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Each week students are required to post a comment about that week’s readings or lectures. These

should be an observation or insight made about the readings or lectures, or they can be a

clarifying question in which you ask about some aspect of the readings or lectures that you did

not understand. In addition to posting your comment, you should also “like” one comment made

by one of your classmates and respond to that comment.

di question

How has your understanding of the pharmaceutical industry changed after reading Busfield and watching the lecture?

POST

Rueshil Fadia11:20amJul 21 at 11:20amManage Discussion EntryI believe it to be problematic that many clinical trials actually pay the participants to join the trial (this was seen in the Tuskegee Syphillis study but is still seen today). I believe that if a participant wants to join a clinical trial, their decision should be only focused on the idea that this could be a revolutionary medicine for their specific conditions that may not be on the market for multiple years. If that in it of itself is not enough lure for the patient to willingly join the study then they should not be in it. Unfortunately, paying patients to join the study adds ulterior motives and disproportionately attracts lower-class patients. Kristina LittleYesterdayJul 20 at 11:28amManage Discussion EntryWhat caught my attention the the readings was the idea of nurses vs. doctors. I have always wanted to go into the medical field ever since I was a child and I felt as if there was a pressure to reach highest by being a doctor rather than a nurse. I was unintentionally taught that doctors were seen as more important than nurses meaning they earned more money and got more benefits. Being a black woman, I was also put under the impression that they need more black doctors to show that we could do as much as others can do. From this lecture/reading, I was able to see the reliance doctors and nurses had on one another which played an important role in their jobs.Sahithi Chekuri2:39pmJul 21 at 2:39pmManage Discussion EntryThe Tuskegee studies, while it was criticized, showed the US how it was possible to lose trust in medical organizations. There is no guarantee that researchers or their doctors for that matter have their best interests at heart especially after this study. But this wasn’t the only instance of medical abuse on minorities. James Sims, who pioneered the field of gynaecology, used black, female slaves to study reproductive organs without giving them anesthesia. The case of Henrietta Lacks showed how there was a lack of consent when researchers took her tumor samples without permission. Furthermore, pharmaceutical companies are notorious for pressuring doctors to prescribe unnecessary drugs in order to drive up profits. Although minorities in the US still have a severe lack of trust in medical organizations, these groups are also victim to medical abuse because they need money or want a free health check-up. This cycle of abuse tends to repeat and each new case bought to light only serves to expose the increasing abuse of power between researchers and the people who volunteer for these tests. It is a shame that only extreme cases of medical abuse bring about change in the scientific community.

The New England Journal of Medicine
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Copyright © 1990 Massachusetts Medical Society. All rights reserved.
The New England Journal of Medicine
Downloaded from nejm.org at SAN DIEGO (UCSD) on May 1, 2018. For personal use only. No other uses without permission.
Copyright © 1990 Massachusetts Medical Society. All rights reserved.
The New England Journal of Medicine
Downloaded from nejm.org at SAN DIEGO (UCSD) on May 1, 2018. For personal use only. No other uses without permission.
Copyright © 1990 Massachusetts Medical Society. All rights reserved.
The New England Journal of Medicine
Downloaded from nejm.org at SAN DIEGO (UCSD) on May 1, 2018. For personal use only. No other uses without permission.
Copyright © 1990 Massachusetts Medical Society. All rights reserved.
The Doctor-Nurse Game
Leonard I. Stein, MD, Madison, Wis
THE
relationship between the doctor and
the nurse is a very special one. There are
few professions where the degree of mutual
respect and cooperation between co-workers
is as intense as that between the doctor and
nurse. Superficially, the stereotype of this
relationship has been dramatized in many
novels and television serials. When, however, it is observed carefully in an interactional framework, the relationship takes on a
new dimension and has a special quality
which fits a game model. The underlying attitudes which demand that this game be
played are unfortunate. These attitudes
create serious obstacles in the path of meaningful communications between physicians
and nonmedical professional groups.
The physician traditionally and appropriately has total responsibility for making the
decisions regarding the management of his
patients’ treatment. To guide his decisions
he considers data gleaned from several
sources. He acquires a complete medical history, performs a thorough physical examination, interprets laboratory findings, and at
times, obtains recommendations from physi¬
cian-consultants. Another important factor
in his decision-making are the recommen¬
dations he receives from the nurse. The
interaction between doctor and nurse
through which these recommendations are
communicated and received is unique and
interesting.
The Game
One rarely hears a nurse say, “Doctor I
would recommend that you order a reten¬
tion enema for Mrs. Brown.” A physician,
upon hearing a recommendation of that na¬
ture, would gape in amazement at the
effrontery of the nurse. The nurse, upon
hearing the statement, would look over her
shoulder to see who said it, hardly believing
the words actually came from her own
mouth. Nevertheless, if one observes closely,
nurses make recommendations of more im¬
port every hour and physicians willingly
and respectfully consider them. If the nurse
Submitted for publication Dec 13, 1966.
From Mendota State Hospital, Madison, Wis.
Dr. Stein is now at the Department of Psychiatry,
College of Medicine, University of Kentucky, Lex-
ington.
Reprint requests to University of Kentucky, Lexington, Ky (Dr. Stein).
is to make a suggestion without appearing
insolent and the doctor is to seriously con¬
sider that suggestion, their interaction must
not violate the rules of the game.
Object of the Game.—The object of the
game is as follows: the nurse is to be bold,
have initiative, and be responsible for
making significant recommendations, while
at the same time she must appear passive.
This must be done in such a manner so as to
make her recommendations appear to be
initiated by the physician.
Both participants must be acutely sen¬
sitive to each other’s nonverbal and cryp¬
tic verbal communications. A slight lowering
of the head, a minor shifting of position in
the chair, or a seemingly nonrelevant com¬
ment concerning an event which occurred
eight months ago must be interpreted as a
powerful message. The game requires the
nimbleness of a high wire acrobat, and if
either participant slips the game can be
shattered; the penalties for frequent failure
are apt to be severe.
Rules of the Game.—The cardinal rule of
the game is that open disagreement between
the players must be avoided at all costs.
Thus, the nurse must communicate her
recommendations without appearing to be
making a recommendation statement. The
physician, in requesting a recommendation
from a nurse, must do so without appearing
to be asking for it. Utilization of this tech¬
nique keeps anyone from committing them¬
selves to a position before a sub rosa agree¬
ment on that position has already been
established. In that way open disagreement
is avoided. The greater the significance of
the recommendation, the more subtly the
game must be played.
To convey a subtle example of the game
with all its nuances would require the tal¬
ents of a literary artist. Lacking these tal¬
ents, let me give you the following example
which is unsubtle, but happens frequently.
The medical resident on hospital call is
awakened by telephone at 1 am because a
patient on a ward, not his own, has not been
able to fall asleep. Dr. Jones answers the
telephone and the dialogue goes like this:
This is Dr. Jones.
(An open and direct communication.)
Dr. Jones, this is Miss Smith on 2 W—Mrs.
Brown, who learned today of her father’s death,
is unable to fall asleep.
(This message has two levels. Openly, it de-
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scribes a set of circumstances, a woman who is
unable to sleep and who that morning received
word of her father’s death. Less openly, but just
directly, it is a diagnostic and recommenda¬
tion statement; ie, Mrs. Brown is unable to
as
ting his work done. His charts will be organ¬
ized and waiting for him when he arrives,
the ruffled feathers of patients and relatives
will have been smoothed down, his pet rou¬
tines will be happily followed, and he will be
in a thousand and one other ways.
helped
given a sedative. Dr. Jones, accepting the diag¬
The doctor-nurse alliance sheds its light
nostic statement and replying to the recom¬
on the nurse as well. She gains a reputation
mendation statement, answers.)
What sleeping medication has been helpful for being a “damn good nurse.” She is
to Mrs. Brown in the past?
respected by everyone and appropriately en¬
(Dr. Jones, not knowing the patient, is asking joys her position. When physicians discuss
for a recommendation from the nurse, who does the
nursing staff it would not be unusual for
know the patient, about what sleeping medica¬
sleep because of her grief, and she should be
tion should be prescribed. Note, however, his
question does not appear to be asking her for a
recommendation. Miss Smith replies.)
Pentobarbital mg 100 was quite effective
night before last.
(A disguised recommendation statement. Dr.
Jones replies with a note of authority in his
voice.)
Pentobarbital mg 100 before bedtime as need¬
ed for sleep, got it?
(Miss Smith ends the conversation with the
tone of a grateful supplicant.)
Yes I have, and thank you very much doctor.
The above is an example of a successfully
played doctor-nurse game. The nurse made
appropriate recommendations which were
accepted by the physician and were helpful
to the patient. The game was successful be¬
cause the cardinal rule was not violated.
The nurse was able to make her recommen¬
dation without appearing to, and the physi¬
cian was able to ask for recommendations
without conspicuously asking for them.
The Scoring System.—Inherent in any
game are penalties and rewards for the play¬
In game theory, the doctor-nurse game
fits the nonzero sum game model. It is not
ers.
like chess, where the players compete with
each other and whatever one player loses
the other wins. Rather, it is the kind of game
in which the rewards and punishments are
shared by both players. If they play the
game successfully they both win rewards,
and if they are unskilled and the game is
played badly, they both suffer the penalty.
The most obvious reward from the wellplayed game is a doctor-nurse team that
operates efficiently. The physician is able to
utilize the nurse as a valuable consultant,
and the nurse gains self-esteem and pro¬
fessional satisfaction from her job. The
less obvious rewards are no less important.
A successful game creates a doctor-nurse
alliance; through this alliance the physician
gains the respect and admiration of the
nursing service. He can be confident that his
nursing staff will smooth the path for get-
her name to be mentioned with respect and
admiration. Their esteem for a good nurse is
no less than their esteem for a good doctor.
The penalties for a game failure, on the
other hand, can be severe. The physician
who is an unskilled gamesman and fails to
recognize the nurses’ subtle recommenda¬
tion messages is tolerated as a “clod.” If,
however, he interprets these messages as in¬
solence and strongly indicates he does not
wish to tolerate suggestions from nurses, he
creates a rocky path for his travels. The old
truism “If the nurse is your ally you’ve got
it made, and if she has it in for you, be pre¬
pared for misery,” takes on life-sized pro¬
portions. He receives three times as many
phone calls after midnight than his col¬
leagues. Nurses will not accept his telephone
orders because “telephone orders are against
the rules.” Somehow, this rule gets suspend¬
ed for the skilled players. Soon he becomes
like Joe Bfstplk in the “Li’l Abner” comic
strip. No matter where he goes, a black
cloud constantly hovers over his head.
