicians open to a holistic approach to health care, “For them, it is

precisely because alternative medicine cannot be encompassed by science that they

value it” (p. 47).

In both theory and professional practice, physicians such as Dworkin are open

to exploring the possibilities within the current state o f medicine. His is an affirmation

that some change to the traditional, exclusive medical discourse may be healthy for

doctors and patients alike. As noted already, one o f the interviewed medical students

provided a different way to regard the move to being open to alternative schemas:

“The doctor is sometimes nervous and unsure; in their profession, competition makes

doubt seem like a weakness rather than something to be explored.” It may be a relief

for some physicians to feel they can use lack of answers as a window toward

discovery rather than as a sign of weakness.

It was not a finding of this study that doctors viewed their patients as being

able to teach them about individual experience of health and illness. But as patients

explore alternative, holistic approaches to their own health care, doctors will

inevitably become exposed to various approaches outside the paradigm of Western

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. medicine. It remains to be seen if doctors will embrace this opportunity as a learning

experience or if they will locate themselves in a defensive perspective. Individual

differences between doctors will likely surface here, just as patient desires vary.

A recent study (Silverstein & Spiegel, 2001) illustrated that although

alternative medical therapies play an increasingly prominent role in health care,

physician age and training were negatively correlated with asking patients about

alternative medicines. This included not checking out side effects or interactions with

drugs in a reference text. Silverstein and Spiegel point out though, that as of 1997,

65% of U.S. medical schools offered either elective or required courses in alternative

or complementary medicine, implying that doctors in the future will exhibit greater

exposure to these approaches. The recommendation o f Silverstein and Spiegel is that,

'‘patient care will be greatly enhanced if physicians educate themselves and stay in

touch with their patients’ beliefs and health care behavior” (p. 173).

5.3 CURRENT WINDS OF CHANGE WITHIN MEDICINE

What has replaced the traditional doctor-patient relation model that is now

regarded as outdated by a growing number of Americans? How do doctors and

patients alike sculpt these new relations? Much current research attention has been

focused on (a) the changing concepts of medical professionalism as taught in medical

schools, (b) the patient-centered approach of medical care delivery (Mead & Bower,

2000), (c) the medical interview itself, (d) the future o f the computers’ role in the

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curriculums within medical education. These areas will be briefly discussed in order

to flame suggested areas of future research.

5.3.1 THE CONCEPT OF MEDICAL PROFESSIONALISM

A recent study by Pescosolido, Tuch, and Martin (2001) questioned if there has

been an erosion of the public’s faith in medicine and its practitioners. They

characterize the period from 1910 to 1970 as the era of great growth, success, and

power for the medical profession, and term it the “Era of Professional Dominion” (p.

3). They claim that their comparison data (the difference in public opinion from 1976

to 1998) do not indicate that physician authority and medicine face serious public

challenge. They did find, though, that women (especially those o f a higher income

level) are now significantly less likely to have a positive attitude toward these (p. 13).

The findings of this study support these data.

What do physicians today consider a medical professional to be? Has this

concept changed since the “Era o f Professional Dominion”? Brownell and Cote

(2001) conducted a study to determine senior medical residents’ views on the meaning

of professionalism and how they learned about it. They found the residents identified

the attributes of respect, competence, and empathy most frequently with medical

professionalism. And the residents claimed to have learned professionalism primarily

from observing role models. No differences were found in gender or medical

specialty. They note that the attributes of respect, empathy, confidentiality, courtesy,

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the residents) are all related to the doctor-patient relationship (p. 736). Residents less

appreciated altruism, and other attributes that related to the social vision of medicine.

Is there more emphasis today on the physician’s actual work with patients?

One might draw such a conclusion given recent studies on both professionalism and

on suggested interview approaches beginning to be taught to medical students.

5.3.2 PATIENT-CENTERED CARE

“A patient-centered approach is increasingly regarded as crucial for the

delivery of high quality care by doctors” (Mead & Bower, 2000, p. 1087). Yet Mead

and Bower voice frustration that there is little consensus as to its meaning. They cite

the most comprehensive description as given by Stewart, Weston, McWhinney,

Me William, and Freeman that characterizes patient-centered care as having six

interconnecting components: (a) exploring both the disease and illness experience, (b)

understanding the whole person, (c) finding common ground regarding management,

(d) incorporating prevention and health promotion, (e) enhancing the doctor-patient

relationship, and (f) “being realistic” about personal limitations and issues such as the

availability of time and resources (p. 1088).

Mead and Bower attempt to identify empirical definitions and measures of

patient-centeredness as they see this as an important step in advancing its usefulness.

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suggesting that interpersonal aspects of care are key determinants to patient

satisfaction (p. 1091).

Findings from the action research portion of this study suggest that Kasulis’

theory of cultural difference may be a useful tool in teaching medical students and

residents ways to enact patient-centered care. A larger study, later in the medical

school curriculum, or within a residency program, needs to be conducted to explore

such a hypothesis.

5.3.2.1 THE MEDICAL INTERVIEW

John Dewey’s (1934) concept of transactional teaching and teaming is based

upon the understanding that the teacher needs to discern the context (including the

level of understanding) of the student before true communication between the players

becomes possible. In Dewey’s vision, teachers also view themselves as learners,

understanding that both parties are changed by the transaction. Recent studies on the

medical interview indicate that physicians could improve upon discerning patient

concerns earlier in the medical interview.

Research by Robinson (2001) focused upon the importance of attending to the

closing remarks made by the patient in a medical encounter. He examined the

problem that patients are not always able to express their foil agenda of concerns

during an office visit. He looked at the phenomenon documented by White, Rosson,

Christensen, Hart, and Levinson (1997) that patients raised new concerns in the

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. closing phase in 23% of medical encounters. White et al. suggest that the frequency of

new problems in closure indicates doctors have the potential to increase their

effectiveness. Why was it not until the closing remarks of the interview that patients

voiced their concerns?

Anderson and Hinckley (1998) emphasize in their study on the roie-

dimensions of patient and physician that the closing moments are critical to patient

satisfaction with the medical encounter. They highlight the relationship between

patient education and satisfaction: “Communication during the conclusion of the

medical interview is particularly important because the nature of this component o f the

visit is educational” (p. 601). If the roles played by the patient and doctor inhibit the

patient becoming educated on how to address their medical concerns, then the most

effective health care is not being actualized. Anderson and Hinckley emphasize that

doctors who want more satisfied patients should be less controlling in the conclusion

of the medical interview (p. 602). If a physician were focused on the lead of the

patient from the beginning of the interview, would the patients concerns surface

earlier?

Robinson recommends a “final-concem sequence” of communication so that

the patient clearly has an opportunity to address his or her concerns. What is it,

though, that keeps the patient from addressing these concerns earlier in the encounter?

Perhaps the way the doctor-patient construct each other creates this problem. If the

sequence suggested by Robinson began the interview, with the physician listening to

patient concerns with ears of the integrity/intimacy model of communication, both

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expectations were met in the encounter. Research needs to be conducted in the

physician-patient encounter with a physician who would be willing to employ Kasulis’

model to the medical encounter. My hypothesis is that using such a model could

increase both physician and patient satisfaction concerning their communication

exchange, and new medical concerns would surface before the closing remarks of the

medical interview.

