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Doing obstetrics : the organization of work routines in a maternity service Ford, James Ellsworth 1974

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DOING OBST. ETRICS: THE ORGANIZATION OF WORK ROUTINES IN A MATERNITY SERVICE by JAMES ELLSWORTH FORD M.A., University of California, Santa Barbara, 1968 A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n the Department of Mthropology and Sociology We accept this dissertation as conforming to the required standard "THE UNIVERSITY OF BRITISH COLUMBIA September, 1974 In presenting th i s thesis in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L ibrary shal l make it f ree ly ava i l ab le for reference and study. I fur ther agree that permission for extensive copying of th is thesis for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i cat ion of th is thesis for f inanc ia l gain sha l l not be allowed without my written permission. Depa rtment The Univers i ty of B r i t i s h Columbia Vancouver 8, Canada Date i i ABSTRACT Despite popular and professional concerns with c h i l d -b i r t h and prenatal care there are few empirical studies of behavior i n hospitals where these events t y p i c a l l y occur. The problem set f o r the study reported here was to observe behavior i n the maternity department of a hos p i t a l and to provide a t h e o r e t i c a l description of what was observed i n terms relevant t o s o c i o l o g i s t s ' i n t e r e s t i n the s o c i a l organization of work routines of professional s t a f f members serving a lay c l i e n t population. The thesis i s thus a desc r i p t i o n of medical s t a f f members' work routines, with an ana l y t i c i n t e r e s t i n how that r e l a t e s to features of work routines of service occupations i n general. S p e c i f i c a l l y , the study reports upon the ways lay patients may d i f f e r from professional medical s t a f f members i n t h e i r perspectives on prenatal care and c h i l d b i r t h and how s t a f f members see these divergences as often r e s u l t i n g i n organiza-t i o n a l problems when they t r y to provide care which i s "com-plete, " e f f i c i e n t and expeditious. Further, the study describes how s t a f f members develop i n t e r a c t i o n a l (and other) methods f o r managing patients, e s p e c i a l l y those who adhere to these non-medical perspectives, so as to cope with such p r a c t i c a l pressures as the need to schedule patients and t h e i r demands, provide a v i s i b l y competent performance f o r superiors, peers and patients, and prepare the patient f o r e f f i c i e n t and expeditious process-i n g at subsequent organizational stages. I t i s asserted that i i i these p r a c t i c a l pressures (termed demand ch a r a c t e r i s t i c s ) are features commonly found i n work routines of service occupa-tions i n general. F i n a l l y , i t i s argued that an ethnographic study of work routines of professional s t a f f members of service i n s t i t u t i o n s , e_. g., hospitals, may be necessary to explain adequately features of apparently natural or b i o l o g i -c a l events, such as c h i l d b i r t h , that occur within them. i v TABLE OF CONTENTS Chapter Page I . INTRODUCTION 1 Pe r s p e c t i v e 1 The S e c i o l o g i c a l L i t e r a t u r e 14 The H o s p i t a l S e t t i n g 20 Methodology 23 Access 28 Recording Observations 36 Org a n i z a t i o n o f the Thesis 40 I I . WORK ROUTINES AND EMBARRASSMENT . 49 Overview o f Routines 49 The O r g a n i z a t i o n o f Eirfoarrassrnent 56 I I I . PREPARING THE PATIENT: THE ORGANIZATION OF MORAL CONTROL IN THE INTAKE AREA 71 IV. IMPLEMENTING A MEDICAL IDEOLOGY IN PRENATAL WORK ROUTINES 113 Taking the Medical H i s t o r y 114 Two Approaches t o P a t i e n t Care 132 Moral C o n t r o l and Experience 144 Talk as a Management P r a c t i c e 179 V. LABOR AND DELIVERY: THE ORGANIZATION OF WORK ROUTINES 213 Coerced Cooperation 250 Nor m a l i z i n g Troubles 281 VI. CONCLUSION 314 Framework 314 Substantive F i n d i n g s 317 BIBLIOGRAPHY 329 V LIST OF FIGURES Figure Page 1. Ground Floor, Obstetrics and Gynecology Building, Outpatient C l i n i c 5# 2, Fourth Floor, Obstetrics and Gynecology Building, Delivery and Labor Floor 59 v i ACKNOWLEDGMENTS I wish to express my appreciation to Roy Turner f o r introducing me to t h i s f i e l d of study and f o r providing me with encouragement, advice and much h e l p f u l c r i t i c i s m during the research and writing of t h i s report. Dorothy Smith and E l v i Whitaker read and commented on the work. I am indebted to them f o r t h e i r encouragement and c r i t i c i s m s . While others have contributed to t h i s e f f o r t , the author alone bears the r e s p o n s i b i l i t y f o r the study. 