The unskilled gamesman nurse also pays
heavily. The nurse who does not view her
role as that of a consultant, and therefore
does not attempt to communicate recom¬
mendations, is perceived as a dullard and is
mercifully allowed to fade into the wood¬
work.
The nurse who does see herself as a con¬
sultant but refuses to follow the rules of the
game in making her recommendations, has
hell to pay. The outspoken nurse is labeled
a “bitch” by the surgeon. The psychiatrist
describes her as unconsciously suffering
from penis envy and her behavior is the act¬
ing out of her hostility towards men. Loose¬
ly translated, the psychiatrist is saying she
is a bitch. The employment of the unbright
outspoken nurse is soon terminated. The
outspoken bright nurse whose recommenda¬
tions are worthwhile remains employed. She
is, however, constantly reminded in a hun¬
dred ways that she is not loved.
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Genesis of the Game
To understand how the game evolved, we
must comprehend the nature of the doctors’
and nurses’ training which shaped the atti¬
tudes necessary for the game.
Medical Student Training.—The medical
student in his freshman year studies as if
possessed. In the anatomy class he learns
every groove and prominence on the bones of
the skeleton as if life depended on it. As a
matter of fact, he literally believes just that.
He not infrequently says, “I’ve got to learn
it exactly, a life may depend on me knowing
that.” A consequence of this attitude, which
is carefully nurtured throughout medical
school, is the development of a phobia: the
overdetermined fear of making a mistake.
The development of this fear is quite under¬
standable. The burden the physician must
carry is at times almost unbearable. He feels
responsible in a very personal way for the
lives of his patients. When a man dies leav¬
ing young children and a widow, the doctor
carries some of her grief and despair inside
himself; and when a child dies, some of him
dies too. He sees himself as a warrior
against death and disease. When he loses a
battle, through no fault of his own, he nev¬
ertheless feels pangs of guilt, and he relent¬
lessly searches himself to see if there might
have been a way to alter the outcome. For
the physician a mistake leading to a serious
consequence is intolerable, and any mistake
reminds him of his vulnerability. There is
little wonder that he becomes phobic. The
classical way in which phobias are managed
is to avoid the source of the fear. Since it is
impossible to avoid making some mistakes
in an active practice of medicine, a substi¬
tute defensive maneuver is employed. The
physician develops the belief that he is
omnipotent and omniscient, and therefore
incapable of making mistakes. This belief
allows the phobic physician to actively
engage in his practice rather than avoid it.
The fear of committing an error in a critical
field like medicine is unavoidable and ap¬
propriately realistic. The physician, howev¬
er, must learn to live with the fear rather
than handle it defensively through a posture
of omnipotence. This defense markedly in¬
terferes with his interpersonal professional
relationships.
Physicians, of course, deny feelings of
omnipotence. The evidence, however, ren¬
ders their denials to whispers in the wind.
The slightest mistake inflicts a large narcis-
sistic wound. Depending on his underlying
personality structure the physician may ob¬
sess for days about it, quickly rationalize it
away, or deny it. The guilt produced is usu¬
ally exaggerated and the incident is handled
defensively. The ways in which physicians
enhance and support each other’s defenses
when an error is made could be the topic of
another paper. The feelings of omnipotence
become generalized to other areas of his life.
A report of the Federal Aviation Agency
(FAA), as quoted in Time Magazine ( Aug
5,1966), states that in 1964 and 1965 physi¬
cians had a fatal-accident rate four times as
high as the average for all other private pi¬
lots. Major causes of the high death rate
were risk-taking attitudes and judgments.
Almost all of the accidents occurred on
pleasure trips, and were therefore not neces¬
sary risks to get to a patient needing emer¬
gency care. The trouble, suggested an FAA
official, is that too many doctors fly with
“the feeling that they are omnipotent.”
Thus, the extremes to which the physician
may go in preserving his self-concept of om¬
nipotence may threaten his own life. This
overdetermined preservation of omnipotence
is indicative of its brittleness and its under¬
lying foundation of fear of failure.
The physician finds himself trapped in a
paradox. He fervently wants to give his pa¬
tient the best possible medical care, and
being open to the nurses’ recommendations
helps him accomplish this. On the other
hand, accepting advice from nonphysicians
is highly threatening to his omnipotence.
The solution for the paradox is to receive
sub rosa recommendations and make them
appear to be initiated by himself. In short,
he must learn to play the doctor-nurse game.
Some physicians never learn to play the
game. Most learn in their internship, and a
perceptive few learn during their clerkships
in medical school. Medical students fre¬
quently complain that the nursing staff
treats them as if they had just completed a
junior Red Cross first-aid class instead of
two years of intensive medical training. In¬
terviewing nurses in a training hospital
sheds consderable light on this phenome¬
non. In their words they said,
A few students just seem to be with it, they
to understand what you are trying to
tell them, and they are a pleasure to work with;
most, however, pretend to know everything and
refuse to listen to anything we have to say and
I guess we do give them a rough time.
In essence, they are saying that those stu¬
dents who quickly learn the game are reare able
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warded, and those that do not are punished. described that premise as, “He’s God al¬
Most physicians learn to play the game mighty and your job is to wait on him.”
after they have weathered a few experiences
To inculcate subservience and inhibit
like the one described below. On the first deviancy, nursing schools, for the most part,
day of his internship, the physician and are tightly rim, disciplined institutions.
nurse were making rounds. They stopped at
Certainly there is great variation among
the bed of a 52-year-old woman who, after nursing schools, and there is little question
complimenting the young doctor on his ap¬ that the trend is toward giving students more
pearance, complained to him of her problem autonomy. However, in too many schools
with constipation. After several minutes of this trend has not gone far enough, and the
listening to her detailed description of pecul¬ climate remains restrictive. The student’s
iar diets, family home remedies, and special schedule is firmly controlled and there is
exercises that have helped her constipa¬ very little free time. Classroom hours, study
tion in the past, the nurse politely interrupt¬ hours, meal time, and bedtime with lights
ed the patient. She told her the doctor would out are rigidly enforced. In some schools
take care of the problem and that he had to meaningless chores are assigned, such as
move on because there were other patients
cleaning bed springs with cotton applicators.
waiting to see him. The young doctor gave The relationship between student and in¬
the nurse a stern look, turned toward the pa¬ structor continues this military flavor. Often
tient, and kindly told her he would order an their relationship is more like that between
enema for her that very afternoon. As they
recruit and drill sergeant than between stu¬
left the bedside, the nurse told him the pa¬ dent and teacher. Open dialogue is inhibited
tient has had a normal bowel movement ev¬ by attitudes of strict black and white, with
ery day for the past week and that in the 23 few, if any, shades of gray. Straying from
days the patient has been in the hospital she the rigidly outlined path is sure to result in
had never once passed up an opportunity to disciplinary action.
complain of her constipation. She quickly
The inevitable result of these practices is
added that if the doctor wanted to order an
enema, the patient would certainly receive
After hearing this report the intern’s
mouth fell open and the wheels began turn¬
ing in his head. He remembered the nurses
one.
comment to the patient that, “the doctor
had to move on,” and it occurred to him that
perhaps she was really giving him a message.
This experience and a few more like it, and
the young doctor learns to listen for the
subtle recommendations the nurses make.
Nursing Student Training.—Unlike the
medical student, who usually learns to play
the game after he finishes medical school,
the nursing student begins to learn it early
in her training. Throughout her education
she is trained to play the doctor-nurse game.
Student nurses are taught how to relate to
physicians. They are told he has infinitely
more knowledge than they, and thus he
should be shown the utmost respect. In addi¬
tion, it was not many years ago when nurses
were instructed to stand whenever a physi¬
cian entered a room. When he would come
in for a conference the nurse was expected
to offer him her chair, and when both en¬
tered a room the nurse would open the door
for him and allow him to enter first. Al¬
though these practices are no longer rigidly
adhered to, the premise upon which they
were based is still promulgated. One nurse
to instill in the student nurse a fear of inde¬
pendent action. This inhibition of independ¬
ent action is most marked when relating to
physicians. One of the students’ greatest
fears is making a blunder while assisting a
physician and being publicly ridiculed by
him. This is really more a reflection of the
nature of their training than the prevalence
of abusive physicians. The fear of being hu¬
miliated for a blunder while assisting in a
procedure is generalized to the fear of hu¬
miliation for making any independent act
in relating to a physician, especially the act
of making a direct recommendation. Every
nurse interviewed felt that making a sugges¬
tion to a physician was equivalent to insult¬
ing and belittling him. It was tantamount to
questioning his medical knowledge and in¬
sinuating he did not know his business. In
light of her image of the physician as an om¬
niscient and punitive figure, the questioning
of his knowledge would be unthinkable.
The student, however, is also given mes¬
sages quite contrary to the ones described
above. She is continually told that she is an
invaluable aid to the physician in the treat¬
ment of the patient. She is told that she
must help him in every way possible, and
she is imbued with a strong sense of respon¬
sibility for the care of her patient. Thus she,
like the physician, is caught in a paradox.
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The first set of messages implies that the
physician is omniscient and that any recom¬
mendation she might make would be insult¬
ing to him and leave her open to ridicule.
The second set of messages implies that she
is an important asset to him, has much to
contribute, and is duty-bound to make those
contributions. Thus, when her good sense
tells her a recommendation would be helpful
to him she is not allowed to communicate it
directly, nor is she allowed not to communi¬
cate it. The way out of the bind is to use the
doctor-nurse game and communicate the rec¬
ommendation without appearing to do so.
Forces Preserving the Game
Upon observing the indirect interactional
system which is the heart of the doctor-
game, one must ask the question,
“Why does this inefficient mode of commu¬
nurse
nication continue to exist?” The forces miti¬
gating against change are powerful.
Rewards and Punishments.—The doctor-
game has a powerful, innate self-per¬
petuating force—its system of rewards and
punishments. One potent method of shaping
nurse
behavior is to reward one set of behavioral
patterns and to punish patterns which devi¬
ate from it. As described earlier, the rewards
ership commensurately increases. In our
culture human life is near the top of our
hierarchy of values, and organizations which
deal with human lives, such as law and med¬
icine, are very rigidly structured. Certainly
some of this is necessary for the systematic
management of the task. The excessive de¬
gree of rigidity, however, is demanded by its
members for their own psychic comfort rath¬
er than for its utility in efficiently carrying
out its mission. The game lends support to
this thesis. Indirect communication is an in¬
efficient mode of transmitting information.