While shared decision-making is currently the espoused model for doctor-

patient relations (Gattellari, Butow, & Tattersall, 2001), and may be the safest

standard approach to doctor-patient relations, Kasulis' model could fine-tune the

communicative relation of the individual doctor and patient. Individualization could

be the standard if medical professionals are provided the tools to discern the patient

wishes concerning both mode of communication and content.

Attempts have been made to investigate the effectiveness o f training the patient

to increase effectiveness o f doctor-patient communication (Cegala, Marinelli, Post,

2000). Their study indicated that trained patients did communicate more effectively

with their doctor, and were more active in controlling the medical interview than

dyads that were untrained.

Physician Robert C. Smith (2002) conducted a study, and then wrote a

textbook for medical students entitled, Patient-Centered Interviewing: An Evidence-

Based Method. His approach integrates traditional doctor-centered interviewing with

patient-centered interviewing. By training medical students in his approach, he feels

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. that the medical student is encouraged to focus on the patient’s lead, and can more

effectively connect with the patient, encouraging a relationship. His work illustrates

that the patient-centered approach is helping shape current research on the medical

interview, and the importance of developing effective ways to teach such an approach

to medical students. Both role-playing and watching experienced doctors were

utilized in Smith’s study. By providing a databased interviewing model, Dr. Smith

attempts to shift the paradigm of medicine in the desired direction (p. 268).

Both doctors and medical students interviewed for this study were convinced

that these skills cannot be learned exclusively from academic learning. This was

reinforced by the positive reaction of the medical students to the role-play exercise

used in the action research portion of this study. Emphasizing the impact that

modeling can have, an experienced oncologist detailed the necessity of students

watching him communicate with his patients in order for the medical student to folly

grasp the communicative process of dealing with a variety of patients:

It's teacher and student, but man it's a great range; it's a tremendous range. It's the range of teaching kindergartners to the range o f teaching post-docs at university. It's an incredible range. You have to make that adjustment appropriate. Sometimes you have to have a bimodal teaching method. Sometimes a patient will come in and their daughter-nurse will be with them. So you have to be careful you don't talk to the nurse in medical terms when the patient's left out in the cold with not knowing what's going on. You talk to the patient and every so often you kind of give a rapid medical summary to the nurse and then you go back to the patient. Sometimes it will be bimodal... You just have to be responsive. It's intuitive. Number one, it's intuitive. Number two, if you're not responsive to the level of the other people there that are interested and want to engage in a dialog with you, they’re going to interrupt you at times that might not be good for the interruption. So it's better to just kind o f make the interruptions yourself at timely places where the patient's train of thought is not going to be disturbed by what you're trying to get across to them.

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How can a physician discern the expectations of individual patients in order to

deliver desirable health care and communication? Should a physician consider the

racial and ethnic background of the patient in the shaping of their delivery? A study

by Gardyn (2000) indicates that there are different attitudes about health care among

Asians, African-Americans, Latinos, and whites. Gardyn found, for example, that

Asians are less satisfied with their doctor’s overall care than any other ethnic group

and they tend to be not as happy with their doctor’s use of technology and

communication skills. Does this indicate that the physician needs to take into account

patients’ cultural background in shaping their health care? Would this be considered

cultural profiling?

My suggestion is that Kasulis’ model be the neutral heuristic in medical

encounters. Physicians could listen to the patient to discern their approach to health

and illness, and then adjust their own communicative style to match that of the patient.

The physician would employ bilingual integrity/intimacy ears to listen to, and

communicate with the individual patient. The action research portion of this study

indicated that medical students considered such an approach to be a useful tool.

Certainly, more research needs to be conducted concerning the most effective way to

introduce Kasulis’ theory within medical education and its various uses within

medicine. Clearly, this model for crafting communication across cultural difference,

meshes well with a patient-centered approach. In a pragmatic sense, Kasulis’ model

may be what the varied doctor-patient relation of today needs.

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A study by the Physician Insurers Association of America (1997) warned that

telemedicine (practicing medicine over the telephone) would expose physicians to new

liability concerns regarding practicing across state lines. Only five years old, yet this

study doesn’t envision the larger and more current issue of the legal ramifications of

using e-mail to communicate with one’s doctor. The concept of telemedicine may be

an outdated concern given the swift shift in the medical literature afforded to both

doctor and patient by cybermedicine. Rather than exchanging missed messages over

voice mail, doctor and patient could (given the available technology) clearly

communicate (at whatever time is convenient for them) over the Internet. Certainly,

this further complicates, and could open a complex web of legal- and insurance-related

issues, all o f which would require a huge amount of attention and research. But, are

patients and doctors open to using the Internet for communication?

Given the findings of this study, (the comfort afforded patients by information,

the medical students feelings of ease with the Internet as an educational means for

both doctors and patients, etc.), the expectation is that patients would feel a greater

sense of empowerment in their relationship with their doctor if they were able to

communicate over e-mail. A study by Lach (2000) reports that in a demographic

study of Americans, 89% of respondents expect that if they were able to communicate

with their physician over the Internet, then in-office visits would decline. How would

this effect the payment structure between physician, patient, and managed care?

Cybermedicine clearly could alleviate some patient concerns that otherwise would

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. necessitate an office visit. The same report predicts that the future health care system

will be influenced by “ empowered consumers” and “consumer friendly” features.

Referring to the patient as consumer highlights the paradigmatic shift from

physician as the exclusive professional possessing medical knowledge, to physician as

service provider of medical care and information. Medical practices that cater to

consumers drawn to e-mail communication could be a desirable feature of health care

provision when choosing a doctor. As medical practices begin to use e-mail for

physician referrals, prescription refills, and scheduling o f appointments, it will be

fascinating to see if there is a push by patients to communicate directly with doctors,

or if this somehow becomes streamlined by medical office personnel.

Physician Warner Slack (2001) considers cybermedicine to be a frontier that

needs to be explored as a new horizon in the practice o f medicine, one that could

increase, rather than decrease time spent with patients. As physicians such as Slack

recognize the cultural influences that impact the practice of medicine, new ways o f

relating between doctor and patient may evolve along with technological and

communicative developments. This researcher expects that such developments would

necessarily have to come from those within medical practice, in order for the medical

profession to respond to such suggestions. Thus, the work of physicians such as Slack

is vitally important in furthering the discussion considering new, innovative means o f

communication.

As patients have access to more and more medical research over the Internet, it

seems more and more unlikely that communication between doctor-patient will not

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. eventually utilize this medium. The access to knowledge has changed the patient’s

ability to educate oneself on particular health issues:

The growth of knowledge which has increased the power of the medical profession, now reduces the power of its practitioners because they are less and less likely to be completely up to date...not because the experts are poor o r slow moving but because research expands so swiftly.. .the importance of medical knowledge continues to increase, but doctors’ control over it is declining. (Heroes, 2001, p. 175-176)

Waiting to ask the doctor’s opinion on information the patient has accessed (if

the next available appointment is weeks/months away) is a situation that the proactive

patient may find extremely frustrating.

