FUCKING MY LIFE TO SAVE YOURS
A mixed method documentary research on medical interns
28 June 2018
Words: 20873
Master Thesis
Supervisor: dr. J.C. (Joke) Hermes Second reader: drs. M.C.C.J. (Maarten) Reesink Master Television and Cross-Media Culture: Professional track
University of Amsterdam
Fucking my life to save yours
Abstract
Although the stressful conditions of studying medicine are widely acknowledged in scholarly literature, the state of affairs during the traineeships of Dutch medicine students remains unknown to the public. The students repeatedly attempt to advocate internship allowance and raise awareness, but the debate consistently lacked support from both the general public as well as politics. Therefore, the aim of this explorative study is to understand the situation and develop a documentary plan about this particular group of students. The central question of the thesis is: What elements should a
documentary about the exploitation of interns in the medical profession contain? In order to answer this question, a mixed method research design combines a literature review of the portrayal of the medical profession and a discourse analysis of eight interviews with the students. The results of the discourse analysis show an unexpected small amount of internal contradiction within the interviews and indicate one single encompassing story: the hospital as a total institution in a neoliberal age. In addition, two Dutch television series (The Co-Assistant and The Real Co-Assistant) about medical interns are compared to the literature review and interview analysis in order to see whether the same trends, stereotypes, and dominant frame of reference recur. To conclude, a start for a documentary film plan was formulated.
KEYWORDS: medicine students, medical profession, discourse analysis, total institution, hierarchy, inmate world, neoliberal, hospital, exploitation, institutional framework
Abstract………3 Chapter 1. Introduction………..6 Chapter 2. Methodology………..9 2.1 Research design 9 2.2 Units of analysis 9 2.2.1 Qualitative interviews 9
2.2.2 Comparing a reality and a drama series to how eight medical students
represent life as a medical intern 10
2.3 Procedures of data collection 11
2.3.1 Qualitative interviews 11
2.3.2 Comparing a reality and a drama series to how eight medical students 11 represent life as a medical intern
2.4 Data analysis 12
2.4.1 Discourse analysis 12
2.4.2 Comparing a reality and a drama series to how eight medical students
represent life as a medical intern 19
Chapter 3. Portrayal of the medical profession in the media: a literature review…………...20
3.1 Television doctors in fiction 20
3.1.1 The ideal doctor 3.1.2 The doctor with flaws
3.1.3 The morally ambiguous doctor
3.2 Non-fiction television doctors 24
3.3 The evolution of television doctors and the risk society 24
3.4 Conclusion 26
Chapter 4. Interview analysis………27
4.1 Conceptualization of the total institution 27
4.2 Repertoires 28
4.2.1 Hierarchy 28
4.2.2 The inmate world 31
4.2.3 Appreciation 37
4.2.4 Passion 40
Chapter 5. Comparing a reality and a drama series to how eight medical students represent life as a medical intern………..43
5.1 Storylines and character depiction of the two series 43
5.1.1 De Co-Assistent (The Co-Assistant) 43
5.1.2 De Echte Coassistent (The Real Co-Assistant) 45
5.2. Conclusion 46
Chapter 6. Conclusion………48
6.1 A start for a documentary film plan 51
6.2 Discussion 53
Media 54
Bibliography 55
Appendix 1 58
“Fucking my life to save yours.” I was introduced to this quote about two years ago, during a
conversation with a friend who studied medicine. It kept crossing my mind ever since. At the time, he attended one of the obligatory internships and told me about his experiences. First, I will briefly explain the study program of medical school in the Netherlands. After graduating the theoretical bachelor, the students’ academic program (master) continues with a period of practice: the internships. This period usually lasts three years and allows the students to become acquainted with a broad range of specializations and practice medicine under supervision. Most important, they experience what it is like to be a doctor. Although I was familiar with how medicine is taught, I felt alienated from my own conceptions and images of medicine students when hearing the stories of the trainee in question: an average working week of 50 hours, night- and weekend shifts, lack of internship allowance, and most surprisingly, the prevailing hierarchy in the hospital and the way in which some students were treated. These notions appear to resemble a form of exploitation that has been identified in other sectors, for instance the fashion industry (Arvidsson, Malossi, and Naro 295; Smestad). In fact, my friend’s story clearly referenced characteristics of being overworked and underpaid (Arvidsson, Malossi, and Naro 302). Furthermore, medical student distress due to excessively workload and pressure to perform is widely acknowledged in scholarly literature (Dyrbye et al.; Dyrbye and Shanafelt; Dyrbye, Thomas, and Shanafelt). It left me questioning, how could this apparently similar state of affairs be unexposed?
Thereafter, I got involved in the subject. I spoke to several trainees and noticed campaigns in which the students argued for internship allowance. In particular 27 October 2016, medicine students collectively demonstrated against this matter (Eggink and van Gassel; de Haan;
“Geneeskundestudenten willen geld voor co-schappen”; “Onmisbare co-assistenten voeren actie voor een vergoeding”). Moreover, to create a more awareness for the demonstration on the 27th of October, a social-media campaign “Dit Doet de Co” (“This is what a medical intern does”) was launched. On platforms including Snapchat and Instagram, students showed what the internships involve and what interns exactly do on a daily base in order to advocate student allowance. Lastly, with regard to the campaign, the activists invited the Minister of Education at the time, Jet Bussemakers, to accompany an intern during the day and become acquainted with the situation. Despite all efforts, the debate lacked support and the political response remained unchanged. The state argued that payment is an arrangement between employer and the trainee, and refused to interfere (de Haan). Indeed, until now, the state of affairs remained unchanged. What exactly is this state of affairs and how to get it more public attention?
The answer to that question was given by Inez de Beaufort, a professor in Health Care Ethics at the Erasmus Medical Centre of Erasmus University Rotterdam. I attended her lecture “The story of morality” last September during the Dag van het Scenario (Day of the Scenario), at the Dutch Film festival in Utrecht. Being an ethicist and a film fanatic, de Beaufort compared ethicists to
screenwriters in her inspiring lecture. In her optic, “a story is the vehicle for a message”. Abstract issues can be concretized through images that address the viewers emotions. “An abstract theory does
not involve feelings. Narratives appeal to your ability to understand someone.” (de Beaufort “Het verhaal van de moraal”). Indeed, narratives have proven to be capable of involving the audience and establishing public debates. Amongst the many examples dr. de Beaufort provided, is one of my favourite films Still Alice. Still Alice is drama movie about a young linguistic professor who is diagnosed with familial Alzheimer. The film drew attention to the politics of Alzheimer and initiated an ethical debate about euthanasia (Kontos; Mills). Although comparing a Hollywood movie to what might be a Dutch documentary on interns seems preposterous, the approach is similar; by putting ethical issues up for question through a story, this dream documentary’s goal is to let the viewer reconsider the interns’ situation. This way, I aim to draw attention to the state of affairs by pulling people to the story, rather than pushing abstract information. “To make people think. That is what you [the screenwriter] and I [the ethicist] have in common (…) Never underestimate the power of a good story.” (de Beaufort “Het verhaal van de moraal”). I truly believe a powerful story requires an accurate representation of reality. In this fashion, the ‘shockingly accurate’ portrayal of dementia in Still Alice is attributed to thorough research into Alzheimer disease (Seymour). Both cast and crew were
partnered to members of the Alzheimer’s Association in order to represent real-life experiences in the movie (Mohney). In view of the desire to portray the medical interns accurately, the analysis of this thesis is twofold.