However, it effectively supports and protects
a rigid organizational structure with the phy¬
sician in clear authority. Maintaining an
omnipotent leader provides the other mem¬
bers with a great sense of security.
Sexual Roles.—Another influence perpet¬
uating the doctor-nurse game is the sexual
identity of the players. Doctors are predomi¬
nately men and nurses are almost exclusive¬
ly women. There are elements of the game
which reinforce the stereotyped roles of
male dominance and female passivity. Some
nursing instructors explicitly tell their stu¬
dents that their femininity is an important
asset to be used when relating to physicians.
given for a well-played game and the pun¬
ishments meted out to unskilled players are
Comment
The doctor and nurse have a shared histo¬
impressive. This system alone would be
sufficient to keep the game flourishing. The ry and thus have been able to work out their
game so that it operates more efficiently
game, however, has additional forces.
The Strength of the Set.—It is well recog¬ than one would expect in an indirect system.
nized that sets are hard to break. A powerful Major difficulty arises, however, when the
attitudinal set is the nurse’s perception that physician works closely with other disci¬
making a suggestion to a physician is equiv¬ plines which are not normally considered
alent to insulting and belittling him. An ex¬ part of the medical sphere. With expanding
ample of where attempts are regularly made medical horizons encompassing cooperation
to break this set is seen on psychiatric treat¬ with sociologists, engineers, anthropologists,
ment wards operating on a therapeutic com¬ computer analysts etc, continued expecta¬
munity model. This model requires open tion of a doctor-nurselike interaction by the
and direct communication between members physician is disastrous. The sociologist, for
of the team. Psychiatrists working in these example, is not willing to play that kind of
settings expend a great deal of energy in game. When his direct communications are
urging for and rewarding openness before rebuffed the relationship breaks down.
direct patterns of communication become
The
disadvantage of a doctorestablished. The rigidity of the resistance to nurselikemajor is its
inhibitory effect on
game
break this set is impressive. If the physician
which
is
stifling and antihimself is a prisoner of the set and therefore open dialogue
The game is basically a transacintellectual.
does not actively try to destroy it, change is
tional neurosis, and both professions would
near impossible.
themselves by taking steps to change
enhance
The Need for Leadership.—Lack of lead¬
the
which breed the game.
attitudes
ership and structure in any organization
Mrs. Gertrude Hermsmeier, RN, Mrs. Joyce Mcproduces anxiety in its members. As the im¬ Collum, RN, Arnold M. Ludwig, MD, and Arnold J.
portance of the organization’s mission in¬ Marx, MD, of Mendota State Hospital, aided in this
creases, the demand by its members for lead- report.
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Fourth Edition
.Perspectives in
Medical
Sociology
Phil Brown
Brown University
GEISEL LIBRARY
UNIVERSITY OF CALIFORNIA, SAN DIEGO
LA JOLLA, CALIFORNlA
Long Grove, Illinois
For information about this book, contact:
Waveland Press, Inc.
4180 IL Route 83, Suite 101
Long Grove, IL 60047-9580
(847) 634-0081
info@waveland.com
www.waveland.com
Copyright © 2008 by Waveland Press, Inc.
10-digit ISBN 1-57766-518-X
13-digit ISBN 978-1-57766-518-2
All rights reserved. No part of this book may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means without permission in writing from the publisher.
Printed in the United States of America
7 6 5 4 3 2 1
20
The Tuskegee Syphilis Experiment
James Jones
In late July of 1972, Jean Heller of the Associated Press broke the
story: for forty years the United States Public Health Service (PHS) had
been conducting a study of the effects of untreated syphilis on black men
in Macon County, Alabama, in and around the county seat of Tuskegee.
The Tuskegee Study, as the experiment had come to be called, involved a
substantial number of men: 399 who had syphilis and an additional 201
who were free of the disease chosen to serve as controls. All of the syphilitic men were in the late stage of the disease when the study began. 1
Under examination by the press the PHS was not able to locate a formal protocol for the experiment. Later it was learned that one never
existed; procedures, it seemed, had simply evolved. A variety of tests and
medical examinations were performed on the men during scores of visits
by PHS physicians over the years, but the basic procedures called for periodic blood testing and routine autopsies to supplement the information
that was obtained through clinical examinations. The fact that only men
who had late, so-called tertiary, syphilis were selected for the study indicated that the investigators were eager to learn more about the serious
complications that result during the final phase of the disease.
The PHS officers were not disappointed. Published reports on the
experiment consistently showed higher rates of mortality and morbidity
among the syphilitics than the controls. In fact, the press reported that as of
1969 at least 28 and perhaps as many as 100 men had died as a direct
result of complications caused by syphilis. Others had developed serious
2
syphilis-related heart conditions that may have contributed to their deaths.
The Tuskegee Study had nothing to do with treatment. No new drugs
were tested; neither was any effort made to establish the efficacy of old
forms of treatment. It was a nontherapeutic experiment, aimed at compiling data on the effects of the spontaneous evolution of syphilis on black
Reprinted with the pennission of The Free Press a division of Simon & Schuster Adult Pub~hing Group, from Bad Blood: The Tuskegee S~hilis Experiment by James H. Jones. Copy·
nght Cl 1981, 1993 by The Free Press. All rights reserved.
310
Jones The Tuskegee Syphilis Experiment
311
males. The magnitude of the risks taken with the lives of the subjects
becomes clearer once a few basic facts about the disease are known.
Syphilis is a highly contagious disease caused by the Treponema pallidum, a delicate organism that is microscopic in size and resembles a corkscrew in shape. The disease may be acquired or congenital. In acquired
syphilis, the spirochete (as the Treponema pallidum is also called) enters
the body through the skin or mucous membrane, usually during sexual
intercourse, though infection may also occur from other forms of bodily
contact such as kissing. Congenital syphilis is transmitted to the fetus in
the infected mother when the spirochete penetrates the placental barrier.
From the onset of infection syphilis is a generalized disease involving
tissues throughout the entire body. Once they wiggle their way through
the skin or mucous membrane, the spirochetes begin to multiply at a
frightening rate. First they enter the lymph capillaries where they are hurried along to the nearest lymph gland. There they multiply and work their
way into the bloodstream. Within days the spirochetes invade every part of
the body.
Three stages mark the development of the disease: primary, secondary,
and tertiary. The primary stage lasts from ten to sixty days starting from the
time of infection. During this “first incubation period,” the primary lesion
of syphilis, the chancre, appears at the point of contact, usually on the genitals. The chancre, typically a slightly elevated, round ulcer, rarely causes
personal discomfort and may be so small as to go unnoticed. If it does not
become secondarily infected, the chancre will heal without treatment
within a month or two, leaving a scar that persists for several months. 3
While the chancre is healing, the second stage begins. Within six
weeks to six months, a rash appears signaling the development of secondary syphilis. The rash may resemble measles, chicken pox, or any number
of skin eruptions, though occasionally it is so mild as to go unnoticed.
Bones and joints often become painful, and circulatory disturbances such
as cardiac palpitations may develop. Fever, indigestion, headaches, or
other nonspecific symptoms may accompany the rash. In some cases skin
lesions develop into moist ulcers teeming with spirochetes, a condition
that is especially severe when the rash appears in the mouth and causes
open sores that are viciously infectious. Scalp hair may drop out in
patches, creating a “moth-eaten” appearance. The greatest proliferation
and most widespread distribution of spirochetes throughout the body
occurs in secondary syphilis. 4
Secondary syphilis gives way in most cases, even without treatment,
to a period of latency that may last from a few weeks to thirty years. As if
by magic, all symptoms of the disease seem to disappear, and the syphilitic
patient does not associate with the disease’s earlier symptoms the occasional skin infections, periodic chest pains, eye disorders, and vague disc~mforts that may follow. But the spirochetes do not vanish once the
disease becomes latent. They bore into the bone marrow, lymph glands,
312
Section 6: Bioethics, Experimentation, and New Technologies
vital organs, and central nervous systems of their victims. In some cases
the disease seems to follow a policy of peaceful coexistence, and its hosts
are able to enjoy full and long lives. Even so, autopsies in such cases often
reveal syphilitic lesions in vital organs as contributing causes of death. For
many syphilitic patients, however, the disease remains latent only two or
three years. Then the delusion of a truce is shattered by the appearance of
signs and symptoms that denote the tertiary stage.
It is during late syphilis, as the tertiary stage is also called, that the disease inflicts the greatest damage. Gummy or rubbery tumors (so-called
gummas), the characteristic lesions of late syphilis, appear, resulting from
the concentration of spirochetes in the body’s tissues with destruction of
vital structures. These tumors often coalesce on the skin forming large
ulcers covered with a crust consisting of several layers of dried exuded
matter. Their assaults on bone structure produce deterioration that resembles osteomyelitis or bone tuberculosis. The small tumors may be
absorbed, leaving slightly scarred depressions, or they may cause wholesale destruction of the bone, such as the horrible mutilation that occurs
when nasal and palate bones are eaten away. The liver may also be
attacked; here the result is scarring and deformity of the organ that
impede circulation from the intestines.
The cardiovascular and central nervous systems are frequent and
often fatal targets of late syphilis. The tumors may attack the walls of the
heart or the blood vessels. When the aorta is involved, the walls become
weakened, scar tissue forms over the lesion, the artery dilates, and the
valves of the heart no longer open and close properly and begin to leak.
The stretching of the vessel walls may produce an aneurysm, a balloonlike
bulge in the aorta. If the bulge bursts, and sooner or later most do, the
result is sudden death.
The results of neurosyphilis are equally devastating. Syphilis is spread
to the brain through the blood vessels, and while the disease can take several forms, the best known is paresis, a general softening of the brain that
produces progressive paralysis and insanity. Tabes dorsalis, another form
of neurosyphilis, produces a stumbling, foot-slapping gait in its victims
due to the destruction of nerve cells in the spinal cord. Syphilis can also
attack the optic nerve, causing blindness, or the eighth cranial nerve,
inflicting deafness. Since nerve cells lack regenerative power, all such
damage is permanent.