Medical sociologist Michael Hardey (1999) concludes in his research on

Internet use that this issue will be the site of a new struggle over expertise in health,

and that it will be a struggle that will transform the relationship between health

professionals and their clients. He illuminates,

The basic design of the Internet represents a challenge to previously hierarchical models of information giving This shift in control is central to the deprofessionalization thesis and may be seen as contributing to the decline and awe and trust in doctors, (p. 832)

Yet, the finding of this study, that medical students view the Internet as an educational

tool for both patients and doctors, may indicate an openness to future communicative

uses o f the computer by the time they are experienced, practicing physicians. Medical

students have grown up in a world in which computers, and all that they afford in

terms of possible information and communication, is simply part of cultural

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changing doctor-patient relation remains to be seen, and is fertile ground for action

research studies on doctor-patient communication.

5.3.4 MEDICAL EDUCATION

American medical education seems a likely site of possible change for the

communication frustration felt by doctors and patients. The transactional nature of the

student-teacher interaction could be taught to medical students from the first day of

medical school as a possible way to imagine their future role as a physician. If each

and every medical student understood that they could view themselves as the teacher

of health information to the patient, perhaps this would nudge a social transformation

along. It could be emphasized to the medical student that the patient is the expert from

whom they can gain useful information concerning the whole patient. And that this

information is essential in making the most appropriate recommendation for that

patient. Perhaps this would encourage medical students to view the doctor-patient

relationship as a fluid teacher-student relation. Was this a point that Margaret Edson

desperately wanted to make in her writing o f WTH

I see teaching and learning in every human exchange, even when someone is dying. The play reflects my belief that most learning happens when you can’t tell the teacher from the student.13

The 2000 publication of a report on the curricular structure and changes in

North American medical education published by the Journal o f the Association of

15 Quoted from an interview with playwright Margaret Edson by Laura Jones, Editor, Last Acts, http://www.lastacts.org. 167

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. American Medical Colleges affirms that there are different visions o f medical

education available today. By virtue of the emphasis being qualitative information

concerning process and change, the future medical student is given inklings that there

are now subtle models of “physician" out there that may not have existed post-Flexner

report. Academic Medicine: A Snapshot o f Medical Students ’ Education at the

Beginning o f the 21st Century; Reports from 130 Schools is an unprecedented

collection of information on 118 of the 125 American medical schools, and 12 of the

16 Canadian medical schools. The tenor of the individual schools comes through in

each report.

This attempt contrasts that of Abraham Flexner (1910) whose agenda was to

promote the path of reform already underway at some medical schools (Anderson,

2000). His aim was to distinguish between the good, ordinary, and bad schools. As

has been stated, it was a consequence of his report that schools allowing women and

people of color to be physicians were largely closed. Due to the 2000 publication, it is

now possible to learn o f the individual school’s approach to teaching and learning.

Does this bleed over into the individual school’s vision o f doctor and patient? This

attempt to qualitatively describe North American medical education clearly affirms

that there is a great and “stimulating” variety of educational approaches in our medical

schools. It is a beginning window to better understand the current structures and

systems that educate our physicians today.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A physician in his late 30s who I interviewed expressed his frustrations of the

traditional medical education that he felt he had received:

Do you want to hear my analogy for medical school? You see a great piano player and you love the way he’s playing music and he’s such an expert and you want to be like that some day. So you decide to become a maestro on the piano. In order to do that, the first thing you have to do is leam how to build pianos. So you have to go four years of piano school and learn how to cut down trees, get the right wood. And you have to leam how to make the strings. And you have to hunt down elephants and get the ivory for the keys. So then after you leam how to build a piano and do all this other elephant killing, you can actually go to the music school. Music school is four years. The first year, the first or second year, all you do is take all these other great musicians like Mozart and Bach and Beethoven and all these other people. You get their music and you just read the music. You don’t get to see the piano yet. You just stare at the notes and you try to memorize them. You’re going to be a good musician by just studying the notes and memorizing the notes. And then after you’ve studied all these sheets and sheets of music - you don’t every hear the music - you just study the notes and try to figure it out in your mind what the music sounds like. Then you get to go to another part of the school where you sit next to a piano player and the maestro plays and you just watch him. You watch him for two years. And then after the first year’s studying the notes on paper and the second year’s watching somebody play and then you graduate and now they put you on stage at the piano and expect you to play.

Dr. S. is very excited at the changes in instruction beginning to happen in medical

education.

One of the changes occurring in medical schools is their approach toward

medical professionalism. Physician Leah Dickstein (2001) outlines various medical

schools' approaches to professionalism, revealing their scope and variety. In a book

review of Educating for Professionalism: Creating a Culture of Humanism in Medical

Education (2000), she promotes the development o f innovative programs “to

counterbalance too many negative images of physicians” (p. 3148), and to make the

point that medical educators have been working on changes for two decades.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The closest example o f implementing a vision o f medical education with

Dewey’s conception of transactional learning in the literature can be found in

Rochester, New York’s, Highland Hospital approach to teaching professionalism.

Physician Kathryn Markakis (2000) details the residency program at the University of

Rochester School of Medicine that attempts to establish and develop professionalism

and humanism as an explicit educational goal. Markakis, Bechman, Suchman, and

Frankel (2000) recognize the parallel between the teacher-student interaction and the

doctor-patient relationship. Descriptors they use to characterize these relationships

include “careful listening, eliciting the other’s perspectives, negotiating, establishing a

partnership, conveying empathy, and providing support” (p. 144). How many people

would characterize either a doctor-patient or teacher-student relationship with these

descriptors? It enacts Dewey’s conception of transactional learning for student, as

medical student, so that when the medical student becomes a doctor, the patient can be

viewed in this way.

The program they describe is similar to the class, The Physician’s Identity,

designed and taught as part of this research project. Both learning situations used

drawing oneself in his or her professional role and role-playing the doctor-patient

interaction, followed by discussion of the role-play. While The Physician’s Identity

was a small attempt at what Glesne (1999) refers to as “catalytic education” (p. 197),

the program at the University of Rochester Medical School is grounded in their overall

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. institutional approach to medical education. For example, their curriculum includes a

home visit where the intern learns the lesson about asking patients about home

environment as a way of assessing barriers to compliance.

The success reported in their research study is overwhelmingly convincing that

to teach a humanistic approach to medicine, a humanistic approach toward the learner

is critical.

In the University of Rochester program, the residents’ mentors are encouraged to use learner-centered methods in their interactions by eliciting the learner’s goals, exploring what the learner believes to be his or her strengths and weaknesses, and discussing these within the context of program evaluations, feedback, and testing performance. (Markakis et al., 2000, p. 147)

They make the point that this program could not operate, or be successful, without a

relationship-centered administrative environment in the hospital. The culture has to be

consistent, at all the institutional levels for the trainee to truly get the foil benefit from

this approach. “The Highland Department of Medicine has a mission statement that

defines its commitment to these goals, this environment, and the learning process. It

includes the statement, 'we will be guided by core values o f respect, intellectual rigor,

compassion, and honesty’” (p. 148). In line with Foucault’s suggestion that

institutions exert overwhelming power, the commitment by Highland Hospital seems

critical.