Medicine students claim that people generally do not know what a medical intern is and contributes in health-care. In addition, graduate student- and activist Christiaan Ponsen states in an interview with a local broadcaster: “the era in which we were going to earn tons is over.” (AT5). Whereas the students tried to display their work as an intern through the “Dit Doet de Co” campaign, the accuracy of society’s image of the medical professions is questionable. To understand how this image is constructed, and because this project interferes in a tradition of representing the medical profession, a literature review seeks to both display and discuss the evolution of television doctors. How come the depiction of the ideal doctor disappeared from the screen and is replaced by
ambiguous, sometimes villainous characters? Secondly as a filmmaker, eight Dutch interns are interviewed about their experiences. By deconstructing their discourse, I aim to understand the trainees’ reality. Does the dissatisfaction rely solely on the lack of internship allowance? Especially Ervin Goffman’s notion of the total institution, which conceptualizes closed social systems
(“Characteristics of Total Institutions” 313), has been useful for exploring the linguistic tools the students employ to give meaning to being an intern. Thereafter, the representation of interns in two Dutch series are compared to how the eight medical students represent life as a medical intern.
This thesis is the result of my passion for the subject and fascination with documentaries in general. It allows me to combine a set of research-skills to a filmmaker’s perspective. Altogether, the three pillars support the construction of a powerful documentary and provide an answer to the central
The methods used to acquire the results of this thesis will be discussed in the following chapter. This study combines a literature review and discourse analysis in order to construct an idea of which elements a documentary about medical interns would have to contain. First, I will elaborate on the mixed method research design. Thereafter, the units of analysis, procedures of data collection, and analysis of the data are explained.
2.1 Research design
This thesis combines a literature review and qualitative interview analysis. In addition, the storylines and character depictions in two Dutch series are compared to the trends, stereotypes, and repertoires identified in the latter. First, transformations in the image- and portrayal of the medical profession in the media are mapped through a literature review. Next, eight Dutch medical interns are interviewed in the interest of their personal experiences and stories. The transcripts of these in-depth interviews will be analysed according to Wetherell and Potters discourse analysis (see 2.4.1). Subsequently it is questioned how the representation of the interns in two Dutch series relates to findings in the literature review and interview analysis. Finally, these three pillars are merged and result in the conclusion of this thesis, indicating elements a documentary on medicine students should contain. In addition, a start for a documentary film plan is formulated.
Before delving into units of inquiry, the procedure of data collection, and analysis, it is important to expand on the reasons to adopts this approach. As a scholar, existing literature about the
representation of physicians in the media is probed in order to understand transformations in the depiction of doctors. Next, from an industry (filmmaker) perspective, open interviews offer data that can lead to a better understanding of the experiences and stories of the experiential experts: the medical students. Lastly, examining two Dutch medical programs will provide insight into how interns are currently portrayed in the media landscape. The series are compared to the discussed literature and students discourse to see whether the same trends, stereotypes, and dominant frame of reference recur. 2.2 Units of analysis
2.2.1 Qualitative interviews
Through the interviews, I aim to obtain a broad view of this phenomenon and make it more likely that the findings about what it is like to be a medical intern represent the situation throughout the Dutch academic training hospitals. Therefore, the eight students who are interviewed have been selected in such a way that they are a varied group in terms of university, residence, age and academic year. Six are women, eight are men. Their ages differ from 23 to 25 I have not systematically inquired into class background or sexuality but have the impression that they are all middle-class and straight. Only Stefan’s sexual orientation is gay. Ethnically all are white, none have a migration background to my knowledge. As I am trying to come to generalizable knowledge about the situation in training
it would be of great interest to select a somewhat larger group to satisfy a fully intersectional research design. Stated differently, the diversification of informants supports the representability of the sample in terms of how the hospitals have organized the training of medical professionals (Marshall 522). All informants were obtained through my personal and friends’ social networks.
To illustrate the diversity of the sample, I will briefly provide an overview of the interviewees background information and possible remarks. Five out of the eight students study at the Radboud University in Nijmegen and live there as well. The other three interviewees live and study in Utrecht, two of them are women and one is a man. The Nijmegen students Lonneke1 (female, 25) and Karen (female, 23) are sixth year student who attended ten internships so far. While Lonneke has decided to specialize as a general practitioner, Karen is still doubting between general practice or surgery. Like Lonneke, Stefan (male, 24) is a sixth-year student who also aims to become a general practitioner. He ran thirteen internships in total. Babs (female, 23) and Claudia (female, 23) have the least experience. Babs finished four internships so far and Claudia is attending her fifth as I spoke to her. Both of them have not made up their minds about their career, albeit Babs indicated interest in general practice. Jolien (female, 23), Roel (male, 25), and Gabi (female, 25) live in Utrecht and study at Utrecht University. Jolien and Roel are both fifth-years students and members of student associations. While Jolien finished seven internships, Roel already completed ten. Roel is deciding whether he wants to specialize in the department of anaesthetics or that he prefers the emergency department. Jolien is working her way to become a general practitioner. The last person I spoke to was Gabi, she graduated her master’s in medicine and works as a consultant in the medical sector. As a matter of fact, Gabi is the only interviewee who already graduated and decided to work (temporarily) in a different area. Owing to her negative internship experiences, she was determined to experience a different work field.
2.2.2 Comparing a reality and a drama series to how eight medical students represent life as a medical intern
The Dutch programs who will be compared to the findings are a drama and a reality series in which interns are protagonists. In fact, these are the only two Dutch programs made about medical trainees.
First, De Co-Assistent (The Co-Assistant) (2007), a television drama series based on the eponymous bestseller by Anne Hermans and the broadcasted by a Dutch commercial channel named NET5. The fiction series is broadcasted in four seasons and consists of forty-nine episodes. In the first season, the episodes were thirty minutes each, but these were extended to sixty minutes each in the following three seasons. To elaborate a bit more, the main character of De Co-Assistent is Elin Dekkers, a trainee who struggles to balance her work and private-life. Each episode, Elin faces new challenges in both her private- and work life.
Secondly in the corpus of this limited narratologic enquiry is a reality series named De Echte
Coassistent (The Real Co-Assistant) (2011). The Dutch public broadcaster AVRO follows six interns
(Jorien, Joost, Lotte, Jonathan, Suzan, and Willem) who are in their fifth year of studying medicine and complete internships in various medical specialties at Deventer Hospital. All students attend several internships in the series, varying in terms of field of interest. For instance, Joost (24) wants to become a surgeon, Jonathan (23) an ear, nose, and throat specialist, and Lotte (23) is still undecided. 2.3 Procedures of data collection
2.3.1 Qualitative interviews
The interviews have been conducted according to a semi-structured interview approach, which requires the identification of themes instead of developing a strict questionnaire (Curtis and Curtis 35). First thing to remember is that the questions who accompany the categories (see Appendix 1) serve as a guideline rather than a checklist. In addition, these themes and questions should be considered as a reminder for the interviewer, to ensure several aspects of what it is like to be a medical intern are questioned. During the interviews, an open approach is maintained for the purpose of letting the interviewee talk freely. Additionally, it is relevant to rely on subjects the students bring to the table, considering the exploratory intention of the interviews.