The germ that causes syphilis, the stages of the disease’s development,
and the complications that can result from untreated syphilis were all
known to medical science in 1932-the year the Tuskegee Study began.
Since the effects of the disease are so serious, reporters in 1972 wondered why the men agreed to cooperate. The press quickly established that
the subjects were mostly poor and illiterate, and that the PHS had offered
t?em incen~ves to participate. The men received free physical examinattons, free ndes to and from the clinics, hot meals on examination days,
Jones The Tuskegee Syphilis Experiment
313
free treatment for minor ailments, and a guarantee that burial stipends
would be paid to their survivors. Though the latter sum was very modest
(fifty dollars in 1932 with periodic increases to allow for inflation), it represented the only form of burial insurance that many of the men had.
What the health officials had told the men in 1932 was far more difficult to determine. An officer of the venereal disease branch of the Centers
for Disease Control in Atlanta, the agency that was in charge of the Tuskegee Study in 1972, assured reporters that the participants were told what
the disease could do to them, and that they were given the opportunity to
withdraw from the program any time and receive treatment. But a physician with firsthand knowledge of the experiment’s early years directly contradicted this statement. Dr. J. W. Williams, who was serving his internship
at Andrews Hospital at the Tuskegee Institute in 1932 and assisted in the
experiment’s clinical work, stated that neither the interns nor the subjects
knew what the study involved. ”The people who came in were not told
what was being done,” Dr. Williams said. “We told them we wanted to test
them. They were not told, so far as I know, what they were being treated
for or what they were not being treated for.” As far as he could tell, the
subjects “thought they were being treated for rheumatism or bad stomachs.” He did recall administering to the men what he thought were drugs
to combat syphilis, and yet as he thought back on the matter, Dr. Williams
conjectured that “some may have been a placebo.” He was absolutely certain of one point: “We didn’t tell them we were looking for syphilis. I don’t
think they would have known what that was.” 5
A subject in the experiment said much the same thing. Charles Pollard
recalled clearly the day in 1932 when some men came by and told him
that he would receive a free physical examination if he appeared the next
day at a nearby one-room school. “So I went on over and they told me I
had bad blood.” Pollard recalled. ‘~d that’s what they’ve been telling me
ever since. They come around from time to time and check me over and
they say, ‘Charlie, you’ve got bad blood.”‘ 6
An official of the Centers for Disease Control (CDC) stated that he
understood the term “bad blood” was a synonym for syphilis in the black
community. Pollard replied, ”That could be true. But I never heard no such
thing. All I knew was that they just kept saying I had the bad blood-they
never mentioned syphilis to me, not even once.” Moreover, he thought that
he had been receiving treatment for “bad blood” from the first meeting on,
for Pollard added: ”They been doctoring me off and on ever since then,
and they gave me a blood tonic.” 7
The PHS’s version of the Tuskegee Study came under attack from yet
another quarter when Dr. Reginald G. James told his story to reporters.
Between 1939 and 1941 he had been involved with public health work in
Macon County-specifically the diagnosis and treatment of syphilis.
Assigned to work with him was Eunice Rivers, a black nurse employed by
the Public Health Service to keep track of the participants in the Tuskegee
314
Section 6: Bioethics, Experimentation, and New Technologies
Study. “When we found one of the men from the Tuskegee Study,” Dr.
James recalled, “she would say, ‘He’s under study and not to be treated.”‘
These encounters left him, by his own description, “distraught and disturbed,” but whenever he insisted on treating such a patient, the man
never returned. “They were being advised they shouldn’t take treatments
or they would be dropped from the study,” Dr. James stated. The penalty
for being dropped, he explained, was the loss of the benefits that they had
been promised for participating. 8
Once her identity became known, Nurse Rivers excited considerable
interest, but she steadfastly refused to talk with reporters. Details of her
role in the experiment came to light when newsmen discovered an article
about the Tuskegee Study that appeared in Public Health Reports in 1953.
Involved with the study from its beginning, Nurse Rivers served as the liaison between the researchers and the subjects. She lived in Tuskegee and
provided the continuity in personnel that was vital. For while the names
and faces of the “government doctors” changed many times over the years,
Nurse Rivers remained a constant. She served as a facilitator, bridging the
many barriers that stemmed from the educational and cultural gap between
the physicians and the subjects. Most important, the men trusted her. 9
As the years passed the men came to understand that they were members of a social club and burial society called “Miss Rivers’ Lodge.” She
kept track of them and made certain that they showed up to be examined
whenever the “government doctors” came to town. She often called for
them at their homes in a shiny station wagon with the government
emblem on the front door and chauffeured them to and from the place of
examination. According to the Public Health Reports article, these rides
became “a mark of distinction for many of the men who enjoyed waving to
their neighbors as they drove by.” There was nothing to indicate that the
members of “Miss Rivers’ Lodge” knew they were participating in a deadly
serious experiment. 10
Spokesmen for the Public Health Service were quick to point out that
the experiment was never kept secret, as many newspapers had incorrectly
reported when the story first broke. Far from being clandestine, the Tuske·
gee Study had been the subject of numerous reports in medical journals
and had been openly discussed in conferences at professional meetings. An
official told reporters that more than a dozen articles had appeared in
some of the nation’s best medical journals, describing the basic procedures
of the study to a combined readership of well over a hundred thousand
physicians. He denied that the Public Health Service had acted alone in
the experiment, calling it a cooperative project that involved the Alabama
State Department of Health, the Tuskegee Institute, the Tuskegee Medical
Society, and the Macon County Health Department. 11
Apologists for the Tuskegee Study contended that it was at best problematic whether the syphilitic subjects could have been helped by the treat·
ment that was available when the study began. In the early 1930s
Jones
The Tuskegee Syphilis Experiment
315
treatment consisted of mercury and two arsenic compounds called arsphenamine and neoarsphenamine, known also by their generic name, salvarsan. The drugs were highly toxic and often produced serious and
occasionally fatal reactions in patients. The treatment was painful and usually required more than a year to complete. As one CDC officer put it, the
drugs offered “more potential harm for the patient than potential benefit.” 12
PHS officials argued that these facts suggested that the experiment
had not been conceived in a moral vacuum. For if the state of the medical
art in the early 1930s had nothing better than dangerous and less than
totally effective treatment to offer, then it followed that, in the balance, little harm was done by leaving the men untreated. 13
Discrediting the efficacy of mercury and salvarsan helped blunt the
issue of withholding treatment during the early years, but public health
officials had a great deal more difficulty explaining why penicillin was
denied in the 1940s. One PHS spokesman ventured that it probably was
not “a one-man decision” and added philosophically, ”These things seldom
are.” He called the denial of penicillin treatment in the 1940s “the most
critical moral issue about this experiment” and admitted that from the
present perspective “one cannot see any reason that they could not have
been treated at that time.” Another spokesman declared: “I don’t know
why the decision was made in 1946 not to stop the program.” 14
The thrust of these comments was to shift the responsibility for the
Tuskegee Study to the physician who directed the experiment during the
1940s. Without naming anyone, an official told reporters: “Whoever was
director of the VD section at that time, in 1946 or 1947, would be the most
logical candidate if you had to pin it down.” That statement pointed an
accusing finger at Dr. John R. Heller, a retired PHS officer who had served
as the director of the division of venereal disease between 1943 and 1948.
When asked to comment, Dr. Heller declined to accept responsibility for
the study and shocked reporters by declaring: ”There was nothing in the
experiment that was unethical or unscientific.” 15
The current local health officer of Macon County shared this view, telling reporters that he probably would not have given the men penicillin in
the 1940s either. He explained this curious devotion to what nineteenthcentury physicians would have called “therapeutic nihilism” by emphasizing that penicillin was a new and largely untested drug in the 1940s. Thus,
in his opinion, the denial of penicillin was a defensible medical decision. 16
A CDC spokesman said it was ”very dubious” that the participants in
the Tuskegee Study would have benefited from penicillin after 1955. In
fact, treatment might have done more harm than good. The introduction
of vigorous therapy after so many years might lead to allergic drug reactions, he warned. Without debating the ethics of the Tuskegee Study, the
CDC spokesman pointed to a generation gap as a reason to refrain from
criticizing it. “We are trying to apply 1972 medical treatment standards to
those of 1932,” cautioned one official. Another officer reminded the public
316
Section 6: Bioethics, Experimentation, and New Technologies
that the study began when attitudes toward treatment and experimentation were much different. ‘~t this point in time,” the officer stated, “with
our current knowledge of treatment and the disease and the revolutionary
change in approach to human experimentation, I don’t believe the program would be undertaken.” 17
Journalists tended to accept the argument that the denial of penicillin
during the 1940s was the crucial ethical issue. Most did not question the
decision to withhold earlier forms of treatment because they apparently
accepted the judgment that the cure was as bad as the disease. But a few
journalists and editors argued that the Tuskegee Study presented a moral
problem long before the men were denied treatment with penicillin. “To
say, as did an officic:K-of the Centers for Disease Control, that the experiment posed ‘a serious moral problem’ after penicillin became available is
only to address part of the situation,” declared the St. Louis Post-Dispatch.
”The fact is that in an effort to determine from autopsies what effects
syphilis has on the body, the government from the moment the experiment
began withheld the best available treatment for a particularly cruel disease. The immorality of the experiment was inherent in its premise.” 18
Viewed in this light, it was predictable that penicillin would not be
given to the men. Time magazine might decry the failure to administer the
drug as “almost beyond belief or human compassion,” but along with
many other publications it failed to recognize a crucial point. Having made
the decision to withhold treatment at the outset, investigators were not
likely to experience a moral crisis when a new a11.d improved form of treatment was developed. Their failure to administer penicillin resulted from
the initial decision to withhold all treatment. The only valid distinction
that can be made between the two acts is that the denial of penicillin held
more dire consequences for the men in the study. The Chicago Sun Times
placed these separate actions in the proper perspective: “Whoever made
the decision to withhold penicillin compounded the original immorality of
the project.” 19
The human dimension dominated the public discussions of the Tuskegee Study. The scientific merits of the experiment, real or imagined, were
passed over almost without comment. Not being scientists, the journalists,
public officials, and concerned citizens who protested the study did not
really care how long it takes syphilis to kill people or what percentages of
syphilis victims are fortunate enough to live to ripe old age with the dis·
ease. From their perspective the PHS was guilty of playing fast and loose
with the lives of these men to indulge scientific curiosity. 20
Many physicians had a different view. Their letters defending the
study appeared in editorial pages across the country, but their most heated
counterattacks were delivered in professional journals. The most spirited
example was an editorial in the Southern Medical Journal by Dr. R. H.