1 CHAPTER I INTRODUCTION Perspective In i n d u s t r i a l i z e d s o c i e t i e s there have emerged sp e c i a l i z e d medical i n s t i t u t i o n s staffed by "experts" and based on s c i e n t i f i c a l l y validated knowledge and techniques. Over the l a s t f i f t y years (approximately), both the technical and administrative scope of these has increased. B i o l o g i c a l processes are more extensively and comprehensively regulated by t h i s administered knowledge now than they have ever been. Ch i l d b i r t h i s one of the "natural" processes that has been an object of a great deal of control by medical science and i n s t i t u t i o n s . As a r e s u l t , modern o b s t e t r i c a l medicine i s concerned with the b i r t h of a c h i l d even before conception. Also, i t attends to the "welfare" of the c h i l d p r i o r to i t s actual b i r t h . In other words, i t treats these periods of a woman's l i f e as medical events, i . e., i t has notions of pre-and post-conception care. In f a c t , modern medicine t r i e s to turn these and many aspects of the layman's l i f e (however remote some of them may appear to be from c h i l d b i r t h ) into medical issues and events, g., conception, b i r t h control practices, dietary and exercise habits, s p e c i f i c methods of giving b i r t h , and ch i l d r e a r i n g p r a c t i c e s . Anthropologist Margaret Mead has aptly described how 2 the high value placed on each i n d i v i d u a l l i f e has been the premise f o r bringing f o l k and "primitive" c h i l d b i r t h perspec-t i v e s and practices under the control of one uniform medical aegis. From the great d i v e r s i t y of human practices, i t i s possible to see that c h i l d b i r t h has always been patterned. No known society has ever depended upon i n s t i n c t to guide the mother or the other members of society. Infants have survived under a great d i v e r s i t y of c o n d i t i o n s — e . g., where the midwife was another young g i r l , or where magical invocations rather than midwifery s k i l l were depended upon. The family has survived whether the father was banished f o r a month, whether he was expected to s i t behind his wife and provide a f i r m human support f o r her labor, whether the father was expected to observe the taboos before and a f t e r c h i l d b i r t h , or whether the c h i l d -b i r t h only involved the mother and other women. A l l the human s o c i e t i e s we know would not be here i f some human infants, some mothers, and some fathers, some brothers and s i s t e r s were not tough enough, healthy enough, and f l e x i b l e enough to meet these variously contrasting st y l e s of s o c i a l behavior. But i n the s o c i e t i e s of the past, only a few babies l i v e d , sometimes les s than h a l f l i v e d . Today we are developing a s t y l e of l i f e i n which our aim i s to save almost every baby. We are no longer dependent upon the f i t n e s s of the "nursing couple." A mother whose c h i l d does not t h r i v e on her milk need not watch her c h i l d sicken and die since there are formulas to be used. A mother f a l l s i l l and must wean her c h i l d does not endanger his l i f e . As we save more and more infants we need better methods; not only t e c h n i c a l l y improved methods of delivery; not only t e c h n i c a l l y improved methods of del i v e r y , and t e c h n i c a l l y improved methods of encouraging breastfeeding and s p e c i a l a r t i f i c i a l feeding, but also better provision f o r the s o c i a l situations i n which a young couple faces parenthood, and f o r a l l the children who must welcome a new baby into the family.1 Mead he r s e l f implies approval of the increasing i n s t i t u t i o n a l i z a t i o n of medical control over "styles of s o c i a l behavior" i n c h i l d b i r t h and even i n the new family's r e l a t i o n -ships . On the other hand, she also suggests that s t r i c t l y speaking, i t i s not the s u r v i v a l of the human race or even of 3 a society that warrants t h i s control, but just the c u l t u r a l l y s p e c i f i c concern f o r infant mortality per se. Mead's reference to the medical perspective on c h i l d b i r t h as a " s t y l e of l i f e i n which our aim i s to save almost every baby" suggests that i t stands as just one of "variously contrasting s t y l e s of s o c i a l