The outlined subjects to be covered in the interviews were: general information about the medical internship (e.g. explaining the purpose and contents of the internship, expectations, and working hours), the team (e.g. interaction with colleagues, patients, and other students), representation in media, and an overall summary and reflection (e.g. strengths and weaknesses of the internship, what is it like to become a doctor?).
Moreover, all interviews were audio recorded and took between 30 and 70 minutes. To make sure the informants felt comfortable, relaxed, and audio record was intelligible, seven out of eight interviews took place at the interviewee’s home and were conducted in an informal way (Richards and Emslie 73). Jolien suggested to meet at a quite café near the library because she was studying that entire day. Eventually, all interviews were transcribed literally, and the transcriptions were checked again with the audio to make sure they were accurate.
2.3.2 Comparing a reality and a drama series to how eight medical students represent life as a medical intern
The series have been viewed on a computer. All episodes of De Co-Assistent were watched on YouTube and the two episodes of De Echte Coassistent were available online on www.npo.nl.
2.4 Data analysis
2.4.1 Discourse analysis
interpretative repertoires”. In addition to this discourse analysis, Strauss and Corbin’s grounded theory in “Basics of qualitative research” is addressed to structure the open and axial coding process. In the fourth chapter of this project, the deconstruction of the students’ discourse is interpreted and result into repertoires (Wetherell and Potter 172). These are explained- and framed by literature. The main reason for this method is the way in which the fairly descriptive themes are taken to a higher level of
interpretation: repertoires. The functionality of the interviewees use of language is deconstructed in order to find the crux of their stories.
First, Strauss and Corbin focus on the structuring of data by splitting it into categories and subsequently unravel patterns through the assessment of relations between these concepts (70). After transcription of the interviews, the program ATLAS.ti was used for the coding process. The first phase was open coding, where meaningful segments in the texts were identified and labelled with a code (58). All the material is explored in this phase without any preconceived themes. Consequently, a long list of 182 codes sifted out, some of which frequently used. Examples of these recurring codes are: balance work-private life, willingness to take action, fear, image of society, appreciation, competition, pressure, motivation to become a doctor, money, hierarchy, learning environment, interaction,
representation in the media, ambiance, working hours, and compensation.
After re-reading the material to check if all relevant segments were labelled, I moved on to the second phase: axial coding (Strauss and Corbin 58). Keen to the process of axial coding is relating labels, renaming them, and clustering the (new) axial codes into overarching themes (97). This way, the relation between codes is determined and result in a handful of categories. These categories - or themes - indicate a number of dominant stories and interesting issues derived directly from the discourse. Eight themes remained, who managed to include nearly all axial labels. The order in which they are listed is according to the number of codes they entail, starting with the highest number: 1) learning path 2) atmosphere 3) pressure 4) dependency situation 5) media 6) money 7) unique position 8) society’s image of the medical profession. A quick side note should be made about the last
category. This category was non-existent after the first round of grouping. However, eight outliers remained. Six of them related to the image society has of the medical profession. Therefore, I decided to create an extra group: society’s image of the medical profession.
When taking a closer look at the eight categories, it appeared some codes belong to multiple groups, resulting in unexpected overlap. I primarily categorized labels based solely on their names. While this was sufficient for the first broad categorization, it became clear that the content of the quotes labelled by these names are not always coherent to the theme. Because certain categories needed tightening in terms of meaning, the process continued by rereading the codes and associated quotes. Maintaining the structured approach, the goal of this step was to exclude non-relevant labels from a group. Take for instance ‘supervision’. At first this code belonged to three categories: learning path, atmosphere, and dependency situation. When taking a closer look, it turned out that all quotes directed towards experiences of students with their supervisor due to the dependent position: “(…)
because you are completely thrown into the deep, depending on the place where you start the
internships. For instance, in the surgery internship, you are not supervised at all, and that was my first one. And yes, because you just have no proper supervision you just have to find the right way on your own. But you do not have a clue about how things work in the hospital.” (Gabi). The other two themes were unlinked as the content of the quotes lacked correspondence to them. Moreover, as a result of rereading the material, the category ‘learning path’ was renamed ‘personal growth’. The former label overlapped substantially with ‘pressure’ and ‘dependency situation’, while the content of the category addresses personal growth. This is partially due to the obligatory learning path, but also because of other factors such as aging and increased confidence. All categories and related axial codes are listed in table 1.
Personal growth Atmosphere
○ Being assertive ○ Treatment by patients ○ Compliments ○ Making your own choices ○ Experience in medicine ○ Hardened by the system ○ Growing ○ Tough world ○ Doing something else ○ Improvising ○ Put to the test ○ Developing yourself ○ Knowledge ○ Low expectations ○ Learning environment ○ Educational ○ Instructive ○ Participating ○ Unable to contribute ○ Development ○ Performing ○ Strengths ○ Putting theory into practice ○ Doubts ○ From watching to working with ○ Responsibility ○ Preparation ○ Self-confidence ○ Search
○ Fear ○ Culture of fear ○ peer group ○ Collegiality ○ Compliment ○ Competition ○ Accepting things ○ Being a burden ○ Internship experience ○ Feedback ○ Hardened by the system ○ Tough world ○ Hierarchy ○ Getting to know someone ○ Learning environment ○ Way you are being treated ○ Less fun ○ Interaction ○ Remarks ○ Payback ○ Collaboration ○ Atmosphere ○ Bad experience ○ Social ○ Team ○ Type of people ○ Rating
Pressure Dependency situation
○ Fear ○ Culture of fear ○ Work-life balance ○ Assessment ○ Burn-out ○ Competition ○ Resume ○ Pressure ○ Work hard ○ Tough world ○ Prove yourself ○ Develop yourself ○ Long days ○ Unable to meet expectations ○ Perform ○ Stress ○ Excessive expectations ○ Exploitation ○ Hours ○ Tiring ○ Expectations from institution ○ Expectations from patient ○ Expectations from within ○ Employment ○ Tough period
○ Dependency situation ○ Fear ○ Culture of fear ○ Authority ○ Supervision ○
Assessment ○ Collegiality ○ Accepting things ○ Feedback ○ Hierarchy ○ Proving yourself ○ Complaining ○ Criticizing ○ Being a burden ○ Learning environment ○ The way you are being treated ○
Participating ○ Mentor ○ Remarks ○ Appearance ○ Atmosphere ○ Bad experience ○ Internship ○ Confidential advisor ○ Weak point
Media Money
○ Representation ○ CMC ○ Co confessions ○ The Intern ○ Doctor Strange ○ Effects media ○ Emotions ○ Grey’s Anatomy ○ House ○ Internet ○ Kees ○ Media and lecture ○ Personal media use ○ Media representation ○ Scrubs ○
Supervillian ○ The good doctor ○ Trauma Center ○ Vier handen op één buik ○ Zembla
○ Take action ○ Part-time job ○ Earn money ○ Work hard ○ Contribute ○ A burden to the hospital ○ Unpaid work ○ Op een houtje bijten ○ Salary ○ Exploitation ○ Compensation ○ Wat doet de co
Unique position Society’s image of the medical profession
○ Being a doctor ○ Privileged position ○ Special places ○ Special situations ○ Motivation to become a doctor ○ Making the difference ○ Contribute ○ Helping people ○ Patient contact ○ Unique opportunity
○ Image interns ○ Society’s view ○ New era ○ Representation in the media ○ Stereotype ○ Prejudice ○ The past
Table 1: Themes and related axial codes
Before delving deeper into the analysis, I will discuss the two axial codes that were not relatable to one of these categories. The first outlier is named ‘culture-related’. This descriptive code is mentioned once in Roels interview when he discusses ‘shared decision making’. This new standard in the medical profession entails higher levels of communication and negotiation between a doctor and the patient to increase patient involvement. To illustrate this way of decision making does not hold true globally, he mentions his internship in Soudan. People do not feel the urge to be involved and simply agree with
the medication or treatment a physician prescribes. “In fact, that is culture-related” (Roel). Despite the fact that it could be integrated in the group: society’s image of the medical profession, him being the only interviewee mentioning a culture related conception, I decided to leave it out of consideration. Besides this being brought up once, the code does not specifically relate to the medicine students. The second outlier, disagreements with patients, is left out due to similar reasons: the absence of
information on medical students. All three quotes labelled with this code are examples of situations in which patients were hard on the interns or doctor for various reasons. For example, Lonneke, who described a situation in which a friend of hers had a disagreement with a patient for no obvious reason: “(…) sometimes you do have those patients. A friend of mine recently was razed to the ground by a patient. He even wrote a letter of complaint and everything. That was not, that was not pleasant for her. But well, he was a bit of a special man.”