Kampmeir of Vanderbilt University’s School of Medicine. No admirer of the
press, he blasted reporters for their “complete disregard for their abysmal
Jones The Tuskegee Syphilis Experiment
317
ignorance,” and accused them of banging out “anything on their typewriters which will make headlines.” As one of the few remaining physicians
with experience treating syphilis in the 1930s, Dr. Kampmeir promised to
“put this ‘tempest in a teapot’ into proper historical perspective.” 21
Dr. Kampmeir correctly pointed out that there had been only one
experiment dealing with the effects of untreated syphilis prior to the
Tuskegee Study. A Norwegian investigator had reviewed the medical
records of nearly two thousand untreated syphilitic patients who had been
examined at an Oslo clinic between 1891 and 1910. A follow-up had been
published in 1929, and that was the state of published medical experimentation on the subject before the Tuskegee Study began. Dr. Kampmeir did
not explain why the Oslo Study needed to be repeated.
The Vanderbilt physician repeated the argument that penicillin would
not have benefited the men, but he broke new ground by asserting that the
men themselves were responsible for the illnesses and deaths they sustained from syphilis. The PHS was not to blame, Dr. Kampmeir explained,
because “in our free society, antisyphilis treatment has never been forced.”
He further reported that many of the men in the study had received some
treatment for syphilis down through the years and insisted that others
could have secured treatment had they so desired. He admitted that the
untreated syphilitics suffered a higher mortality rate than the controls,
observing coolly: “This is not surprising. No one has ever implied that
syphilis is a benign infection.” His failure to discuss the social mandate of
physicians to prevent harm and to heal the sick whenever possible seemed
to reduce the Hippocratic oath to a solemn obligation not to deny treatment upon demand. 22
Journalists looked at the Tuskegee Study and reached different conclusions, raising a host of ethical issues. Not since the Nuremberg trials of
Nazi scientists had the American people been confronted with a medical
cause cilebre that captured so many headlines and sparked so much discussion. For many it was a shocking revelation of the potential for scientific
abuse in their own country. “That it has happened in this country in our
time makes the tragedy more poignant,” wrote the editor of the Philadelphia Inquirer. Others thought the experiment totally “un-American” and
agreed with Senator John Sparkman of Alabama, who denounced it as
“absolutely appalling” and “a disgrace to the American concept of justice
and humanity.”
Memories of Nazi Germany haunted some people as the broader
~mplications of the PHS’s role in the experiment became apparent. A man
m Tennessee reminded health officials in Atlanta that ‘~dolf Hitler allowed
similar degradation of human dignity in inhumane medical experiments
on humans living under the Third Reich,” and confessed that he was
“much distressed at the comparison.” A New York editor had difficulty
believing that “such stomach-turning callousness could happen outside the
wretched quackeries spawned by Nazi Germany. “23
318
Section 6: Bioethics, Experimentation, and New Technologies
The specter of Nazi Germany prompted some Americans to equate the
Tuskegee Study with genocide. A civil rights leader in Atlanta, Georgia,
charged that the study amounted to “nothing less than an official, premeditated policy of genocide.” A student at the Tuskegee Institute agreed. To
him, the experiment was “but another act of genocide by whites,” an act
that “again exposed the nature of whitey: a savage barbarian and a devil.”24
Most editors stopped short of calling the Tuskegee Study genocide or
charging that PHS officials were little better than Nazis. But they were certain
that racism played a part in what happened in Alabama. “How condescending and void of credibility are the claims that racial considerations had nothing to do with the fact that 600 [all] of the subjects were black,” declared the
Afro-American of Baltimore, Maryland. That PHS officials had kept straight
faces while denying any racial overtones to the experiment prompted the editors of this influential black paper to charge “that there are still federal officials who feel they can do anything where black people are concemed.” 25
The Los Angeles Times echoed this view. In deftly chosen words, the
editors qualified their accusation that PHS officials had persuaded hundreds of black men to become “human guinea pigs” by adding: “Well, perhaps not quite that [human guinea pigs] because the doctors obviously did
not regard their subjects as completely human.” A Pennsylvania editor
stated that such an experiment “could only happen to blacks.” To support
this view, the New Courier of Pittsburgh implied that American society was
so racist that scientists could abuse blacks with impunity. 26
Other observers thought that social class was the real issue, that poor
people, regardless of their race, were the ones in danger. Somehow people
from the lower class always seemed to supply a disproportionate share of
subjects for scientific research. Their plight, in the words of a North Carolina editor, offered “a reminder that the basic rights of Americans, particularly the poor, the illiterate and the friendless, are still subject to violation
in the name of scientific research.” To a journalist in Colorado, the Tuskegee Study demonstrated that “the Public Health Service sees the poor, the
black, the illiterate and the defenseless in American society as a vast
experimental resource for the government.” And the Washington Post
made much the same point when it observed, ”There is always a lofty goal
in the research work of medicine but too often in the past it has been the
bodies of the poor … on whom the unholy testing is done.” 27
The problems of poor people in the rural South during the Great
Depression troubled the editor of the Los Angeles Times, who charged that
28
the men had been “trapped into the program by poverty and ignorance. ”
Yet poverty alone could not explain why the men would cooperate with a
study that gave them so little in return for the frightening risks to which it
exposed them. A more complete explanation was that the men did not understand what the experiment was about or the dangers to which it exposed
them. Many Americans probably agreed with the Washington Post’s argument
that experiments “on human beings are ethically sound if the guinea pigs are
Jones The Tuskegee Syphilis Experiment
319
fully informed of the facts and danger.” But despite the assurances of PHS
spokesmen that informed consent had been obtained, the Tuskegee Study
precipitated accusations that somehow the men had either been tricked into
cooperating or were incapable of giving informed consent. 29
An Alabama newspaper, the Birmingham News, was not impressed by
the claim that the participants were all volunteers, stating that “the majority of them were no better than semiliterate and probably didn’t know
what was really going on.” The real reason they had been chosen, a Colorado journalist argued, was that they were “poor, illiterate, and completely
at the mercy of the ‘benevolent’ Public Health Service.” And a North Carolina editor denounced “the practice of coercing or tricking human beings
into taking part in such experiments.”30
The ultimate lesson that many Americans saw in the Tuskegee Study
was the need to protect society from scientific pursuits that ignored human
values. The most eloquent expression of this view appeared in the Atlanta
Constitution. “Sometimes, with the best of intentions, scientists and public
officials and others involved in working for the benefit of us all, forget that
people are people,” began the editor. ”They concentrate so totally on plans
and programs, experiments, statistics-on abstractions-that people
become objects, symbols on paper, figures in a mathematical formula, or
impersonal ‘subjects’ in a scientific study.” This was the scientific blindspot
to ethical issues that was responsible for the Tuskegee Study-what the
Constitution called “a moral astigmatism that saw these black sufferers simply as ‘subjects’ in a study, not as human beings.” Scientific investigators
had to learn that “moral judgment should always be a part of any human
endeavor,” including “the dispassionate scientific search for knowledge.”31
Notes
1
2
New York Times, July 26, 1972, pp. 1, 8.
Because of the high rate of geographic mobility among the men, estimates of the mortality
rate were confusing, even in the published articles. PHS spokesmen in 1972 were reluctant to
be pinned down on an exact figure. An excellent example is the interview of Dr. David Sencer
by J. Andrew Liscomb and Bobby Doctor for the U.S. Commission on Civil Rights, Alabama
State Advisory Committee, September 22, 1972, unpublished manuscript, p. 9. For the calculations behind the figures used here, see Atlanta Constitution, September 12, 1972, p. 2A
3
During this primary stage the infected person often remains seronegative: A blood test will
not reveal the disease. But chancres can be differentiated from other ulcers by a dark field
examination, a laboratory test in which a microscope equipped with a special indirect
lighting attachment can view the silvery spirochetes moving against a dark background.
: At the secondary stage a blood test is an effective diagnostic tool.
Dr. Donald W. Prinz quoted in Atlanta Journal, July 27, 1972, p. 2; Birmingham News, July
27, 1972, p. 2.
; New York Times, July 27, 1972, p. 18.
Dr. Ralph Henderson quoted in ibid.; Tuskegee News, July 27, 1972, p. 1.
8
New.
York. Times, July 27, 1972, p. 2.
9
Eunice Rivers, Stanley Schuman, Lloyd Simpson, Sidney Olansky, “Twenty Years of Followup Experience in a Long-Range Medical Study,” Public Health Reports 68 (April 1953):
391-95. (Hereafter Rivers et al.)
320
Section 6: Bioethics, Experimentation, and New Technologies
lO Ibid., p. 393.
Millar quoted in Birmingham News, July 27, 1972, pp. 1, 4; Atlanta Journal,
July 27, 1972, p. 2.
12 Prinz quoted in Atlanta Journal, July 27, 1972, p. 2.
13 Millar quoted in Montgomery Advertiser, July 26, 1972, p. 1.
14 Ibid.; Prinz quoted in Atlanta Journal, July 27, 1972, p. 2.
lS Millar quoted in Montgomery Advertiser, July 26, 1972, p. 1; New York Times, July 28,
1972, p. 29.
16 Dr. Edward Lammons quoted in Tuskegee News, August 3, 1972, p. 1.
17 Prinz quoted in Atlanta Journal, July 27, 1972, p. 2; Millar quoted in Montgomery Adver·
tiser, July 26, 1972, p. 1.
18 St. Louis Dispatch, July 30, 1972, p. 2D.
19 Time, August 7, 1972, p. 54; Chicago Sun Times, July 29, 1972, p. 23.
20 Their reactions can be captured at a glance by citing a few of the legends that introduced
newspaper articles and editorials that appeared on the experiment. The Houston Chronicle
called it “A Violation of Human Dignity” (August 5, 1972, Section I, p. 12); St. Louis Post·
Dispatch, “An Immoral Study” (July 30, 1972, p. 2D); Oregonian, an “Inhuman Experi·
ment” (Portland, Oregon, July 31, 1972, p. 16); Chattanooga Times, a “Blot of Inhumanity”
(July 28, 1972, p. 16); South Bend nibune, a “Cruel Experiment” (July 29, 1972, p. 6);
New Haven Register, ”A Shocking Medical Experiment” (July 29, 1972, p. 14); and Virginia’s
Richmond Times Dispatch thought that “appalling” was the best adjective to describe an
experiment that had used “Humans as Guinea Pigs” (August 6, 1972, p. 6H). To the Los
Angeles Times the study represented “Official Inhumanity” (July 27, 1972, Part II, p. 6); to
the Providence Sunday Journal, a “Horror Story” (July 30, 1972, p. 2G); and to the News
and Observer in Raleigh, North Carolina, a “Nightmare Experiment” (July 28, 1972, p. 4).