behavior" that has existed i n s o c i e t i e s . Within the medical perspective i t s e l f , s p e c i f i c approaches to prenatal care and c h i l d b i r t h may change accord-ing to "new s c i e n t i f i c d iscoveries." However, what t h i s simply e n t a i l s i s more frequent changes i n the content of r u l e s governing events i n c h i l d b i r t h compared to those of f o l k and "primitive" cultures and subcultures. For these "backward" members, pregnancy and c h i l d b i r t h frequently i s not a health problem. For these events, according to Mead, there e x i s t c e r t a i n rules over d i e t and other a c t i v i t i e s . In i n d u s t r i a l -ized s o c i e t i e s , p a r t i c u l a r l y , these rules have been medical-ized, as Mead hers e l f implies. The rules have been displaced to frame the member's l i f e from conception through b i r t h and motherhood. As a r e s u l t , medicine sees as i t s domain (e_. g.,) what members do f o r a l i v i n g and t h e i r c h i l d rearing p r a c t i c e s . The professional medical l i t e r a t u r e i t s e l f can be c i t e d to support the assertion that medical practices and goals i n regard to c h i l d b i r t h constitute a c o l l e c t i o n of rules based on c u l t u r a l l y s p e c i f i c value premises. The following professional writer, a nurse, discusses the f a c t that whatever the source f o r s p e c i f i c changes i n o b s t e t r i c a l p r a c t i c e s — s c i e n t i f i c d i s -coveries, or "taboos" borrowed from "primitive" c u l t u r e s — 4 modern medicine adopts them as moral prescriptions and pro-s c r i p t i o n s ("dogma" and "duties") and i n s t i t u t i o n a l i z e s them i n h o s p i t a l routines and prenatal regimens. At each stage as we make new s c i e n t i f i c discoveries, we f i n d that the attempt to use them d i f f e r s from culture to culture, and that we need to be continuously aware of how a s c i e n t i f i c discovery w i l l be used i n a given c u l -ture. Just as we e a r l i e r turned maternity into a duty, l i k e eating the r i g h t food, women are now attempting to turn the new freedoms of giving b i r t h to a baby without an anesthetic i f there are no complications, or of breast feeding t h e i r baby i f he and the mother f l o u r i s h , into new oughts. As a consequence, women are developing extreme anxieties i f they do not have "natural c h i l d b i r t h , " f a i l to breast feed, and cannot manage "self-demand." Unless we r e a l i z e that matters of health i n our culture are c l o s e l y t i e d to duty and conscience—we ought to eat the r i g h t food, get enough vitamins, have enough sleep, take the r i g h t exercise, watch our weight, relax—we f a i l to understand the kinds of anxieties that any changes i n maternity behavior introduces. Childbearing generally i n America i s not an i n t r i n s i c a l l y rewarding, pleasurable experience i n which a woman expects to take an immediate, day-to-day d e l i g h t . Instead, i t i s a series of necessary, hygienic, d i f f i c u l t , and unrewarding a c t i v i t i e s which w i l l culminate i n a c h i l d who can then be enjoyed only to the extent that he grows, gains weight, learns to walk and ta l k , establishes good t o i l e t habits, takes naps, plays i n the fresh a i r , and goes to bed on time. 2 On the other hand, s o c i a l s c i e n t i s t s have pointed out how i n some contexts the professional and organizational structures d e l i v e r i n g t h i s extended scope of medical care i s "imposed" on a population whose ordinary health care practices do not correspond to or f i t with the technical and/or adminis-t r a t i v e r u l e s and requirements of i t s organization. In other words, researchers (and health personnel themselves) have found that some people have not been trained to "want" i t s services or do not know or do not want to know how to pa r t i c i p a t e as properly competent receivers of the routine delivery of i t s 5 services (medical personnel may pejoratively c a l l them "bad patients" as a r e s u l t ) . Thus, the practice of o b s t e t r i c s , as well as other medical s p e c i a l t i e s , may take place i n cross-c u l t u r a l (or cross-subcultural) scenes wherein there are problematical r e l a t i o n s between professional administrative/ t e c h n i c a l routines and people who do not subscribe to them.3 S o c i a l s c i e n t i s t s a t t r i b u t e patients' "resistance" to medical control to several " c u l t u r a l variables": (1) t h e i r subscribing to subculturally prescribed t r a d i t i o n a l and f o l k methods of health care (medical personnel c a l l them "old wives' t a l e s " ) ; (2) t h e i r subscribing to subculturally prescribed notions ( d i f f e r i n g from medical s t a f f ) of how to behave while playing the "sick r o l e , " due to d i f f e r i n g backgrounds (from medical s t a f f ) , including s o c i a l c l a s s , ethnic, educational, and even occupational differences (especially i n t h e i r accep-t i n g preventative "care").