When taking a closer look at content of the eight identified themes, it surprisingly stood out that four codes are classified in three out of eight categories: fear, tough world, culture of fear, and learning environment. Table 2 illustrates this finding.
Personal growth Atmosphere
○ Being assertive ○ Treatment by patients ○ Compliments ○ Making your own choices ○ Experience in medicine ○ Hardened by the
system ○ Growing ○ Tough world ○ Doing
something else ○ Improvising ○ Put to the test ○ Developing yourself ○ Knowledge ○ Low
expectations ○ Learning environment ○
Educational ○ Instructive ○ Participating ○ Unable to contribute ○ Development ○ Performing ○ Strengths ○ Putting theory into practice ○ Doubts ○ From watching to working with ○ Responsibility ○ Preparation ○ Self-confidence ○ Search
○ Fear ○ Culture of fear ○ peer group ○ Collegiality ○ Compliment ○ Competition ○ Accepting things ○ Being a burden ○ Internship experience ○ Feedback ○
Hardened by the system ○ Tough world ○
Hierarchy ○ Getting to know someone ○
Learning environment ○ Way you are being treated ○ Less fun ○ Interaction ○ Remarks ○ Payback ○ Collaboration ○ Atmosphere ○ Bad experience ○ Social ○ Team ○ Type of people ○ Rating
Pressure Dependency situation
○ Fear ○ Culture of fear ○ Work-life balance ○ Assessment ○ Burn-out ○ Competition ○
Resume ○ Pressure ○ Work hard ○ Tough world
○ Prove yourself ○ Develop yourself ○ Long days ○ Unable to meet expectations ○ Perform ○ Stress ○ Excessive expectations ○ Exploitation ○ Hours ○ Tiring ○ Expectations from institution ○ Expectations from patient ○ Expectations from within ○ Employment ○ Tough period
○ Dependency situation ○ Fear ○ Culture
of fear ○ Authority ○ Supervision ○ Assessment ○ Collegiality ○ Accepting things ○ Feedback ○ Hierarchy ○ Proving yourself ○ Complaining ○ Criticizing ○
Being a burden ○ Learning environment ○
The way you are being treated ○ Participating ○ Mentor ○ Remarks ○ Appearance ○ Atmosphere ○ Bad experience ○ Internship ○ Confidential advisor ○ Weak point
Media Money
○ Representation ○ CMC ○ Co confessions ○ The Intern ○ Doctor Strange ○ Effects media ○ Emotions ○ Grey’s Anatomy ○ House ○ Internet ○ Kees ○ Media and lecture ○ Personal media use ○ Media representation ○ Scrubs ○
Supervillian ○ The good doctor ○ Trauma Center ○ Vier handen op één buik ○ Zembla
○ Take action ○ Part-time job ○ Earn money ○ Work hard ○ Contribute ○ A burden to the hospital ○ Unpaid work ○ Op een houtje bijten ○ Salary ○ Exploitation ○ Compensation ○ Wat doet de co
Unique position Society’s image of the medical profession
○ Being a doctor ○ Privileged position ○ Special places ○ Special situations ○ Motivation to become a doctor ○ Making the difference ○ Contribute ○ Helping people ○ Patient contact ○ Unique opportunity
○ Image interns ○ Society’s view ○ New era ○ Representation in the media ○ Stereotype ○ Prejudice ○ The past
Table 2: Enlargement of the four reciprocal codes
Although unusual for this type of discourse analysis, this finding represents an unusual, small amount of internal contradiction within the interviews that appears to be indicative for a single encompassing story. Connected with the themes, these codes might indicate the crux of the stories and therefore raise questions regarding the nature of this near-ubiquitous shared frame of reference. What notions of the internships do informants share? Figure 3 shows this segment of the thematic map.
Figure 1: Segment of the thematic map
Before discussing the repertoires in chapter four, the meaning of the four recurring codes mentioned above will be explored. Although the concept ‘fear’ is quite self-explanatory, it is striking that almost all students fear bad assessments if they were to provide genuine feedback to their supervisors. Not only would it affect their grades, several interviewees implied a chance of risking their future. “That is the problem, because you are in a dependency situation. No, yeah when you would actually negatively comment about the situation you will get yourself into trouble.” (Stefan).
You will definitely not tear down the system being an intern. (…) Dare to speak up. I agree. I want to repeat that. Because when I asked people if they wanted to participate in this
interview, they immediately said it must be anonymous. That is when I think well. We are at the beginning of our career and thus no one dares to speak up. That is something, I think that is very striking. While yes, officially we have to be able to give feedback, but nobody is courageous enough to do that, nobody really dares to say how they experienced their
internships. Only when you have attained your assessment, you stop beating around the bush. (Lonneke)
The next descriptive code ‘tough world’, is used literally when describing training hospitals.
Some doctors have said that literally. Yes, the internships are terrible. Well, terrible. They are just exhausting and demanding, like they have always been. Sometimes it kind of feels like the survival of the fittest. Well it is, I guess it is just a tough world. And you know, yeah. If you endure it, you not only learn a lot about medicine, but also a lot about yourself. (Karen) Seemingly similar to ‘fear’ is the ‘culture of fear’. However, the culture of fear refers to the general sphere in the medical profession rather than the fear of bad assessments during the internships. “I have
noticed that some people [nurses and doctor’s assistants] walk around with red spots in their neck due to stress when they have to visit hospitalized patients. That is ridiculous.” (Lonneke).
Last but not least the descriptive code ‘learning environment’. Accompanying quotes entail experiences with the situation in terms of atmosphere, interaction, and effects on personal
development. Noticeable is the fact that all students distinguish between specialisms when discussing the learning environment. The hospital is often perceived as a less pleasant place than a general practice centre. This corresponds with discussed differences between large hospitals and teams, versus smaller hospitals and teams.