The program at Highland Hospital was organized around the belief that the

socialization process in residency training is reflected in subsequent practice behavior.

“All too often, lack of explicit attention to the values of humanism and

professionalism creates learning environments that are antithetical to good medical

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. care” (p. 148). They recognize the power exerted by physician teachers and the

medical institution in influencing the way in which residents will treat the patient.

Markakis et al. conclude in saying “the challenge for the future is translating and

extending this cultural shift to conventional learning environments, so that programs

such as ours are not the exception but the norm” (p. 149).

Dr. P., one of the physicians interviewed, a professor at a medical school, cites

the necessity of the school itself demanding that the medical student attend to new

visions of learning how to become a doctor. He maintains it is not all from medical

texts:

We’re a medical school that’s strong in the humanities. We expect you to write essays and read poetry and stories and discuss it. We think it will be relevant to your education. If that’s not your bag, go someplace else.

5.3.5 PATIENTS CHOOSING ALTERNATIVE CARE

The suggestion of pursuing areas of research in medical education using the

principles of patient-centered care (specifically applying Kasulis’ theory of cultural

difference) as a way to ease the communication difficulties often experienced in the

doctor-patient relation has been the central focus of this concluding chapter. But,

following Kuhn, Foucault, and the numerous feminist philosophers of science, it is

appropriate to suggest research investigating patients who present with serious illness

and who pursue alternative approaches for their disease management. What are they

looking for? Why have they pursued an alternative approach? Was it the Western

scientific paradigm, the traditional doctor-patient relationship within this paradigm, or

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. something else entirely that led them in a different direction? Do they incorporate

traditional and alternative medicine? A descriptive study of these patients could

provide some important information for physicians who are daily faced with patients

who incorporate (or would like to incorporate) both holistic and allopathic care.

The patient of the 21s century has therapies outside of Western science

available to them in a way that was not readily available 20 years ago. Does this

change the practice o f medicine for today’s physician? As complementary medicine

becomes part of mainstream America with many people aware of alternative medicine

and that other paradigms exist, where does this locate the medical doctor?

It may be that alternative medicine is appealing, as it represents a counter

discourse to the objectifying nature o f the scientific approach in Western medicine.

The discourse of nature is heard in the alternative therapy approach and this fits in

with a poststructuralist approach to paradigm shills. Many writers have turned their

attention to the intersection between alternative therapies and post-structuralist

thought. An example is Lupton (2000) who claims that there is a new morality of

preventative care in which alternative therapies have a strong emphasis and value on

people “taking control'’ of their health. She sees this as the value in deconstructing the

socio-cultural representation and meaning of health and medicine.

One o f the most important insights of socio-cultural analyses is the identification of the link between knowledge, discourse, power, and notions of reality. Their value lies in challenging the status quo by deconstructing taken- for-granted perspectives and representations, and in the process producing new ways o f seeing, thinking, and acting, (p. 61)

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Thomas Kuhn (1970) may not have envisioned the physician’s role to be

effected by the presence of this particular alternative paradigm, but he would certainly

admit that today’s physician is operating in a different medical world than 40 years

ago. Kuhn said, “Though the world does not change with a change of paradigm, the

scientist afterward works in a different world” (p. 121). Does Kuhn’s statement

characterize the world of today’s physician? The possibility of cybermedicine,

alternative therapeutic approaches, managed care, the proliferation o f medical

information available to the patient over the Internet, and an increased interest in

ability to understand one’s disease pathology, have all transformed the practice of

medicine. Additional studies need to be conducted tracking how these various cultural

developments have affected the practice o f medicine from the standpoint of both

physician and patient, and the relation between them.

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MATERIALS RELATING TO QUALITATIVE INTERVIEWS WITH AUDIENCE MEMBERS

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. * PHYSICIANS / PATIENTS * ( and physicians-in-training ) Your voices are needed... come explore the implications of

Ohio State University doctoral student research on Physician/Patient Communication Since 1995, at productions around the country, WIT has touched people who occupy many different roles: doctors, patients, nurses, and family members of people in need. In an attempt to explore the doctor- patient relation, I am conducting a research study using audience reaction to WIT. If you are interested in putting WIT to work, consider participating in a 20-minute interview via e-mail, US Mail, or by phone. Please contact [email protected] or respond to Maryanna Klatt, Doctoral Candidate, do Dr. Kleinman, Cultural Studies, Ohio State University, 165 Ramseyer Hall, 29 W. Woodruff, Col. Oh., 43210. Or call 614-688-5590. FAX 614-292-7900. Or leave in box: Name e-mail

Address______

phone ______

Preferred method/time for interview: 176

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. PHTSICIANS/PATHNTS/PHTSICIAHS-IH-TRAINniG Your voices are needed...

Come explore the implications of WIT.

Join an OSU doctoral research study on PHYSICIAN/PATIENT COMMUNICATION. Was the portrayal of the doctor-patient relationship portrayed in WIT realistic? Was it a stereotypical exaggeration? Was it helpful for doctors, and/or for patients? In an attempt to explore these issues, I am using audience reaction to WIT as a prompt for your own story of doctor-patient relationship. What role does this relationship play? If you are interested in putting WIT to work, please respond to Maryanna Klatt in the Cultural Studies Program, School of Educational Policy and Leadership. Participation involves a 20-minute interview via e-mail or phone. Fill out a flyer in the lobby of the theater with your contact information, or e-mail Maryanna at [email protected].

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Research Interview Schedule o f Questions:

First of all, I want to make sure that you know that I will use a fictitious name and city for each participant in my research. The reason I feel it is necessary to even change the city name is that some medical specialties are so small that someone looking at the research theoretically might be able to guess at a specific doctor or patient's identity. By doing this I want to assure you of my intentions that you remain anonymous.

I thought it might be helpful for you to know how I came to use audience reaction to the play WIT in my research on doctor-patient communication. I am in the process o f getting my doctorate in the college of Education at OSU. I am interested in how medical schools go about educating future doctors in their communication skills. I have interviewed doctors on their educational history and it has been enlightening. But I wanted to interview doctors and patients to gather their ideas on what they think are important factors in positive doctor/patient communication. I want to give doctors and patients a voice. Last year I saw WIT off Broadway in NYC, and I started thinking about how I might use WIT to help me get some people to tell their own stories. This is where you come in! I so appreciate your willingness to help me leam about the your perspective on the importance /role of communication in the healing process.

1. Could you please tell me a bit about yourself-age, marital status, job, those kinds of things?

2. Could you describe the kinds of interactions /relationships that you have had with doctors, as a patient? Did it matter what type of specialty the doctor came from?

3. What factors do you think largely determine the native of the doctor-patient relationship?

4. Please describe your feelings as you imagine yourself as a future patient in a health care setting.

5. For example, if you imagined a conversation between you and a physician, what is the first feeling that comes to mind? Can you describe the conversation?