The St. Petersburg Times in Florida voiced cynicism, entitling its editorial “Health Service?”
(July 27, 1972, p. 24), while the Milwaukee Journal made its point more directly by intro·
ducing its article with the legend “They Helped Men Die” (July 27, 1972, p. 15).
21
R. H. Kampmeir, “The Tuskegee Study of Untreated Syphilis,” Southern Medical Journal 65
(1972): 1247-51.
22
Ibid., p. 1250.
23
Roderick Clark Posey to Millar, July 27, 1972; Tuskegee Files, Centers for Disease Control.
Atlanta, Georgia. (Hereafter TF-CDC); Daily News, July 27, 1972, p. 63; see also Milwaukee
Journal, July 27, 1972, p. 15; Oregonian, July 31, 1972, p. 16; and Jack Slater, “Con·
demoed to Die for Science,” Ebony 28(November1972), p. 180.
24
Atlanta Journal, July 27, 1972, p. 2; Campw Digest, October 6, 1972, p. 4.
25
Afro-American, August 12, 1972, p. 4. For extended discussions of the race issue, see Slater,
“Condemned to Die,” p. 191, and the three-pan series by Warren Brown in Jet 43, “The
Tuskegee Study,” November 9, 1972, pp. 12-17, November 16, 1972, pp. 20-26, and,
especially, November 23, 1972, pp. 26-31.
26
Los Angeles Times, July 27, 1972, Part II, p. 6; New Courier also stated, “No other minority
group in this country would have been used as ‘Human Guinea Pigs,'” and explained,
“because those who are responsible knew that they could do this to Negroes and nothing
would be done to them if it became known,” August 19, 1972, p. 6.
27
Greensboro Daily News, August 2, 1972, p. 6; Gazette-Telegraph, Colorado Springs, August
3, 1972, P· SA; Washington Post, July 31, 1972, p. 20A. See also Arkansas Gazette, July 29,
1972, p. 4A.
28
Los Angeles Times, July 27, 1972, p. 20A.
: w_ash.ington Post, July 31, 1972, p. 20A.
Brnmngham News, July 28, 1972, p. 12; Gazette-Telegraph August 3 1972, p. BA; Greens·
boro Daily News, August 2 • 1972’ p • 6A.


31
Atlanta Con.nitution, July 27, 1972, p. 4A.
11 DI: John D.
Fourth Edition
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31
The Growth of Medicol Authority
Paul Starr
The rise of the professions was the outcome of a struggle for cultural
authority as well as for social mobility. It needs to be understood not only
in terms of the knowledge and ambitions of the medical profession, but
also in the context of broader changes in culture and society that explain
why Americans became willing to acknowledge and institutionalize their
dependence on the professions. The acceptance of professional authority
was, in a sense, America’s cultural revolution, and like other revolutions, it
threw new groups to power-in this case, power over experience as much
as power over work and institutions.
In a society where an established religion claims to have the final say
on all aspects of human experience, the cultural authority of medicine
clearly will be restricted. But this was no longer the principal barrier to
medicine in the early nineteenth century. Many Americans who already
had a rationalist, activist orientation to disease refused to accept physicians as authoritative. They believed that common sense and native intelligence could deal as effectively with most problems of health and illness.
Moreover, the medical profession itself had little unity and was unable to
assen any collective authority over its own members, who held diverse
and incompatible views.
Authority, as I’ve indicated, involves a surrender of private judgment,
and nineteenth-century Americans were not willing to make that surrender to physicians. Authority signifies the possession of a special status or
claim that compels trust, and medicine lacked that compelling claim in
nineteenth-century America. The esoteric learning, knowledge of Latin,
and high culture and status of traditional English physicians were more
compelling grounds for belief in a hierarchically ordered society than in a
democratic one. The .basis of modem professionalism had to be reconstructed around the claim to technical competence, gained through standardized training and evaluation. But this standardization of the
From The Social Transformation of American Medicine, by Paul Starr, pp. 17-24. Copyright ©
1982 by Paul Starr. Reprinted by pennission of Basic Books, a member of Perseus Books, L.L.C.
475
476
Section 9: Health-Care Providers
profession was blocked by internal as well as external barriers-sectarianism among medical practitioners and a general resistance to privileged
monopolies in the society at large.
The forces that transformed medicine into an authoritative profession
involved both its internal development and broader changes in social and
economic life. Internally, as a result of changes in social structure as well
as scientific advance, the profession gained in cohesiveness toward the
end of the nineteenth century and became more effective in asserting its
claims. With the growth of hospitals and specialization, doctors became
more dependent on one another for referrals and access to facilities. Consequently, they were encouraged to adjust their views to those of their
peers, instead of advertising themselves as members of competing medical
sects. Greater cohesiveness strengthened professional authority. Professional authority also benefited from the development of diagnostic technology, which strengthened the powers of the physician in physical
examination of the patient and reduced reliance on the patient’s report of
symptoms and superficial appearance.
At the same time, there were profound changes in Americans’ way of
life and forms of consciousness that made them more dependent upon
professional authority and more willing to accept it as legitimate. Different
ways of life make different demands upon people and endow them with
different types of competence. In preindustrial America, rural and smalltown communities endowed their members with a wide range of skills and
self-confidence in dealing with their own needs. The division of labor was
not highly developed, and there was a strong orientation toward self-reliance, grounded in religious and political ideals. Under these conditions,
professional authority could make few inroads. Americans were accustomed to dealing with most problems of illness within their own family or
local community, with only occasional intervention by physicians. But
toward the end of the nineteenth century, as their society became more
urban, Americans became more accustomed to relying on the specialized
skills of strangers. Professionals became less expensive to consult as telephones and mechanized transportation reduced the cost of time and
travel. Bolstered by genuine advances in science and technology, the
claims of the professions to competent authority became more plausible,
even when they were not yet objectively true; for science worked even
greater changes on the imagination than it worked on the processes of disease. Technological change was revolutionizing daily life; it seemed
entirely plausible to believe that science would do the same for healing,
and eventually it did. Besides, once people began to regard science as 8
superior and legitimately complex way of explaining and controlling reality, they wanted physicians’ interpretations of experience regardless of
whether the doctors had remedies to offer.
At a time when traditional certainties were breaking down, professional authority offered a means of sorting out different conceptions of
Starr
The Growth of Medical Authority
477
human needs and the nature and meaning of events. In the nineteenth
century, many Americans, epitomized by the Populists, continued to
believe in the adequacy of common sense and to resist the claims of the
professions. On the other hand, there were those, like the Progressives,
who believed that science provided the means of moral as well as political
reform and who saw in the professions a new and more advanced basis of
order. The Progressive view, always stated as a disinterested ideal, nevertheless happily coincided with the ambitions of the emerging professional
class to cure and reform. The cultural triumph of Progressivism, which
proved more lasting than its political victories, was inseparable from the
rise in status and power of professionals in new occupations and organizational hierarchies. Yet this was no simple usurpation; the new authority of
professionals reflected the instability of a new way of life and its challenge
to traditional belief. The less one could believe “one’s own eyes”-and the
new world of science continually prompted that feeling-the more receptive one became to seeing the world through the eyes of those who
claimed specialized, technical knowledge, validated by communities of
their peers. 1
The growth of medical authority also needs to be understood as a
change in institutions. In the nineteenth century, before the profession
consolidated its position, some doctors had great personal authority and
they pronounced on all manner of problems, by no means restricted to
physical illness. Indeed, in the small communities of early American society, where the number of educated men was relatively small, some physicians may have possessed even broader personal authority than do most of
their counterparts today. What I am talking about here, on the other hand,
is authority that inheres in the status of physician because it has been institutionalized in a system of standardized education and licensing. The
establishment of such a system reproduces authority from one generation
to the next, and transmits it from the profession as a whole to all its individual members. Before the profession’s authority was institutionalized in
the late nineteenth and early twentieth centuries, physicians might win
personal authority by dint of their character and intimate knowledge of
their patients. But once it was institutionalized, standardized programs of
education and licensing conferred authority upon all who passed through
them. The recognition of authority in a given doctor by laymen and col!eagues became relatively unambiguous. Authority no longer depended on
~ndividual character and lay attitudes; instead, it was increasingly built
into the structure of institutions.
“Built-in” dependence on professional authority increased with such
developments as the rise of hospitals. I do not mean only the development
of mental hospitals and procedures for involuntary commitment, though
the asylum is obviously an important and radical form of institutionalized
medical authority. Even the voluntary shift of seriously ill patients from
their homes to general hospitals increases the dependent condition of the
478
Section 9: Health-Care Providers
sick. At home, patients may quite easily choose to ignore the doctor’s
instructions, and many do; this is much more difficult in a hospital. For the
seriously ill, clinical personnel subordinate to the doctor have, in effect,
replaced the family as the physician’s vicarious agent. They not only
administer treatment in the doctor’s absence, but also maintain surveillance, keep records, and reinforce the message that the doctor’s instructions must be followed.
Other institutional changes have also made people dependent on medical authority regardless of whether they are receptive or hostile to doctors. As the various certifying and gatekeeping functions of doctors have
grown, so has the dependence of people seeking benefits that require certification. Laws prohibiting laymen from obtaining certain classes of drugs
without a doctor’s prescription increase dependence on physicians. “The
more strategic the accessories controlled by the profession,” Eliot Freidson
writes, “the stronger the sanctions supporting its authority. “2 In the twentieth century, health insurance has become an important mechanism for
ensuring dependence on the profession. When insurance payments are
made only for treatment given by physicians, the beneficiaries become
dependent on doctors for reimbursable services. A doctor’s authorization
for drugs and prosthetics has become necessary for a host of insurance and
tax benefits. In all these ways, professional authority has become institutionally routine, and compliance has ceased to be a matter of voluntary
choice. What people think about doctors’ judgments is still important, but
it is much less important than it used to be.