Well I was in a place where that [blunt colleagues] was not the case at all, that was actually really pleasant. I experienced that specific internship in a very positive manner. I did discover paediatrics are truly super social people. It feels like coming home, you are more than
welcome. That is just, that is how I experienced it. But that depends on the specialisation, for instance surgery, those people are way more direct. It is just a bit more direct. Yet, I was in a small hospital without physician assistants and thus forced to have direct contact with the surgeons themselves. That makes a difference. (Claudia)
(…) that also differs much between specialisms. For example, in general practice, everybody is very kind to you. Furthermore, within gynaecology, everywhere I have been, doctors were really motivated to teach you something. I cannot provide a clear example, still there are always a few [people] that consider you as an accessory. ‘I have to supervise an intern, here is a stool, just sit down and watch me do my job’. While others take all the time they need to explain everything and do not mind if they end up delaying their schedule. If a patient leaves the room they will expound ‘so, I handled this patient this way because’. Actually, most of them are really keen to teach you something. (Roel)
Now that these codes have been clarified, the discourse analysis will be continued in chapter four where the repertoires are introduced and discussed in detail. By addressing the underlying pattern in what the inmates said and combining it with scholarly literature, I aim to find the linguistic tools they employ to give meaning to being an intern and elucidate the overarching story told by the
interviewees. In this final analysis, four repertoires are identified and discussed: hierarchy, the inmate world, appreciation, and passion. Finally, the findings are briefly summarized in order to elucidate what it is like to become a doctor from the students’ point of view.
The repertoires’ basic validity is guaranteed by the inclusion of a large number of extensive quotes from the interviews (Marshall and Rossman 275). Furthermore, the construct validity of the findings is powerful given the single encompassing story (Cronbach and Meehl 282). Because of the solid linguistic structure identified in the discourse through which the students give meaning to being
an intern, the interpretations discussed in chapter four are generalizable - or transferrable as Marshall and Rossman prefer to name it - to similar sites (Marshall and Rossman 201).
2.4.2 Comparing a reality and a drama series to how eight medical students represent life as a medical intern
After the literature review and discourse analysis, a number of trends (e.g. ideal doctor, ambiguous doctor), stereotypes (inhuman doctors, characteristic inmates, arrogant surgeons, and unfriendly specialists), and dominant frame of reference came to light (the hospital as a total institution in a neoliberal age). By reviewing De Co-Assistent and De Echte-Coassistent, I aim to understand the way in which the series relate to identified trends, stereotypes, and near-ubiquitous shared frame of
reference found in the interviewees discourse. Stated differently, this limited narratologic enquire takes a small corpus of two Dutch series about medicine students to explain how its main storylines and characters account interns and discuss if the literature review and interview results comply with the representation of interns on the Dutch television.
Before moving on, I want to emphasize that the two television series do not claim to be a direct reflection of reality. Nevertheless, the reality series suggest representing everyday experiences. On the contrary, drama series deal with different genre conventions, often prioritizing drama over a true reflection of reality. “A ‘message’ has been stylized and conventionalized by the intervention of a highly organized set of codes and genre-conventions (…) The intervention of the codes appears to have the effect of neutralizing one set of meaning, while setting another in motion.” (Hall 9-10). To put it differently, the genre conventions allow transformation and dislocation of messages, thereby bring about “a transformation in the signification” (10). Thus, the reality series De Echte Coassistent indeed is partially responsible to reflect reality, while De Co-Assistent’ conventions allow the series to deviate from ‘true’ underlying matters. In my opinion, a well-executed documentary gives the viewer the opportunity to reconsider certain matters. In this project, I aim to take medicine students as the subject for reconsideration.
Chapter 3. Portrayal of the medical profession in the media: a literature
review
The door opens. A handsome, tall man in a white coat enters the room. He is calm, confident and has a perfect demeanour. There is no doubt his patient will be in good hands. The perfect doctor at first sight. Unfortunately, this physician is a utopian dream embodied in the first few medical dramas that aired between the 1950s and 80s. In recent years, story worlds have started abandoning the image of the perfect doctor. Is the standard depiction of physicians as ideal personalities indeed being replaced by more ambiguous, sometimes villainous characters? And if yes, why is this shift taking place?”
On the one hand, researchers claim that media obtain a powerful role in distributing
information on health care and have the ability to create perceptions of physicians and the health care system in general (Chory-Assad and Tamborini, “Television doctors” 500). On the other hand, the argument can also be reversed. “The history of television's doctors speaks loudly of the character of the public's present and future conception of real doctors as well as their faith in the aims and institutions of modern medicine” (Tapper 399). Furthermore, this thesis interferes in a tradition of portraying medical professionals. Therefore, it is important to map this tradition and scrutinize the state of affairs at the moment. This chapter seeks to both display and discuss the evolution of television doctors.
3.1 Television doctors in fiction
3.1.1 The ideal doctor
Between the 50’s and 80’s, most fictional doctors possessed characteristics of the ideal doctor2 (Chory-Assad and Tamborini, “Television doctors” 499-502; Jiwa 603). The portrayal of medics was largely positive; they were characterized as good, successful, rational, stable, and sociable people (Chory-Assad and Tamborini, “Television doctors” 502). Illustrative of this depiction is the narrated introduction of a 30-minute episode of Medic (1954), the world’s first medical television drama. “Guardian of birth, healer of the sick, comforter of the aged, to the profession of medicine, to the men and women who labour in its cause, this story is dedicated” (Tapper 393).
About a decade after World War II, content creators articulated general expectations of the health care system through a set formula as a means of generating favourable institutional publicity (Turow “Television entertainment” 1241). Generally, the doctors were depicted as young males who were ruling the hospital and are often accompanied by male specialists (1241). Additionally, the medical possibilities in the portrayed hospital seemed boundless and financial concerns were left out 2 A sample of 192 American citizens were interviewed to thematically construct the ideal doctor. According to these interviews, the ideal doctor is characterized as being: confident, empathetic, humane, person, forthright, respectful, and thorough. For more information see: Bendapudi et al. (338–44).
of consideration (1241). In fact, the main characters played the role of deus ex machina3, rarely causing their patients to pass away (1241).
An example of this deus ex machina is the iconic doctor Ben Casey, played by Vince Edwards in the medical drama series of that name (1961; Jiwa 603). Casey is a neurosurgeon with a flawless demeanour and confident manner of speaking. He is always perfectly prepared and reassures his patients that they are in good hands (603-604). Usually the surgeon meets his promise; the patient’s life is saved and at the end of each episode, he or she leaves the Country General Hospital alive and kicking (604).
Countering the established surgeon, Dr. Kildare (1961) articulates the story of an intern who learns the medical practice. It was the first television series to display a physician’s personal struggle (Tapper 294). Over the episodes, he developed from an insecure and clumsy intern into a secure, self-esteemed doctor (394). “Kildare did not want to portray doctors as gods but rather as flawed human beings who – through and within the demands, obligations, virtues, and values of medicine – are elevated to- or partake in something far greater than themselves” (394).
Joseph Turow claims that early television shows such as Ben Casey and Dr. Kildare add to the audiences’ perception of doctors in a positive way (Turow “Playing doctor”). However, the set formula of these programs did not remain static over the years.