6. Now, can you describe your vision of a "best scenario" of your sharing of health information with a physician? What factors might facilitate this happening? What factors get in the way of this happening?

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7. What were/are the most important elements that have helped you deal with the day to day reality of your health concerns? Is there anything your doctor might have done to help with this?

8. If you were asked to think of a metaphor or analogy to describe your dealings with a doctor what would it be? (Or, if you are a doctor, what metaphor might describe your dealings with your patients?)

9. To switch gears a bit, what did you think of WTH

10. Was there a particular scene, or character in the play that struck a particular cord in you? Why do you think you felt that way?

11. The actress that first played Vivian in the NYC run of WIT, had this to say, "Vivian is also in battle with her doctors-clinicians-who in a grotesque twist of fete, are as removed from reality as she once was. They view her as a disease to be conquered, not a human being who is suffering from terminal illness". How would you react to this summation, or how would you describe the communication that happened between Vivian and her health care providers?

12. Based on your own experiences, was the portrayal of doctor-patient communication in WIT realistic?

13. What purpose might a play like WIT serve?

14. What else would you like to tell me about doctor-patient communication based upon your experience that I haven't addressed?

15. Could I call you, or e-mail you again, if after I've done all my interviews, I discover that there is a key question that I failed to ask you? 16. Thank you so much for the time you spent talking to me and for sharing your story. I really appreciate your help!

Maryanna D. Klatt Doctoral Candidate, Ohio State University Cultural Studies in Education School of Educational Policy and Leadership 122 Ramseyer Hall, 29 W. Woodruff Ave. Columbus, Ohio 43210 [email protected] phone: 614-262-7546 Home: 345 Walhalla Rd.. Columbus, Oh. 43202

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Questions for Physicians

Research Interview Schedule of Questions:

I thought it might be helpful for you to know how I came to use audience reaction to the play WIT in my research on doctor-patient communication. I am in the process of getting my doctorate in the college of Education at OSU. I am interested in how medical schools go about educating future doctors in their communication skills. I have interviewed doctors on their educational history and it has been enlightening. But I wanted to interview doctors and patients to gather their ideas on what they think are important factors in positive doctor/ patient communication. I want to give doctors and patients a voice. Last year I saw WIT off Broadway in NYC, and I started thinking about how I might use WIT to help me get some people to tell their own stories. This is where you come in! I so appreciate your willingness to help me leam about the your perspective on the importance /role of communication in the healing process.

1. Could you please tell me a bit about yourself-age, educational background, marital status, job, those kinds of things?

2. Can you describe the most important role that you feel you have as a doctor?

3. What variables/factors are necessary for you to fulfill the role as you see it?

4. If you think about a patient in your daily practice that you really enjoy working with, can you describe that patient? Can you describe the interaction that you have with that patient?

5. Is there any kind of patient that you dread seeing, that you see their name on your schedule and you think, “Ugh”? Can you describe that patient?

6. Is there a metaphor or an analogy you might use to describe the interaction that happens between yourself and a patient during an office visit?

7. How do you think you most effectively learned to communicate with patients? Do you think this is a skill that can be taught?

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8. Has the accessibility of health information over the Internet affected your dealings with patients?

9. To switch gears a bit, what did you think o f WIT!

10. Was there a particular scene, or character in the play that struck a particular cord in you? How did you come to feel that way?

11. The actress that first played Vivian in the NYC run o f WIT, had this to say, "Vivian is also in battle with her doctors-clinicians-who in a grotesque twist of fate, are as removed from reality as she once was. They view her as a disease to be conquered, not a human being who is suffering from terminal illness". How would you react to this summation, or how would you describe the communication that happened between Vivian and her health care providers?

12. Based on your own experiences, was the portrayal of doctor-patient communication in WIT realistic?

13. What purpose might a play like WIT serve?

14. What else would you like to tell me about doctor-patient communication based upon your experience that I haven't addressed?

15. Could I call you, or e-mail you again, if after I've done all my interviews, if I discover that there is a key question that I failed to ask you?

Thank you so much for the time you spent sharing your story. I really appreciate your help! I would be happy to send you my final report on my findings.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Research Interview Schedule of Questions for Medical Students:

I thought it might be helpful for you to know how I came to use audience reaction to the play WIT in my research on doctor-patient communication. I am in the process of getting my doctorate in the college of Education at OSU. I am interested in how medical schools go about educating future doctors in their communication skills. I have interviewed doctors on their educational history and it has been enlightening. But I wanted to interview doctors and patients to gather their ideas on what they think are important factors in positive doctor/ patient communication. I want to give doctors and patients a voice. Last year I saw WIT off Broadway in NYC, and I started thinking about how I might use WIT to help me get some people to tell their own stories. This is where you come in! I so appreciate your willingness to help me leam about the your perspective on the importance /role of communication in the healing process.

9. Could you please tell me a bit about yourself-age, gender, marital status, educational background, area o f the country you come from, those kinds of things?

10. Can you describe the most important role that you feel you will have as a doctor?

11. What variables/factors are necessary for you to fulfill the role as you see it?

12. If you think about a patient in your daily practice that you imagine really enjoy working with, can you describe that patient? Can you describe the interaction that you would like to have with that patient?

13. Is there any kind o f patient that you can imagine that you might dread seeing, that you see their name on your schedule and you think, “Ugh”? Can you describe that patient?

14. Is there a metaphor or an analogy you might use to describe the interaction that you envision happening between yourself and a patient during an office visit? Or, if this seems too abstract since you are in the first-year of medical education, what analogy would you use to describe the doctor-patient relationship?

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 15. How do you think you most effectively learned (or will leam) to communicate with patients? Do you think this is a skill that can be taught?

16. Was the introduction o f communication via a theory of cultural relationship a helpful way to think about md/patient communication? Why or why not? Has this effected the way you might think about your dealings with patients?

17. Has the accessibility o f health information over the Internet effected how you imagine yourself dealing with patients? How do you think you might use the Internet in your practice?

9. To switch gears a bit, what did you think of WIT?

10. Was there a particular scene, or character in the play that struck a particular cord in you? How did you come to feel that way?

11. The actress that first played Vivian in the NYC run of WIT, had this to say, "Vivian is also in battle with her doctors-clinkians-who in a grotesque twist o f fete, are as removed from reality as she once was. They view her as a disease to be conquered, not a human being who is suffering from terminal illness". How would you react to this summation, or how would you describe the communication that happened between Vivian and her health care providers?

12. Based on your own experiences, was the portrayal of doctor-patient communication in WIT realistic?

13.What purpose might a play like WIT serve?

14.What else would you like to tell me about doctor-patient communication based upon your experience that I haven't addressed?