In their combined effect, the mechanisms of legitimation (standardized education and licensing) and the mechanisms of dependency (hospitalization, gatekeeping, insurance) have given a definite structure to the
relations of doctors and patients that transcends personalities and attitudes. This social structure is based, not purely on shared expectations
about the roles of physicians and the sick, but on the institutionalized
arrangements that often impose severe costs on people who wish to
behave in some other way.*
* Role expectations are the bean of what was once the most influential schema in the sociol·
ogy of medicine-that of Talcott Parsons. According to Parsons, the social structUre of medi·
cal practice can be defined by the shared expectations about the “sick role” and the role of
the doctor. On the one hand, the sick are exempt from normal obligations; they are not held
responsible for their illness; they must try to get well; and they must seek competent help. On
the other, the physician is expected to be “universalistic,” “functionally specific,” “affectively
neutral,” and “collectfvity·oriented.” These complementary normative rules have a functional
relation to the therapeutic process and the larger society. 3
,
While useful as a point of departure for understanding doctor-patient relations, Parsons
model is open to severe objections as a model of medical practice. It fails to convey ~
ambivalence of doctor-patient relationships and the contradictory expectations with wh1Ch
each party must contend.” It also accepts the ideological claims of the profession-for exam·
pie, to be altruistic (“collectivity·oriented”)-and ignores evidence of contrary rules of behlV·
ior, such as tadt agreements to ignore colleagues’ mistakes. 5 Parsons’ approach concentntet
almost entirely upon the system of norms in purely voluntary doctor-patient relations. That
Starr
The Growth of Medical Authority
479
The institutional reinforcement of professional authority also regulates the relations of physicians to each other. The doctor whose personal
authority in the nineteenth century rested on his imposing character and
relations with patients was in a fundamentally different situation from the
doctor in the twentieth century whose authority depends on holding the
necessary credentials and institutional affiliations. While laymen have
become more dependent on professionals, professionals have become
more dependent on each other. Both changes have contributed to the collective power of the profession and helped physicians to convert their clinical authority into social and economic privilege.
From Authority to Economic Power
The conversion of authority into high income, autonomy, and other
rewards of privilege required the medical profession to gain control over
both the market for its services and the various organizational hierarchies
that govern medical practice, financing, and policy. The achievement of
economic power involved more than the creation of a monopoly in medical practice through the exclusion of alternative practitioners and limits on
the supply of physicians. It entailed shaping the structure of hospitals,
insurance, and other private institutions that impinge on medical practice
and defining the limits and proper forms of public health activities and
other public investment in health care. In the last half century, these organizational and political arrangements have become more important as
bases of e.conomic power than the monopolization of medical practice.
The emergence of a market for medical services was originally inseparable from the emergence of professional authority. In the isolated communities of early American society, the sick were usually cared for as part of
the obligations of kinship and mutual assistance. But as larger towns and
cities grew, treatment increasingly shifted from the family and lay community to paid practitioners, druggists, hospitals, and other commercial and
professional sources selling their services competitively on the market. Of
course, the family continues even today to play an important role in health
care, but its role has become distinctly secondary. The transition from the
household to the market as the dominant institution in the care of the
sick-that is, the conversion of health care into a commodity-has been
one of the underlying movements in the transformation of medicine. It has
simultaneously involved increased specialization of labor, greater emotional distance between the sick and those responsible for their care, and a
such relations are not wholly voluntary, both because of dependency conditions and the historical process that lies behind the professional dominance, is a point Parsons simply overlooks. The distribution of power, control of markets, and so on do not enter significantly into
his analysis. Parsons also neglects other relations imponant to medical practice, such as those
among doctors and between doctors and organizations. The more imponant these collegial
and bureaucratic reladons become, the less useful Parsons’ approach appears.
480
Section 9: Health-Care Providers
shift from women to men as the dominant figures in the management of
health and illness.
What sort of commodity is medical care? Do doctors sell goods (such
as drugs), advice, time, or availability? These questions had to be worked
out as the market took form. To gain the trust that the practice of medicine
requires, physicians had to assure the public of the reliability of their
“product.” A standardized product, as Magali Sarfatti Larson points out
about the professions, requires a standardized producer. 6 Standardization
of training and licensing became the means for realizing both the search
for authority and control of the market.
Through most of the nineteenth century, the market in medical care
continued to be competitive. Entry into practice was relatively easy for
untrained practitioners as well as for medical school graduates; as a result,
competition was intense and the economic position of physicians was
often insecure. Toward the end of the century, although licensing laws
began to restrict entry, many doctors felt increasingly threatened by the
expansion of free dispensaries, company medical plans, and various other
bureaucratically organized alternatives to independent solo practice. In
the physicians’ view, the competitive market represented a threat not only
to their incomes, but also to their status and autonomy because it drew no
sharp boundary between the educated and uneducated, blurred the lines
between commerce and professionalism, and threatened to tum them into
mere employees.
The contradiction between professionalism and the rule of the market
is long-standing and unavoidable. Medicine and other professions have
historically distinguished themselves from business and trade by claiming
to be above the market and pure commercialism. In justifying the public’s
trust, professionals have set higher standards of conduct for themselves
than the minimal rules governing the marketplace and maintained that
they can be judged under those standards only by each other, not by laymen. The ideal of the market presumes the “sovereignty” of consumer
choices; the ideal of a profession calls for the sovereignty of its members’
independent, authoritative judgment. A professional who yields too much
to the demands of clients violates an essential article of the professional
code: Quacks, as Everett Hughes once defined them, are practitioners who
continue to please their customers but not their colleagues. This shift from
clients to colleagues in the orientation of work, which professionalism
demands, represents a clear departure from the normal rule of the market.
When fully competitive, markets do not obey the organized judgment
of any group of sellers. A market is a system of exchange in which goods
and services are bought and sold at going prices. In the ideal case cherished by economists, each buyer and seller acts independently of every
other, so that prices are set impersonally by levels of supply an~ d~~an~
There are no relations of dependency in the ideal market: Any md1Vld~
buyer is supposed to have a free choice of sellers, any seller a free choice
Starr The Growth of Medical Authority
481
of buyers, and no group of buyers or sellers is supposed to be able to force
acceptance of its terms. Nor are there supposed to be any relations of
authority in the market, except those necessary to provide rules of
exchange and the enforcement of contracts. Whereas the household and
the state both allocate resources according to decisions made by governing
authorities, the distinctive feature of a market is the absence of any such
authoritative direction. The absence of power is, paradoxically, the basis of
order in a competitive market. Collectively, sellers might wish to keep the
prices of commodities higher than their marginal cost, but so long as they
act individually, they are driven to bring them down into equilibrium to
secure as large as possible a share of the market for themselves.
This is not a prospect that sellers usually enjoy and, whenever the
means are available, it is one they quickly subvert. Power abhors competition about as intensely as nature abhors a vacuum. Professional organization is one form that resistance to the market may take. Similarly,
concentrations of ownership and labor unions are other bases of market
power. These cases are parallel. Just as property, manual labor, and professional competence are all means of generating income and other rewards,
so they can be used by a monopolistic firm, a strong guild or union, or a
powerful, licensed profession to establish market power. This was what the
medical profession set about accomplishing at the end of the nineteenth
century when corporations were forming trusts and workers were attempting to organize unions-each attempting, with varying success, to control
market forces rather than be controlled by them.
Doctors’ increasing authority had the twin effects of stimulating and
restricting the market. On the one hand, their growing cultural authority
helped draw the care of the sick out of the family and lay community into
the sphere of professional service. On the other, it also brought political
support for the imposition of limits, like restrictive licensing laws, on the
uncontrolled supply of medical services. By augmenting demand and controlling supply, greater professional authority helped physicians secure
higher returns for their work.
The market power of the profession originated only in part from the
state’s protection. It also arose from the increasing dependence of patients
on physicians. In the ideal market no buyer depends upon any seller, but
patients are often dependent on their personal physicians, and they have
become more so as the disparity in knowledge between them has grown.
The sick cannot easily disengage themselves from relations with their doctors, nor even know when it is in their interests to do so. Consequently,
once they have begun treatment, they cannot exercise that unfettered
choice of sellers which characterizes free markets.
. One reason that the profession could develop market power of this
kind was that it sold its services primarily to individual patients rather
than organizations. Such organizations, had they been more numerous,
could have exercised greater discrimination in evaluating clinical perfor-
482
Section 9: Health-Care Providers
mance and might have lobbied against cartel restrictions of the physician
supply. The medical profession, of course, insisted that salaried arrangements violated the integrity of the private doctor-patient relationship, and
in the early decades of the twentieth century, doctors were able to use
their growing market power to escape the threat of bureaucratic control
and to preserve their own autonomy.
Notes
1
For an excellent account of the struggle for authority and its relation to changing social
organization, see Thomas L. Haskell, The Emergence of Professional Social Science (Urbana:
University of lllinois Press, 1977).
2
Eliot Freidson, Professional Dominance: The Social Structure of Medical Care (New York:
Atherton, 1970), 117.
3
For Parsons’s classic statement, see The Social System (Glencoe, IL: Free Press, 1951),
Chap. 10.
4
See Robert K. Merton and Elinor Barber, “Sociological Ambivalence,” in Sociological Theory, Values and Sociocultural Change, ed. Edward A. Tiryakian (New York: Free Press,
1963), 91-120.
5
See Freidson, Profession of Medicine, esp. Chap. 7.
6
Magali Sarfatti Larson, The Rise of Professionalism (Berkeley: University of California Press,
1977), 14.
Social Science & Medicine 160 (2016) 94e101
Contents lists available at ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
Review article
Detached concern?: Emotional socialization in twenty-first century
medical education
Kelly Underman*, Laura E. Hirshfield
Department of Medical Education, University of Illinois at Chicago, 808 S. Wood St., Chicago, IL 60612, USA
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 14 January 2016
Received in revised form
13 May 2016
Accepted 16 May 2016
Available online 17 May 2016
Early works in medical sociology have been pivotal in the development of scholarly knowledge about
emotions, emotional socialization, and empathy within medical training, medical education, and medical
contexts. Yet despite major shifts in both medical education and in medicine writ-large, medical sociologists’ focus on emotions has largely disappeared. In this paper, we argue that due to recent radical
transformations in the medical arena, emotional socialization within medical education should be of
renewed interest for sociologists. Developments in medical education such as increased diversity among
enrollees, the rise of patient health movements, and curricular transformation have made this context a
particularly interesting case for sociologists working on a variety of questions related to structural,
organizational, and cultural change. We offer three areas of debate within studies in medical education
that sociologists may be interested in studying: 1) gendered and racialized differences in the performance of clinical skills related to emotion, 2) differences in self-reported empathy among subspecialties,
and 3) loss of empathy during the third year or clinical year of medical school.