3.1.2 The doctor with flaws
The overwhelmingly positive depiction of physicians altered when television makers’ main focus moved away from the patient’s perspective towards emphasizing the perspective of doctors themselves (Chory-Assad and Tamborini, “Television doctors” 503). Instead, they focus on aspects like their humanity, personality, and personal problems (503). Elaborating on Kildare’s depiction of physicians, a shift to a less flawless, more realistic and somewhat controversial view on the medical profession can be observed around the 1980s (Chory-Assad and Tamborini, “Television doctors” 499-502; Jiwa 604; Strauman and Goodier 128; Turow “Television entertainment” 1241-1242). The portrayal of physicians’ personal struggles allowed the viewer to learn about physician’s personalities through a sense of recognition (Strauman and Goodier 128; Turow 1242).
Markedly, the acclaimed series ER (1994) was written by Michael Crichton in 1974 but denied by every television network until 1994 (Tapper 396). It appeared the broadcasters were not ready to accept the series’ depiction of physicians at the time (396). Tapper argues the appearance of three events established the willingness to allow the refocus on doctors: the Watergate scandal, The House
of God, and St. Elsewhere (1982; Tapper 396). During the Watergate scandal, the publics’ trust in- and
perception of the nation’s institutions was vigorously damaged, which affected the health care system 3 According to Pfau, Mullen and Garrow, Deus ex machina, ‘god from the machine’ is an ancient plot device wherein the story evolves in an unexpected way (441-458). For example, a solution to an
as well (396). This new frame of mind is captured by Stephan Bergman in his bestseller The House of
God. Bergman’s doctors did not genuinely care about their patients and enthusiastic interns developed
into insensitive cynic’s due to the psychological damage and dehumanization caused by their internships (396).
Based on The House of God, St. Elsewhere’s hospital featured multidimensional, complex, doctor characters as they tried their hardest to maintain their humanity amidst the many pressures of its hierarchies, pitfalls, and demands” (Jiwa 604; Tapper 396). The television drama was highly serialized in terms of plotlines and featured a large cast. St. Elsewhere’s doctors showed errors; they made substantial mistakes and struggled with challenging patients (Jiwa 604). On top of that, the American health care system was exposed to show its foibles (605).
Another well-known example of the doctor with flaws, is the main character of BBC’s
Casualty (1986; Jiwa 605). Dr. Ruth Winters entered a new era as the series slowly uncovers her
personal struggles and conflicts during her time as a junior (Jiwa 605). For example, she misdiagnoses a patient with catastrophic consequences in the first season, she is reluctant to ask for help and blames others for her own mistakes (605). In the end, after another misdiagnosis causes a patient to die, the feeling of guilt and the pressure become unbearable, causing Winters to tragically commit suicide.
During the period St. Elsewhere and Casualty aired, the Dutch drama series Medisch Centrum
West (Medical Centre West) (1988) was introduced on national television and quickly gained much
popularity. At the time, Medisch Centrum West was considered being health education combined with television entertainment, as the series conveyed a cardiovascular health message in name of the Dutch Heart Foundation (Bouman, Maas, and Kok 504). Corresponding to the American representation of doctors with flaws, the series contained drama, intrigues and romances, and it displayed ethical dilemmas based on realistic medical themes (504).
3.1.3 The morally ambiguous doctor
As briefly mentioned above, broadcasters disagreed with the depiction of doctors in ER at the time it was written. However, twenty years later, St. Elsewhere broke ground for the approval of ER (Tapper 397). The program portrayed doctors who lived in poverty and had drugs and alcohol problems (Tapper 397). While some characteristics of the ideal doctor stayed intact, ER’s protagonists are morally ambiguous (Strauman and Goodier 128). Correspondingly, rather than displaying the hospital as the bustling centre of life, ER made it become inhospitable, reflective of the audience’s unease with the health care system (Tapper 397). Illustrative of these efforts are emphases on conflicting doctor-patient relationships and financial problems due to the costs of medicine. Although previous series (e.g. St. Elsewhere) displayed dissatisfaction with the health care system and flawed doctors, ER chose to show superlatives; physicians making wrong decisions on a regular basis and complaints of
of the characters and the physicians perpetually act in the best interest of the patient, allowing the viewer to sympathize with them (Strauman and Goodier 128; Tapper 397).
In several popular hospital series which followed, it became harder to sympathize with the physicians as their foibles are constantly exposed, enlarged, and emphasized (Jiwa 605; Tapper 397). Since 2000, it appears that the image of the ideal doctor increasingly fades (Jiwa 605). An apparent example is Fox’s House (2004). Taking the fashion from the ideal doctor to the doctor with flaws even further, House’s main protagonist Dr. Gregory House no longer meets the characteristics of the ideal doctor (Strauman and Goodier 129). Almost opposite to, for instance, Ben Casey, Dr. House does not seem to care about the feelings or humanity of the patient. He treats them as objects and is solely focused on diagnosing illness. As a matter of fact, House does not want to talk to his patients because “all patients lie” (Strauman and Goodier 130). He is extremely impatient, rude, addicted to painkillers and shows characteristics of a misogynist (130). Admitting his persona juxtaposes the kind and gentle physicians that used to typify fictional television doctors, Dr. House embodies the omnipotent doctor. After all, he is the chair of ‘diagnostic medicine’ and each episode results in a genius revelation through which dr. House finds a cure, making him a highly ambiguous character (Tapper 397-398). Interestingly, in 2007 viewers collectively voted Dr. House the most reliable physician on television (398). All things considered, caring apparently became subordinate to diagnosing and curing, presenting a distortion of the medical professional as being nothing more than a tool utilized by the patient (398). “It is because House does not care that he cures. His uniquely shrewd calculations empower a bold recklessness that allows him to save lives.” (398).
House’s premise is inverted in its contemporary counterpart, Grey’s Anatomy (2005; Tapper
398). This medical drama centres around the personal and professional life of a group of surgery interns in the Grey Sloan Memorial Hospital in Seattle. Important to note is that the producer of the series, Shonda Rhymes, eschews the emphasis on health care in the show: “it is really a relationship show with surgery in it” (Barnhart; Strauman and Goodier 129). It can also be argued that the medical profession in general is attractive for Rhymes because it breaks with genre conventions and
expectations of a traditional romance. In addition, the audience might be drawn to the intrigues of the authoritarian characters as these are non-disclosed in daily life and older series. It contrasts with the role of the doctor in House, Grey’s Anatomy lets patients become extensions of the physicians in a different fashion (Tapper 398). Here, they serve as objects for practice and are judged solely based on their ailments (398). “Patients are not vulnerable people with diseases; they are diseases, and their connection with their doctor is contractual and convenient” (398). Although the medical profession is elevated in both House and Grey’s Anatomy, the depiction of doctors in these shows is absurd and relationships with their patients one-dimensional.
3.2 Non-fiction television doctors
In comparison to the amount of literature on fictional television doctors, very little is written about non-fictional doctors in documentary media. Nevertheless, Rebecca Chory-Assad and Ron Tamborini extend work on the media’s portrayal of the medical profession by conducting content analysis on the portrayal of both fictional as well as non-fictional doctors (Chory-Assad and Tamborini, “Television doctors” 499). Included in the analysis are several news programs, soap operas, and talk shows (499). By acknowledging the appearance of the medical profession in several media genres, the researchers broaden the view on the different possible images of doctors in the media, whereas former research tends to focus merely on prime-time fiction series (499-500).