15. Is there anything else about WIT you would like to say?

16. If I need to follow up on with a question that needs clarification, may I e-mail you? Maryanna D. Klatt Doctoral Candidate, Ohio State University Cultural Studies in Education School of Educational Policy and Leadership 122 Ramseyer Hall, 29 W. Woodruff Ave. Columbus, Ohio 43210 [email protected] phone: 614-262-7546

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. March/16, 2001

Vear Vr. Seda/,

Thank/you/so- much/for taklng^tim eoutofyour busy day totalk/to- m eaboutdiedoctor-patient relattonship. WITvyyAJch/a/greatplay to-use ay cc springboard/for suxh/a/discussioni aneLyow were so- \tery helpful/to-me. I would/ be honored/to-haA/eyow look/ over my work/ when I am/finished/. (Which/1 hope iy sooner rather than later!) Vr. HartpcUcL me a/ great compliment by suggesting I talk/to-you/ You/ were SO' insightful/ inyour analysis'of so- many o f die scenes'. Thank/ you/ agoing

Maryanna/V. Klatt Voctoral/Candidate, Ohto-StoXeUniverstty Cultural/Studies' in Education/ SchooVofEdaoational/PoUcy and/ Leadership 122 'Ratmeyer Halli 29 W. Woodruff Ave. CoiumJbuy, Ohio-43210

klatt.8@>ozw.ecLv phone: 6 1 4- 262-7546 Home: 345 Walhalla/'Rd/., Cdumbuy, Oh* 43202

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX B

SURVEY OF COLLEGE STUDENT AUDIENCE MEMBERS

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I YI nc k * QOCTorrpgpcni-* — —» - —/— —A? » n 1 —»t p o m -1- • — p 2 portrayed in WIT wasa reahatic one.

2 .1 want to become a healthcare provider 2 in the future.

3 .1 expect to haw the doctor/patient 2 relationship I desire.

4. The patient largely determines the 2 nature o f the doctor/patient TCHOOIBnp*_ -a—• *-

5. The doctor largely determines the nature o f the doctor/patient rcaunarap.

6. Managed cane/insurancc fcenburacntent largely determines the nature o f the doctor/patient relatioaihip.

7. Theater such as WIT can play a role in 2 societal change.

8. It is possible to teach people to become 2 better listeners md communicators.

9. Time constraints on the doctor largely 2 determine the nature o f the doctor/patiem relationship.

10. My doctor’s interest in getting to know me “as a person” largely afiects the nature o f the doctor/patient fdationslup.

11. The relationship between the patient and the disease is different than the one between the doctor and the disease.

12. A member o f my immediate family has been heed with a serious Olnem.

Age: Famaie. k ta ie

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. WIT 1. Ifl were asked the question, “Whet is the phy WIT about?" I would say

2. The character or scene in the plqy that strode a choidai me was

3. When I imagine myself as a future patient in a health care setting. I fed

4. Ifl become a health care worker (doctor, nuree, x-ray technician, etc.) what I will ram noer uutu wt t /i I Ti wM

S. Describe the doctor/patient relationship youIMAGINE yourself having in the future.

6. Is this the same or different then the doctor/patient relationship that youHOPE to have in the future? Please explain.______

7. Overall, my impressions o f WIT were

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MATERIALS RELATING TO THE MEDICAL SCHOOL COURSE, “THE PHYSICIANS IDENTITY”

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Script for first day of class:

I am so happy that you have registered for this mini-module exploring “Physician Identity”. My hunch is that the way doctors and patients think o f themselves impacts the way they communicate with one another. This is what I am writing my dissertation on. I would like to see how medical students react to these ideas. As part o f my research, I would like to jo t down my impressions o f your thoughts during our class discussions. This is in no way part of your grade for this class, and no names of any medical students will be used at anytime. I simply would like to jot down my impressions of what I hear from you during our four classes together. My notes about your reactions will simply inform my thinking about future classes for the Medical Humanities Program. If this would bother anyone please let me know today. If, after seeing WIT, any o f you would like to fill out my flyer and complete an interview with me, then I would be thankful, but this will have absolutely no impact on your grade in this class. Your pass/fail status will result from your completion of the class requirements (which does not include completing an interview for me.) That is totally voluntary. If you are “moved’ by WIT one way or another, and are interested in having me interview you, then you can fill out a flyer which will be in the lobby o f the Drake theater. That is a separate activity from this class. I am very much looking forward to leading this mini module!

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Mini-Module Course: Medical Humanities Program, Ohio State University Medical School

THE PHYSICIAN’S IDENTITY

Mini-Module m:

April 25,1:00-3:30 p.m. May 2, 1:00-3:30 p.m. May 9, 8:00-10:00 p.m., WIT performance, Drake Union May 16,1:00-3:30 p.m.

Instructors:

Maryanna Klatt, Doctoral Candidate, Educational Policy and Leadership Laurie Dangler, M.D., Worthington Family Practice Thomas Kasulis, Ph.D., Department of Comparative Studies Lesley Ferris, Ph.D., Chair, Department of Theater

Description:

This module is based upon the use of theater as a prompt to discuss the identities of both physician and patient in our changing world of medicine. WIT by Margaret Edson, the 1999 Pulitzer Prize-winner for Drama, has been enjoyed and utilized by 30 U.S. medical schools thus far. Join us for two sessions preceding the play as we employ the learning techniques of Bemie Siegel, M.D. to explore the meaning of “physician” in contemporary society. Experiencing WIT as the piece o f self-conscious theatre it is, may enrich the way you choose to view yourself as “physician” in your journey to become one.

Course Goal:

To introduce students to the factors/forces at play in imagining oneself as “physician” within the practice of medicine today.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Schedule of Topics:

• April 25, 1:00-3:30 p.m. Mary anna Klatt. Doctoral Candidate Laurie Dangler, M.D.

“Physician Identity” will be explored through experiential activities/discussion in an attempt to understand that the medical care system, medical providers, and patients all interact in the construction of “health care” delivery. Dr. Dangler will offer thoughts concerning her personal navigation o f this role as a Family Practice Physician.

• May 2, 1:00-3:30 p.m. Maryanna Klatt Thomas Kasulis, Ph.D., Department of Comparative Studies

Through a presentation of Dr. Kasulis’ Theory of Cultural Relationship, the medical students will be exposed to a way o f listening to how a patient describes his or her illness as a way to truly be able to dialogue with the patient. This application of theory to the practice of “doctor-patient communication” is a skill the medical students could carry with them throughout their practice as “physician.” A short pre-performance talk will be given on the background/setting/context of WIT as it applies to medicine.

• May 9, 8:00-10:00 p.m., Drake Union WIT performance, OSU Department of Theater

• May 16, 1:00-3:30 p.m. Maryanna Klatt Lesley Ferris, Ph.D., Chair, Department of Theater

Small group, post-performance discussion on the implications of WIT for the physician. Dr. Lesley Ferris will share her insights gained by directing WIT as part of the 2000-2001 OSU theater season. Maryanna Klatt will present her qualitative research study using WIT as a prompt to discuss the identities within the doctor-patient relationship - the origins of physician identity and possible avenues of growth.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Required Reading:

"Palliative and End-of-Life Care: A Course Requirement for Doctor-in- Training?” by Jennifer Proctor, AAMC Reporter. December, 1999.

“Play Shares One Patient’s Experience o f Dying” by Jay Greene, American Medical News. September 11,2000.