© 2016 Elsevier Ltd. All rights reserved.
Keywords:
Medical education
Emotion
Emotional socialization
Professional socialization
Biomedicine
1. Introduction
Early works in medical sociology have been pivotal in the
development of scholarly knowledge about emotions, emotional
socialization, and empathy within medical training, medical education, and medical contexts. Indeed, influential works on these
topics, such as Becker et al. (1961), Fox (1988), and Smith and
Kleinman (1989), have been cited 2287, 637, 382 times respectively. Yet despite major shifts in both medical education and in
medicine writ-large, medical sociologists’ focus on emotions has
largely disappeared. Sociologists’ role in medical education, once
considered both valuable and central, has declined in the past thirty
to forty years (Badgley and Bloom, 1973; Hafferty and Castellani,
2011). This is of key importance because scholarship and interest
about empathy, emotional socialization, and professionalization
more broadly within the field of medical education has increased
exponentially over the past few decades (Pedersen, 2009). At the
same time, research on emotion and affect has been of renewed
interest in sociology (Turner and Stets, 2005; Clough and Halley,
2007).
* Corresponding author.
E-mail address: Kunder2@uic.edu (K. Underman).
http://dx.doi.org/10.1016/j.socscimed.2016.05.027
0277-9536/© 2016 Elsevier Ltd. All rights reserved.
In this paper, we argue that due to recent radical transformations in the medical arena, emotional socialization within
medical education should be of renewed interest for sociologists.
Developments in medical education such as increased diversity
among enrollees, the rise of patient health movements, and
curricular transformation have made this context a particularly
interesting case for sociologists working on a variety of questions
related to structural, organizational, and cultural change. To
demonstrate our claim, we begin by reviewing past sociological
contributions to understandings of emotional socialization within
medical education. Next, we describe some of the key shifts in
medical education and larger medical contexts, followed by a discussion of how these changes specifically affect emotions and
emotional socialization in both medicine and medical training.
Finally, we offer three areas of debate within studies of medical
education that sociologists may be interested in studying, and we
situate these debates within micro-, meso-, and macro-levels of
sociological analysis.
1.1. Classics in the sociology of medical professionalization
Within medical sociology, a key focus for many early scholars
was on professional socialization of trainees into the medical field.
Boys in White (Becker et al., 1961) is considered particularly
K. Underman, L.E. Hirshfield / Social Science & Medicine 160 (2016) 94e101
foundational among these studies of the sociology of medical education. This well-cited, in-depth, ethnographic study followed
medical students as they collectively made meaning of their medical school experiences and learned to “play their role” as doctors.
Many of the experiences Becker and his colleagues describe relate
to emotional socialization. For example, in Becker’s study, medical
students learned to contain their anxiety about patient contact not
to reassure patients but in order to impress their supervisors. They
also learned to adopt cynical and depersonalizing attitudes toward
patients, such as deriding patients who don’t present any clinical
findings with their complaints as “crocks.”
Also in this line of research on the adoption of attitudes in
medical school, Renee Fox’s path-breaking work on medical education described the process as training for uncertainty (1957) and
detached concern (1988). Training for uncertainty involved grappling with the limitations of medical knowledge while detached
concern was the “counterattitudes of detachment and concern to
attain the balance between objectivity and empathy expected of
mature physicians in the various kinds of professional situations
they encounter” (1988: 56). While training for uncertainty focused
mainly on the management of medical students’ own emotions,
detached concern involved management of both patients’ and
medical professionals’ emotions. Specifically, detached concern was
the balance between distancing themselves from the emotionladen experiences they faced as medical students and professionals and maintaining appropriate amounts of concern for
patients. Fox argued that it is through encounters with the autopsy
that medical students learned to develop detached concern in order
to manage the emotionally-charged situation of handling and
cutting open a dead body, and thus to develop their self-identity as
physicians. Such aspects like the nakedness of the dead body and
waiting for a cadaver to arrive (and thus for a person to die)
heightened the emotional response of students to autopsy. The
sterility of the room and covering the face and genitals promoted
detachment, as did adopting a “scientific orientation” or a focus on
the pathology and anatomy of the autopsy. Students also learned to
curtail or manage their discussion of emotions about the autopsy:
“Students share the unspoken conviction that ‘admitting you had
qualms about the autopsy’ or that ‘it made you feel queasy’ is not in
keeping with standards of professional objectivity” (Fox, 1988: 67).
Notably, while Fox raised the concept of the “new” medical student
of the 1970s, who maintains objectivity in dealing with patients
with “regret” (Fox, 1988: 100), she did not focus much on which
aspects of medical training led to such development. Nevertheless,
Fox’s mention of this “new” medical student foreshadowed a
number of changes to medical school culture and medical student
demographics that occurred during the 1980s and 1990s, which we
discuss below. In his work on psychiatrists, Donald Light (1980)
builds on Fox’s concept of training for uncertainty and describes
the emotional components of the development of their professional selves.
While Becker’s and Fox’s work did not focus solely on emotional
socialization, further studies have made them an explicit topic of
interest. Frederic Hafferty (1988, 1991) built upon Fox’s work in
considering how experiences with corpses shape students’ emotions during medical training. Indeed, according to Hafferty, the
anatomy lab was an important arena in which medical students
learned the “feeling rules” of medical culture. Medical students
learned to detach their fear, anxiety, and disgust from their judgments about patient care because that was what was expected of a
physician. Hafferty (1988) used narrative analysis of “cadaver
stories” to understand the values and norms about emotions that
medical students learned. Hafferty demonstrated how cultural
objects such as jokes and “urban legends” about medical students
who are pranked by their fellows with cadavers stolen from the
95
cadaver lab served to reinforce the implicit lesson that in the face of
death and dead bodies, medical students must remain
unemotional.
Allen Smith and Kleinman (1989) likewise used ethnography/
participant observation to study medical students’ encounters with
cadavers, but also with living patients. They connected how medical students learn to experience and express emotion with the
power of the profession of medicine: “Because we associate authority in this society with an unemotional persona, affective
neutrality reinforces professionals’ power and keeps clients from
challenging them” (1989: 56). Despite this, students learned early
on in their training that they cannot and should not talk about their
emotions, especially not to faculty. Smith and Kleinman (1989)
outlined several strategies that medical students learned to use to
manage their emotions about bodily contact. These included the
use of clinical language and reducing the body to anatomical points
of contact to transform the context, while taking pride in their
training as professionals to reduce stigma. Students also made jokes
or blamed the patient to reduce their anxiety. This kind of
emotional socialization led to dehumanizing and objectifying
patients.
The overarching findings of these studies is that it is through
pivotal moments in medical training, such as encounters with
living patients and with cadavers, and through the mundane
everyday experiences of clinical work that medical students are
emotionally socialized into the profession of medicine. A key part of
this process is how medical students learn to adopt the emotional
dispositions valued in the clinical medicine. This was variously
described as training for detached concern (Fox, 1988) or as
becoming affectively neutral (Smith and Kleinman, 1989); scholars
since have discussed this process in terms of learning how to not
feel, as if emotion is being socialized out of the medical student
(Underman, 2015). These findings influenced how the profession of
medicine is understood; the culture of medicine is now believed to
strive for objectivity and emotionally-neutrality (Good and Good,
1989). As Mary-Jo DelVecchio Good (1995) has argued, the pursuit of competence in medical training is often at odds with the
push to develop caring and compassion. Yet this model of socialization is based on processes, demographics, and structural arrangements that are no longer commonplace in medical schools
today. We turn toward a consideration of these changes in the next
section.
2. Transformations in medical education
The studies we have described were all written prior to the mid1990s, yet medical education has since undergone massive transformation, echoing the broader shift in medicine from medicalization to biomedicalization (Clarke et al., 2003). Indeed, medicine
since the 1980s has been reorganized from within and without by
transformations in science and technology (hence the bio in biomedicalization) (ibid). The increasingly rapid uptake of new technologies and the proliferation of scientific techniques and ways of
knowing, coupled with the pressures of patient health movements
and managed care, means that almost all aspects of daily life and
even health itself become the patients’ constant focus and responsibility to manage through engagement with medical advances (ibid).
As a result, the medical profession is no longer the autonomous,
self-regulating world that Becker et al. (1961) studied. In their
recent review of the literature on the medical profession,
Timmermans and Oh (2010) identify three crucial changes to the
profession. First, patient consumerism has accelerated since the
1980s alongside declining trust in physicians. Patients increasingly
manage their own care through choice of physician and adherence
96
K. Underman, L.E. Hirshfield / Social Science & Medicine 160 (2016) 94e101
or refusal of treatments. Additionally, patients now gather their
own information about health and illness via patient groups, the
Internet, and complementary and alternative medicine. Second, the
rise of evidence-based medicine in the mid-1990s has reorganized
physicians’ relationship to knowledge and their practices in the
clinic. Evidence-based medicine has standardized clinical decisionmaking and reduced the degree to which individual physicians rely
on their own expertise. Third, the pharmaceutical industry and
direct-to-consumer marketing has shaped the medical profession’s
power in such a way that physicians and the pharmaceutical industry are now interdependent.
As a result of these transformations, the profession that medical
students are being prepared to enter has greatly changed. Physicians have different kinds of interactions with patients, as they
must manage trust, authority, and patient experiences in new ways
(Mechanic, 2008; Timmermans and Oh, 2010). Likewise, clinical
decision-making is different; the rise of evidence-based medicine
centralizes and disciplines physicians’ work (Timmermans and
Angell, 2001; Timmermans and Kolker, 2004). In addition, now
patients are to be collaborated with, not ordered to follow the
doctor’s orders, through shared decision-making (Charles et al.,
1999; Shay and Lafata, 2015). Finally, the professional autonomy
of physicians looks much different, with many scholars decrying
the death of the profession due to the countervailing powers of
insurance and pharmaceutical companies (Hadley and Mitchell,
2002). A physician can no longer expect that his (and we do use a
male pronoun deliberately) expertise alone dictates patient care.
Furthermore, there have been significant changes in the dem…
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