Real-life doctors appear regularly in the news media and are attributed to a variety of causes, both positive as well as negative. (Jiwa 605). First, physicians are characterized as real-life heroes if they accomplish something extraordinary (605). For example: developing a new medicine or vaccine, cure a seemingly incurable patient or perform a ground-breaking operation (605). In contrast of praising a doctor, the news media every now and then depict them as villains. These depictions vary from unsuccessful treatments or experiments, to criminal cases among which accusations of deliberate overdosing (606). The lack of representing a middle ground is understandable as the news covers events that deviate from a daily routine. Nonetheless, in reality there are more types of doctors than portrayed in the news. Take for example: overworked, underpaid, overpaid, satisfied or dissatisfied. Because of the polarised representation of physicians in the news, these other images are left out of consideration for the viewers.
In sum, the portrayal of physicians in non-fiction television and news magazines is more positive than in fiction television, indicating a difference in representation of the medical professional between different genres (Chory-Assad and Tamborini, “Television doctors” 514-517). Flaws in the doctor’s personalities and decisions are often left out in non-fiction television and news media, where they are portrayed as credible and able (516). This finding is attributed to the informational purpose of the genres (516). Furthermore, Chory-Assad and Tamborini implicated that exposure to a more negative image of doctors might affect the viewer by their perceptions of them (518).
3.3 The evolution of television doctors and the risk society
All things considered, it is evident that the depiction of doctors in the media changed dramatically since the 50s, especially in the fiction genre (Jiwa 603). The ideal physician is no longer existent, flaws developed into faults, and characters became morally more ambiguous (603). In recent medical dramas, “the doctor is far from priest like” (Tapper 399). Because the media is – to a certain extent – reflective of the publics’ attitude, the question rises why distrust is increasingly displayed regarding the medical profession (Jiwa 607; Tapper 399). In order to shed light on this phenomenon, I aim to address the relationship between the evolution of television doctors and the ‘risk society’, as conceptualized by sociologist Ulrich Beck (1992).
In short, Beck describes how people live in a world full of risks: the risk society (Beck “Risk Society” 21). In the article “The Terrorist Threat: World Risk Society Revisited”, Beck lists several events to clarify the layers and dynamics of this society. For example: the 9/11 attacks, Chernobyl, and global warming (Beck “The Terrorist Threat”, 39). Not only the events itself articulate the risk society, but also the accompanied language collapse, especially during the 9/11 attacks (39-40). At the time, the government struggled in communicating the event. There was a lack of appropriate language and symbols (40). “This is exactly what world risk society is all about. The speeding up of modernization has produced a gulf between the world of quantifiable risk in which we think and act, and the world of non-quantifiable insecurities that we are creating.” (40). There is a significant difference between
dangers that have been around since pre-modernity and risks, a modern concept which inheres a
notion of control (40). Dangers are ascribed “to nature, gods, and demons”, while risks entail decision-making (40). People try to calculate what is uncalculatable (40-41).
When the risk society is related to the health care system, the evolution of television doctors could be explained on account of the fallibility of doctors. As a result of the fear that accompanies the increasing risk society, fewer people rely on fate. Their trust in physicians declines as they might be a big risk in life. Patients occasionally have to trust their life to the hands of a doctor, but what if that person makes the wrong decision? What if the person you entrusted your health to, errors? The visibility- and fear of risks in daily life increase and are reflected in the way television doctors are depicted.
In addition to this increasing fear in the risk society, Tapper argues that real-life doctors are not able to live up to the high expectations brought about by television doctors (Tapper 399). Second, as mentioned briefly in the latter (see: 3.1.2) the publics’ trust in public institutions decreased
significantly due to major events among which the Vietnam war and the Watergate scandal (396-399). Consequently, as health care is a vital element of the public institutions, the medical profession simultaneously encountered diminishing fate of the public (399). At the same time, medical knowledge and technology gained accessibility (Nelkin 1602-1603; Tapper 399). As a result, the autonomy of patients increased, and people started to approach physicians as intermediaries between themselves and the medical technology (Nelkin 1602-1603; Tapper 399).
Furthermore, the triumph of managed care and patient autonomy will likely support for some time the two types of dissonance between patient and doctor depicted in today’s shows. The persistent demand for doctors on TV, however, also represents a persistent fascination with the doctor’s craft, science, and character. The opportunity for a positive change is there. If the history of this genre has taught us anything, it ought to be that it is and always has been in a state of flux, responding to extremes with corrections as needed. (Tapper 399)
3.4 Conclusion
In conclusion, Becks theory of the risk society helps to understand the transformation from the ideal television doctor to ambiguous, sometimes villainous characters. As a result of the speeding up of modernity, increasing fear of risks in daily life, and triumph of patient autonomy, people take matters into their own hands. Correspondingly, trust levels in doctors have suffered because of public scandals and the disability to live up to high expectation that have been brought about by ideal television doctors. The disappearance of the ideal doctor on television is the result of a changed image society has of the medical profession in general. Because the results of this project will interfere in a tradition of representing medics, it is important to understand the evolutions of portraying physicians and inhere notions among which the reflective risk society as an element of this documentary.
Chapter 4. Interview analysis
The students’ accounts displayed surprisingly little contradictions and directed towards one
overarching story: the hospital as a total institution in a neoliberal age. This finding is established by the four repertoires that are derived from the themes found across the interview material. Hence this chapter will discuss the content of these repertoires and explain the way in which they address being part of a total institution. Before going into this, the total institution will be discussed. Subsequently, the four central repertoires will be introduced successively: hierarchy, the inmate world, appreciation, and passion. Finally, the findings are briefly summarized in order to answer the central question of this chapter: what is it like to become a doctor according to eight Dutch medicine students?
4.1 Conceptualization of the total institution
The organization and social system of the internships resemble characteristics of the total institution, as introduced by sociologist Erving Goffman in 1957. According to Goffman’s influential text
Asylums: “A total institution may be defined as a place of residence and work where a large number of
like-situated individuals cut off from the wider society for an appreciable period of time together lead an enclosed formally administered round of life.” (Goffman, “Asylums” 11). In other words, the total institution is an organization of life in a closed social system. Commonly used examples of these systems are prisons, mental health facilities or military schools (Goffman, “Characteristics of Total Institutions” 313). Within these encompassing institutions, an authority is in charge of the rules, norms, and schedule that maintain the system (315). What is fascinating about the medical internships, is the absence of any form of documented rules or principles of behaviour. When studying the
interviews, the impression is given that since the framework is in operation for this long, it maintains itself. “Sometimes it is the general atmosphere in the department. ‘It is supposed to be like this, so I will act that way. It has happened to me too, therefore I can do it to you too’.” (Gabi). “A couple doctors made me feel like ‘well you are a trainee, we have been there as well and did not have a good time either, so you have to dislike being here.’”. (Lonneke). Furthermore, of interest about maintaining the system, is the fact that all students who expose the unwritten behavioural rules, simultaneously appoint the inability to chance it. A paradox appears through the lack of faith in the possibility to adjust the framework and contradictory dissatisfaction with the situation.