“Physicians and Personal Grief’ by Dave Smith, M.D., Last Acts Electronic Newsletter, October 5,2000.

“The Lessons Learned” in How We Die by Sherwin B. Nuland, M.D., Vintage: New York, 1993.

Reflective Exercise:

Post-performance reflection questions (3-4 double-spaced, typed pages) to be turned in by May 16, the final session.

Evaluations:

A passing final grade for this module will be determined by the 1.) full participation of each student in all activities and discussion, 2.) attendance at “Wit,” and all mini-module sessions, and 3.) the completion of a 3 - 4 page typed paper answering questions based on “Wit.”

Students will be given the opportunity to include their confidential answers in the research study being conducted on physician/patient identity. A student’s participation in this module does not require participation in the research study. Participation is fully voluntary.

The primary focus of this module is educative. Students will complete an evaluation of 1.) the instructors, and of 2.) the course content, including the use o f WIT as a pedagogical tool within medical education.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. MEMBER CHECK Re-cap o f Session 1 o f the “Physician’s Identity” 1. Why did I have you introduce yourselves by what you might have been if you weren’t going to be a doctor?

2. What came through about how Dr. Dangler envisioned herself as a physician?

My impressions o f her points: -personality is the most important factor in who you become as a doctor

-she considers herself “down to earth” and this has helped her in her practice

-she stressed that the majority of what she does is to treat people for emotional needs

-somewhere in residency she thinks that it is often natural to stop thinking of the patients as people and to think o f them as simply “bodies”

Any other generalizations you would make about what she said?

3. When asked to draw yourself as a physician, here’s what I generalized from the drawings:

-there were a variety of salient features in how each of you viewed yourself as “physician”

-6/12 of you pictured yourself interacting with patients when you imagined yourself as “doctor”

-8/12 of you distinguished yourself from the patient either by the presence of a stethoscope or the clothes you would be wearing (either a white coat or scrubs). What does the stethoscope say? (if anything) What does the demarcation by clothes say? (if anything)

-only two of the pictures contained other features of the doctor’s life that would impact them as doctor. What does this say? (if anything)

-did anyone think at all about the picture after you drew it? Would you draw it differently after some thought? How would you change it?

- any other generalizations that might be drawn about how first-year medical students picture themselves as future doctors? (from the drawings) 193

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. MEDICAL STUDENT DRAWINGS

r \ p ? n n

• '

m m

Figure C. 1: Examples of medical student drawings of self as doctor (continued)

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure C. 1: Continued

MEDICAL STUDENT DRAWINGS

ft %

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Example of Medical Student Role-Playing Scripts

You are a Doctor who can only understand integrity talk. Even if a patient uses intimacy discourse, only respond and explain the treatment options using integrity discourse.

You are a doctor who typically uses integrity talk but is able to switch to intimacy discourse if it is necessary and is what the patient needs. You listen to how the patient is talking about their problem and you take your lead from them.

You are a doctor who listens to how the patient is describing their problem and then responds in a manner that you think will match that of the patient. You are a truly bi lingual doctor.

You talk only integrity talk (you are the doctor) and refuse to acknowledge any intimacy talk that the patient might use. You totally ignore some central issues that may be important to the patient because they are uncomfortable with the way the patient talks about them.

You are a patient who presents with symptoms that appear to fit with a diagnosis of adult onset diabetes. You talk about how you came to present with all these symptoms in a very integral manner. You never use any words or images that would reflect you consider yourself at all intimate with the diabetes.

You are a patient who presents with symptoms that appear to fit with a diagnosis of adult onset diabetes. You talk about how you came to present with all these symptoms in a intimacy sort of way. You never use any words or images that would reflect you consider yourself at all integral with the diabetes. You view it as your fault that you have allowed yourself to come to the point of developing this disease. Given your orientation, how should you look at living with this disease? This is what you need to know from your doctor. Try to focus on using intimacy terms only.

You have sprained your ankle vety badly and it looks like there may be ligament damage. The focus of your questions for the doctor center on how you are supposed to get around as a single mother with a 2-and 4-year old at home. All of your concerns are framed in intimacy discourse.

You have sprained your ankle very badly and it looks like there may be ligament damage. The focus of your questions for the doctor center on how you are supposed to get around as a single mother with a 2- and 4-year-old at home. All of your concerns are framed in integrity discourse. You want to find out the best way to hasten your recovery

196

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. You are diagnosed with ovarian cancer. You are trying to ask the doctor about your future chances of survival and treatment options. You have 3 kids at home, ages 16-6. You primarily use integrity talk but incorporate some intimacy talk. Your husband is along with you but insists on only using integrity talk because that is how he likes to attack problems.

You are diagnosed with ovarian cancer. You are trying to ask the doctor about your future chances of survival and treatment options. You have 3 kids at home, ages 16-6. You primarily use intimacy talk. Your husband is along with you but insists on only using integrity talk because that is how he likes to attack problems. You become frustrated that the doctor cant seem to talk your language.

197

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX D

NUMERICAL RESULTS OF COLLEGE STUDENT SURVEY

198

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. FREQUENCY TABLES

OISTRIBUTION OF RESPONSES BY OENPEW Table of Gender by ql Frequency, 1. 2, 3, 4, 5, Total ifffffffrwfwnffwtrwffffrffjwfnwwr F 28 149 48 37 1 263 ffffffffrfffffffrfffffffnifffffnffffffnffffffr M , 22. 142, 54. 46. 4. 268 ffffffffrfffffffrfffffffrfffffffnffffffnffffffr Total 50 291 102 83 5 531

Table of Gender by q2 Frequency, 1, 2, 3, 4, 5, Total ffffffffrfffffffrfffffffrfffffffffffffffrifffmr F . 47. 16 . 32 . 81. 87 . 263 ffffffnnffffffrfffffffrfffffffffffffffrfffffffr M 14 11 37 90 119 271 fffffmrf'mffirfffhffriffffffrfffffffrfffffffr Total 61 27 69 171 206 534

Table of Gender by q3 Frequency, 1, 2, 3, 4, 5. Total ffffffffrffmffrfffffffrfffffffrfffffffrfffffffr F . 87, 120. 35. 15. 6. 263 ffffffffrfffffffffffffffrfffffffrfffffffrfmiffr

Total 145 245 93 38 12 533

Table of Gender by q4 Frequency, 1. 2, 3, 4, 5, Total ffffffffrfffffffffffffffrfffffffrfffffffrfffffffr F . 10 . 76 , 65. 100, 12 . 263 ffffffffrfffffffffffffffrfffffffrfffffffrfffffffr M 9 . 85 , 64. 104 , 9 . 271 ffffffffrfffffffrfffffffrfffffffffffffffrfffffffr Total 19 161 129 204 21 534

Table D. 1: Response frequency by gender. (continued)

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Table o f Gender by q5 Frequency, 1. 2, 3, 4, 5, Total ffffffffrfffffffffffffffffffffffrfffffffrfffffffr F . 42. 156 , 43 . 21. 0 . 262 ffffffffrfffffffrffmffrmfffirtffffffnfffffir M 36 159 47 27 1 270 ffffMfrfhffff'rfffffffriffffffrfffffffrfffffnr Total 78 315 90 48 1 532