^ Furthermore, one medical s o c i o l o -g i s t , E l i o t Freidson, even implies that medical personnel often have d i f f i c u l t i e s getting patients to cooperate f u l l y i n accepting treatment, due to the almost ine v i t a b l e differences between the lay c l i e n t perspective and that of the professional health personnel. Medicine i s a consulting, not a scholarly, profession. The bulk of a consulting p r a c t i t i o n e r ' s work r e l a t i o n -ships involves c l i e n t s , not colleagues. C l i e n t s , unlike colleagues, are not usually i n the same s o c i a l world as the professional. C l i e n t s , therefore, do not "speak the same language" as the professional; the two do not share the same phenomenological meanings, assumptions, or con-cepts. I l l n e s s never means the same thing to the c l i e n t and to the professional. Everett Hughes put his f i n g e r on the most obvious difference between professional and c l i e n t perspectives when he said that what was routine to the 6 professional was an emergency to the c l i e n t . The c l i e n t , however, can ignore or handle his emergency himself i f he so wishes. The professional, on the other hand, needs c l i e n t s to carry out his work, to apply his knowledge, to practice his c a l l i n g . He must persuade c l i e n t s to accept his ministrations or be able to place them i n a p o s i t i o n where they have nothing to say about the matter. Professional practice cannot exist without c l i e n t s , but the influence of the c l i e n t over the professional does not end with that simple dependence . . . medical prac-t i c e owes much of i t s variety and patterning to the type of c l i e n t dealt with. This i s not to say merely that c l i e n t s of d i f f e r e n t classes, cultures, or degrees of cosmopolitanism present the p r a c t i t i o n e r with a variegated work l i f e . The power of the c l i e n t goes much deeper than that . . . d i f f e r e n t types of c l i e n t s make d i f f e r e n t demands on the p r a c t i t i o n e r , and the way he meets these demands s i g n i f i c a n t l y shapes his routines of work. "Tmy emphasis) . . . The everyday work l i f e and the s o c i a l i d e n t i t y of the professional are thus intimately related to his c l i e n t e l e . . . . the professional's autonomy over his work (is) hard won, as (is) his s o c i a l prestige . . . analyses of the e f f e c t s of c l i e n t s on professional work indicate that autonomy and prestige must be c a r e f u l l y nurtured every working day. As a r e s u l t , many professional a c t i v i t i e s are probably best viewed as stemming from a c o n f l i c t over control of the s i t u a t i o n . The p a r t i c u l a r form t h i s con-f l i c t takes depends on the r e l a t i v e s o c i a l status of pro-f e s s i o n a l and c l i e n t , and on the extent of i n s t i t u t i o n a l -ized control the professional wields, but i n a symbolic sense, a l l patients are i d i o t s to professionals.5 Here Freidson can be seen as i n d i c a t i n g the importance of studying patient management techniques i n any analysis of medical personnels' work routines. He appears to be espousing t h i s a n a l y t i c a l approach on the grounds that the cross-subcultural (and other) differences between lay c l i e n t s and professionals w i l l often r e s u l t i n c o n f l i c t when medical personnel t r y to " r e c r u i t " patients f o r treatment and t r y to gain t h e i r cooperation when they do come f o r treatment. Thus, professional doctors (and presumably other medical personnel) 7 develop methods of (as Freidson puts i t ) "managing patients," which . . . " s i g n i f i c a n t l y shape (their) routines of work . . . ." In f a c t , i t i s the purpose of t h i s thesis to show how such methods s i g n i f i c a n t l y shape o b s t e t r i c a l work routines and e s p e c i a l l y how these methods themselves are shaped by p r a c t i c a l work "pressures," such as those glossed by Freidson as a pro-fess i o n a l ' s concern f o r "autonomy and prestige." Besides the research l i t e r a t u r e , the published accounts of working medical professionals themselves can also be c i t e d to show how they may struggle with " r e c a l c i t r a n t " patients, e. g., those subscribing to t r a d i t i o n a l and f o l k "old wives' t a l e s " governing prenatal and post-natal care, as well as other subcultural notions seen as " a n t i t h e t i c a l " to the professional medical perspective. In other words, these "behind the scene" accounts also suggest issues of c r o s s - c u l t u r a l or cross-subcultural c o n f l i c t between medical personnel and patients (e. g., d i e t , s t y l e s of delivery, exclusive use of medical sources f o r advice, etc.) as well as the ways personnel t r y to organize t h e i r work routines so as to manage "bad patients" and bring them into compliance with t e c h n i c a l l y and administra-t i v e l y required "treatment" routines. For example, a private o b s t e t r i c i a n r e l a t e s his experience of having to e s t a b l i s h a c l i n i c i n an "urban ghetto" to t r y to overcome the members' view of c h i l d b i r t h as a non-hospital or non-medical event. As he describes i t , t h i s "ghetto" was populated by blacks, Puerto Ricans, and "poor whites," most of whom were unemployed or on welfare. Mothers-to-be from t h i s area had caused a hospital "problems" by appearing there only as emergency cases, t i e i n g up much of the f a c i l i t i e s and disrupting the s t a f f members' work schedules. Again, t h i s doctor reports that members of these c u l t u r a l groups regarded the hospital only as a place to d i e . By moving prenatal f a c i l i t i e s to the "ghetto" i t was hoped that they would not be frightened away by the hospital m i l i e u and would use the prenatal c l i n i c to a much greater extent. However, t h i s doctor found that the members of the neighborhood s t i l l "neglected" to use medical resources during the prenatal period or made "poor patients" i n adhering to medically prescribed prenatal routines of "preventative care" and i n keeping t h e i r appointments f o r regularly scheduled check-ups. Even more of a b a r r i e r than fear and superstitution was simple apathy. The poor, l a r g e l y ignorant people looked upon pregnancy and b i r t h as natural processes, not much more complicated than eating, and nothing to get excited about. I f a prospective mother developed health problems, that was just, bad luck or, perhaps, a curse. The symptoms might be t e r r i b l y i n t e r e s t i n g and worth gossiping about, quite unrelated to the f a c t that she might be s u f f e r i n g from anemia, toxemia of pregnancy, diabetes, s y p h i l i s , or tuberculosis. I t was taken f o r granted that quite a few babies would be born prematurely, s t i l l b o r n , or retarded. The more r e l i g i o u s tended to look on such wastage as the w i l l of God and a matter f o r prayers, not medical attention. Because I've seen the deadly e f f e c t of impersonal assembly-l i n e medical attention i n m i l i t a r y service, I treated the patients exactly as I d i d those i n my private p r a c t i c e . I kidded with them, raised h e l l i f they didn't follow in s t r u c t i o n s , and kept a close check on t h e i r progress. We paid great attention to follow-up: I f a patient missed a regular appointment, a nurse c a l l e d her to f i n d out why and to reschedule her. We even sent out aides to make sure that the patient showed up next time. . . . With ghetto patients, as opposed to my private ones, 9 I found that g i v i n g instructions on di e t or medication wasn't enough. Many of my center patients simply couldn't help cheating on t h e i r d i e t and seemed to f e e l that i f they could f o o l the doctor, the e f f e c t on themselves and t h e i r baby wouldn't count. I had an answer to t h i s . When I discovered that they hadn't followed orders, my achtung s p i r i t rose, and I slapped them i n the ho s p i t a l , where they couldn't cheat, u n t i l t h e i r blood sugar l e v e l s declined. In a way, I suppose, I was playing God i n the ghetto, but i n a p o s i t i v e way, making decisions that enabled l i f e to improve i t s e l f . On the whole, i t was a highly s a t i s f y i n g experience. 