Albeit the displayed examples of the total institutions indicate involuntary participation, they can also be joined on a voluntary base, likewise medical school. Susie Scott revisited Goffman’s concept of total institution: “I (…) critically assess the extent to which it has changed from being repressively coercive to relatively voluntarist.” (Scott 214). Herewith, she takes the debate forward arguing the origins of the total institutions are less repressive than posed and the actors should not be
the concept and introduce the reinventive institution; a place wherein people participate seeking self-improvement (218). “This reflects a wider shift towards the culture of late modernity (Giddens, 1991) or reflexive modernization (Beck et al., 1994), with its themes of individualism, self-reflection, existential anxiety, and a quest for authentic living.” (Scott 218). One way to this pursue self-enhancement is education, alike medical school (215-218). The following discussion elaborates how this theory enacts during the course of becoming a doctor.
4.2 Repertoires
4.2.1 Hierarchy
Hierarchy is frequently addressed in the interviews and appears to be present throughout- and central to the entire course of becoming a doctor. Mostly, these experiences and stories are attributed to a prevailing hierarchy in the medical profession.
So really, the medical specialist is on top. Below them are the residents, followed by the semi-doctors - if there are any - and lastly the interns. And that is just really, the longer you are into your training, the higher you will be on that ladder, so yes that is the case being an intern. Just at the bottom. (Gabi)
The interviewees consistently position themselves ‘at the bottom of the ladder’. Down this metaphorical ladder, the respect of colleagues to the trainees often leaves much to be desired.
It is kind of a pick-order and you are simply the lowest in that order. (…) it are often small disparaging things. It is assumed that you are not able to do anything useful and thus you are not allowed to do anything. And yeah as a result you are a hinder to everybody. Even if you ask something ordinary, sometimes your question is simply ignored. It is super uncomfortable if your questions disappear. They pretend like they did not hear you. (…) Actually, the surgeons themselves are quite friendly. Especially the nurses and assistants often thwart us during operations. (…) for instance: a physician suggested an intern could stitch a wound. Before I was able to respond, the assistant already panics: ‘No doctor, we cannot do that. Really, we do not have the time for them to do it. I will quickly fix it.’ And before you know it, it is done already. (…) regularly, the floor is swept with the intern as if we are some sort of inferior product. (Stefan)
Furthermore, this quote illustrates the clear distinction between the interns and other employees. Within total institutions, participants are labelled inmates, and the authority - or group of people who carries out the authorities will – are characterised as staff (Goffman, “Characteristics of Total
hierarchical layers, among which supervisors, doctors, specialists, doctor-assistants, residents, and nurses. Staff in lower levels of the hierarchy are easier to approach than the ones on top. “I would rather ask a resident than the specialist. That is unmistakably due to the hierarchy”. (Lonneke). As shown above and confirmed in Goffman’s theory: “staff tends to feel superior and righteous; inmates tend, in some ways at least, to feel inferior, weak, blameworthy and guilty. (…) Expressive signs of respect for the staff are coercively and continuously demanded.” (“Characteristics of Total
Institutions” 315-318). Indeed, the interviewees feel inferior and experience feelings of submissiveness, for instance during encounters at (morning) meetings.
The atmosphere was not that good either. During the meetings in the morning it was always the questions whether there were any seats left. Often this process went smoothly and works merely as ‘first come, first served’. Or ‘you can be in the front-row’, things like that.
Nevertheless, instead of doing so, it was more as if they preferred us to sit on top of the closet of in the trash bin, instead of taking place on a chair. (..) That felt horrible. And those doctors, they looked down us in the extreme. (Karen)
Well there is just a visible hierarchy in the sense of the interns having to sit at the front during meetings, in order for them to clearly see everything and sometimes they have to. In the middle of the room you have this large round table where everyone gathers around. But you also have seats on the side of the room if the other chairs are all taken. Interns are expected to sit on the side anyway, so that everybody from the team can sit at the table. (Roel)
The inability to work against this system and its staff can be explained with reference to two distinct elements regarding the authority system within the total institution (Goffman, “Characteristics of Total Institutions” 318). First, the staff obtains the right to discipline the interns (318). Rather than
conspiratorial repression, the staff legitimize their authority “on the administration of bureaucratic rules” (215). In a way, their superiority is attributed to educational purposes. “Look, you are often criticized. However, it must be that way, at the end you are there to learn.” (Jolien). Nevertheless, I insist the urge to acknowledge this attribution does not justify all behaviour; in what way does
humiliation contribute to educating students? Second, “the authority of corrective sanctions is directed to a great multitude of items of conduct of the kind that are constantly occurring and constantly coming up for judgment” (Goffman, “Characteristics of Total Institutions 319). This element applies directly to the constant assessment of the interns. “It is obligatory to continuously ask questions, otherwise they will say afterward you did not participate. It is better to ask questions you already know the answer to, just to make sure everyone believes you are actively participating. But yeah, it is about
Moreover, a quote from Lonneke’s interview illustrates not merely feelings of inferiority, but literally states that the interns are told that they are a burden to the doctors. “We are a burden. That is it. We are. We, we actually do not contribute, at least that is what they say, so they tell us we are particularly time consuming and hospitals are bothered by us.” (Lonneke). In view of the work performed by the trainees combined with the educational purpose of the internships, these remarks are unjustified, and solely serve to make students feel inferior and enable obedience.
Albeit the discourse about the process to become a doctor implicates the origins of a total institution in several ways, it must be kept in mind that the stories deviate on a couple fronts. Contrary to well-known examples, medical school is not separated from the rest of the society in terms of distance, the students are voluntary participants who have the ability to take care for themselves and oppose the typical inmates who have to be kept away from society due to safety precautions
(Goffman, “Characteristics of Total Institutions” 312-316). In addition, there are also several examples in which the interviewees did experienced close bonds within the teams, felt equal, and staff was keen on educating them. “Well, among others I enjoyed neurology a lot. Under supervision of Freek Bijl4 (…) And there they were just very nice, treating us as equals.” (Karen). “It was such a pleasant environment, everyone was lovely. The assistants, the doctor's assistants, and the general practitioner themselves were genuinely kind. That was a great team.” (Gabi). It is remarkable that in these, and all other examples of pleasant experiences, there were no notions of hierarchy. In fact, this refers to the
greedy institution - a variation of the total institution - coined by Lewis Coser in 1974.
Greedy institutions are exclusive and demand absolute commitment: new recruits are expected to weaken existing ties with other social groups and give the organization their undivided loyalty. Unlike Goffman’s total institution, the greedy institution rarely physically confines its inmates, but creates a symbolic boundary between insiders and outsiders that is equally powerful. (Scott 218)
These greedy institutions claim the identity of its inmates and demand to pervade every aspect of their lives (218). Examples of these systems are “religious cults, vocational training schools, and secret societies” (218). Members of these institutions admire the framework due to both voluntary
participations as well as rewards through empowerment, emancipation, and self-actualization (219). The interns appear to feel rewarded through experiences in the hospital. The reward which is
repeatedly mentioned by the interns, is the experience of rare situations or being present during special moments: a lifesaving operation, childbirths or a patient’s rehabilitation.
In my opinion, it is a highly fascinating profession. Because of the possibility to experience these rare situations. Usually I, or another person, does not get to experience those. Often, we 4 Pseudonym.