Table o f Gender by q6 Frequency, 1. 2, 3, 4. 5, Total ffffffffrfffffffrfffffffffffffffrfffffffrffffffir F 7 . 55, 124 , 58, 19 . 263 ffffffffrfffffffffffffffnffffffnffffffrfffffffr M . 15 . 58. 111. 64 . 23 , 271 ffffffffrfffffffrfffffffrfffffffrfffffffnmmr Total 22 113 235 122 42 534

Table o f Gender by q7

Frequency, 1. 2, 3. 4, 5. Total tfwifirfffiwrwfwnwwnffwinwim F . 27. 126 . 85. 19 . 2 , 262 ffffffffnffffffrffffffinffffffnffffffnffffffr M . 10. 126 . 77 . 49 . 8 . 270 ffffffffffffffffrfffffffrfffffffrfffffffrffffwr Total 37 255 162 68 10 5

Table o f Gender by q8 Frequency 1 2, 3, 4 5 Total ffffffffrfffffffnffffffnffffffrfffffffrfffffffr F . 83. 148. 19. 10 . 2 . 262 ffffffffrfffffffffffffffrmffffrfffffffrfffffffr m iw inw im Total 151 314 39 23 4 531

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Table o f Gender by q9

Frequency 1, 2, 3, 4, 5, Total ffffffffrfffffffrfffffffffffffffrfffffffrfffffffr F . 34. 148 , 35 . 41. 4 . 263 nwitirwwinfwm iwtijrtm wnwm r M 39 143 S3 34 1 270 fffifmrf'ffffff'rffffffirfffffffrfffffffrfffffffr Total 73 292 88 75 5 533

Table o f Gender by qlO Freouencv 1 2. 3. 4 Total ffffffff'nffffffnffffffrfffffffrfffffffr F .91. 144, 19 . 8 . 282 fiffffffrfffffffrfffffffrfffffffr/ffffffr M , 70. 141. 37 . 21. 269 ffffffffrfffffffffffffffrfffffffriffffffr Total 161 285 56 29 531

Table o f Gender by q 11 Frequency. 1, 2, 3, 4, Total ffffffffrfffffifrfffffffriffffffrffffffff F . 106. 121. 29 . 7 . 263 mfffffrfffffffnmfffnffffffnffffffr M . 111, 124. 26. 9 . 270 ffffffffrffffffirfffffffrffffmnffffffr Tatd 217 245 55 16 533

Table of Gender by ql2 Frequency, 1, 2. 3, 4. 5. Total ffffffffnifffffrfffffffrfffffffnffffffrfffffffr F , 127. 65. 7 . 36, 27. 262 ffffffffrfffffffrfffffffrfffffffnffffffffffffffr M . 92 . 70 . 21. 46 . 40 . 269 ffffffffnffffffnffffffrfffffffrfffffffrfffffffr Total 219 135 28 82 67 531

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Frequency Procedure

Cumulative % 95% Lower 95% Upper o f Confidence Confidence Agree/ Strongly Limit Limit Agree

’‘The doctor’s interest in 84% .8059 .8701 getting to know me as a person” (Q10)

“The doctor” (Q5) 74% .6992 .7756

“Time constraints on the 68% .6435 .7241 doctor” (Q9)

“The patient” (Q4) 34% .2970 .3789

“Managed care” (Q6) 25% .2165 .2919

Table D.2: College students’ perceptions of factors determining the doctor-patient relation.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. T-Test Values Confidence Levels

Mean Lower Upper Qi -0.139 -0.0291 0.014 Q2 -0.515 -0.734 0.297 Q3 -0.252 -0.415 -0.09 Q4 -0.364 -0.132 0.2046 Q5 -0.088 -0.225 0.0497 Q6 0.215 -0.141 0.1841 Q7 -0.311 -0.457 -0.165 Q8 -0.086 -0.216 0.0453 Q9 0.04 -0.109 0.2022 Q10 -0.247 -0.38 -0.114 Q ll 0.008 -0.12 0.1374 Q12 -0.398 -0.644 -0.152

Q2 was the only response >.50 of a difference in mean scores.

Table D.3: Impact of gender on questions 1-12.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. T-Test Values Confidence Levels

Mean Lower Upper Ql 0.1237 -0.083 0.3301 Q3 -0.614 -0.837 -0.392 Q4 -0.085 -0.313 0.144 Q5 -0.26 -0.071 0.1172 Q6 0.3079 0.0874 0.5285 Q7 -0.064 -0.271 0.1437 Q8 -0.181 -0.361 -0.001 Q9 -0.072 -0.287 0.1434 Q10 -0.151 -0.339 0.0369 QH -0.132 -0.308 0.0443 Q12 -0.449 -0.783 -0.115

Q3 was the only response that showed >.50 of a difference in mean scores.

Table D.4: Degree to which “planning on becoming a health care worker” impacted other responses.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. T-Test Values Confidence Levels

Mean Lower Upper Q i -0.038 -0.213 0.1358 Q2 -0.175 -0.427 0.0772 Q3 -0.111 -0.295 0.0735 Q4 0.0307 -0.16 0.2211 Q5 -0.153 -0.306 0.001 Q6 0.0643 -0.122 0.2507 Q7 -0.046 -0.214 0.1226 Q8 -0.164 -0.311 -0.018 Q9 0.0712 -0.107 0.2492 Q10 -0.037 -0.187 0.1135 QU -0.195 -0.337 -0.052

Q11 was the highest difference in mean scores, but was <.50.

Table D.5: Degree to which students’ experience with serious illness impacted other responses.

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SOCIETAL INTEREST IN DOCTOR-PATIENT COMMUNICATION

206

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Paul______. 09:23 PM 04/25/20. Article in NY Times X-Origmating-IP:_T216.127.5.2141 X-PH: V4.4@orb2 From.PaulXXXXX" To: [email protected] Subject: Articiel in NY Times Date: Tue, 25 Apr 2000 21:23:21 PDT Hi Maryanna, I came across an article in the NY Times that I think you might be interested in (I'm usually about 1-2 weeks behind in my reading!!). It was in the Sunday edition on April 16, 2000, Section 4, page 5. The title of the article is "Back to the Future: Medicine and our Genes" and was written by two physicians - David A. Shaywitz, MD, research fellow at the Dept of Medicine at Massachusetts General Hospital and Dennis M. Ausiello, MD, Jackson Professor o f Clinical Medicine at Harvard Medical School. The thrust of the article is that all the technological advances in medicine have distanced physicians from patients. They state, however, that some of the new technology related to gene research will "enable medicine and medical research to return to some of its best, and most old-fashioned, traditions", namely, the communication between physician and patient. It talks about getting away from the "ten minute office visit" and back to "the sort of relationship that the eminent 19th century physician, Sir William Osier, had in mind when he said, "the good physician treats the disease, but the great physician treats the patient."' It was an interesting article in view of what you’re trying to do with your research. Hope this may be helpful to you.

Paul

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