6 This working obstetrician's account suggests that medical personnel may routinely coerce, castigate (". . . r a i s e h e l l . • • . " ) , and generally hold members accountable f o r t h e i r non-medical perspectives and p r a c t i c e s . His remark on ". . . playing God• . ." to improve l i f e also suggests that medical s t a f f t r y to exercise t h i s moral control over patients i n order to transform them in t o "good patients" and proper prospective mothers. He implies that i n the medical perspec-t i v e each i n d i v i d u a l l i f e i s valued very highly, while recognizing that i t may not be i n other segments of i n d u s t r i a l -ized, Western socie t y . Indeed, he implies that medical per-sonnel see i t as t h e i r mandate as medical professionals to t r y to teach " r e s i s t a n t " patients a professional medical view of proper pregnancy, c h i l d b i r t h and motherhood, and thereby t r y to produce "good patients" who conform to established organiza-t i o n a l work routines. In sum, there i s a so-called "medical" view of con-ception, prenatal care, c h i l d b i r t h and post-natal care which contrasts with various c u l t u r a l , ethnic, and general l a y views of these events and phases and t h e i r s i g n i f i c a n c e . While i t i s 10 posed as a "medical" view, i n fac t i t can be argued to have a thoroughly moral and culture-bound set of ingredients, e.. g., views of "proper" family l i f e and spouse r e l a t i o n s and r e s p o n s i b i l i t i e s ; "proper" orientations to the future, occupa-t i o n a l progress and ambition; the future l i f e s t y l e and " r i g h t s " of the unborn c h i l d , etc. Since the medical view contains such components—i. <»., matters which do not require medical t r a i n -ing, but are culture c h a r a c t e r i s t i c s — p a t i e n t s obviously d i f f e r i n the extent to which they seem "accepting" or " r e s i s t a n t , " and thus they get characterized i n moral terms although the t r e a t -ment i s as though only medically relevant matters are at stake. In other words, among s t a f f members at City Hospital, where I conducted the study on which t h i s thesis i s based,(and presumably at other hospitals as well) there i s a r e l a t i v e l y c l e a r set of views on conception, pregnancy, labor, c h i l d b i r t h -and care which add up to an "ideology." Nevertheless, s t a f f members at C i t y treat t h i s set of views as a medical matter which they have a mandate to enforce. This medical ideology i s seen as making strong moral claims on s o c i e t a l members and leads to a view of the well-programmed patient. However, the society does not necessarily produce a steady flow of such " i d e a l " patients. Staff are thus faced with what from t h e i r perspective, rooted i n work, professional and organizational routines and b e l i e f systems, must appear to be " r e c a l c i t r a n t " patients. S t a f f thus develop views and procedures f o r "shaping" the r e c a l c i t r a n t i n the image of the "good patient." As a r e s u l t , some contacts with patients provide f o r the development 11 of occupational routines which focus on "teaching" patients to adopt such views, and which serve to detect patients as, g. g., morally d e r e l i c t i f they choose alternative arrangements, are i n d i f f e r e n t to matters which s t a f f view as " e s s e n t i a l , " etc. Thus, some contacts allow s t a f f to map sharing the "proper perspective" i n t o compliance with s p e c i f i c behaviors, plans, expectations, etc. The operation of the ideology thus d i s -plays patients as, e. g., "ignorant," " c u l t u r a l l y backward," etc., and motivates s t a f f to "work on" patients so as to bring them into greater conformity with the image of the good p a t i e n t — s h e who gives promise of adapting to and accepting organizationally bound requirements. From the s t a f f s ' point of view, then, there may be much to "teach" patients and ce r t a i n i d e o l o g i c a l l y prescribed ideals of how they should be treated, g., as i n d i v i d u a l "persons" with t h e i r own self-defined "needs," deserving of respect and propriety. Nevertheless, work exigencies make strong claims on various categories of s t a f f i n a hospital (supervising physicians, medical students, nursing personnel, medical s o c i a l workers, etc.) which sometimes reinforce the ideology and sometimes c o n f l i c t w i t h . i t . In other words, despite the sometimes e x p l i c i t l y verbalized coherent set of views which good patients should share with s t a f f and s t a f f s ' espousal of ideals of resp e c t f u l and proprietous treatment of patients, i n the course of managing the work flow, s a t i s f y i n g h o s p i t a l regulations, accommodating the doctors' work flows, students' teaching needs, etc., adequate conformity i n a 12 procedural sense i s more important to s t a f f than attitude s h i f t s and proprietous " i n d i v i d u a l " treatment, and sanctions are often directed at obtaining such conformity. In con-clusion, the "medical view" has implications; i . e_., i t translates into a set of routines, procedures and a c t i v i t i e s which are taken to implement i t . When you look at such routines and procedures i n d e t a i l you f i n d , of course, that not only are they urged, defended and practiced under the auspices of a concern with, e. g., "health," but that they have t h e i r own exigencies (or demand c h a r a c t e r i s t i c s ) ? as organizational events and work-related a c t i v i t i e s and routines. It i s t h i s general topic of the implementation of a medical ideology i n the management of pregnancy and c h i l d -b i r t h v i a organizational and occupational demand characteris-t i c s and t h e i r attendant problems which I wish to examine i n t h i s t h e s i s . More generally, I intend t h i s thesis to be an ethno-graphic examination of t h i s topic which w i l l stand as a study of the organization of work routines i n a "people-work" organi-zat i o n . I w i l l attempt to follow the works of Sudnow, Goffman, Cicourel, Zimmerman, and o t h e r s 0 which have analyzed the methods and procedures whereby professional "servers" have t r i e d to implement a professional ideology or b e l i e f system i n t h e i r work routines with (often) "troublesome" c l i e n t s while, at the same time, attending to organizational and work exigencies, e. g., the maintenance of a manageable work schedule and providing a v i s i b l y competent performance f o r c l i e n t s and superiors. As i n those studies, ray primary focus w i l l be on discovering and describing the routines and procedures s t a f f members develop to manage and "work on" such patients ( c l i e n t s ) so as to bring them into greater conformity with the image of the good p a t i e n t — s h e who gives promise of adapting to and accepting organization-bound requirements—or at l e a s t to coerce from them conformity with established "treatment" pro-cedures. This study, then, w i l l deal with s t a f f and medical personnels' problems i n managing a population of transient c l i e n t s , who often have "deviant" or divergent views from those of the s t a f f on the kind and quality of "service" (treatment) they should receive from the organization, and who are not subject to long-term enforcement procedures. Also, i n com-parison to other "people work" organizations, d i s t i n c t i v e problems of management are created i n part at least by v i r t u e of the f a c t that s t a f f are dealing with a p r o c e s s — l a b o r and c h i l d b i r t h — that i s not wholly controllable and does not f i t neatly into work routines, although the work i s t y p i c a l l y carried out i n organizations with quite f i x e d procedures and a momentum that i s not e n t i r e l y geared to patient "needs." More s p e c i f i c a l l y , the organization of shiftwork, the require-ment that a physician be i n attendance at d e l i v e r y , etc., are organizational arrangements and ideologies that are perhaps somewhat at odds with labor and c h i l d b i r t h viewed as "natural" processes. As a r e s u l t , the s t a f f develop patient management techniques to t r y to bring labor and childbearing patients 14 in t o greater conformity with the image of the "good patient," whose labor and delivery " f i t s " i nto organizational and occu-pational routines and ideologies. However, as with management techniques employed i n d e l i v e r i n g prenatal care, these control routines r e l y on i n t e r a c t i o n a l and physical methods which may be seen as causing "problems" by patients and other outside observers, such as researchers: the frequent use of anesthesia, caesarian sections, a r t i f i c i a l inductions of labor, "teaching" the patient to "hold" the baby back from being delivered, etc., (although such "problems" may often be mistaken by out-side observers as r e s u l t i n g from the processes and a t t r i b u t e s of the p a t i e n t ) . In other words, the ideals of medical ideology support the s e r v i c i n g of the i n d i v i d u a l childbearing patient's "needs" (and the avoidance of such "problems") while i n fact those ideals w i l l only sometimes be actually implemented i n s t a f f ' s everyday work routines, depending on t h e i r p a r t i c u l a r work exigencies or demand c h a r a c t e r i s t i c s . Not a l l of the routine patient management techniques I w i l l describe i n t h i s thesis w i l l appear to " v i o l a t e " ideals of the medical ideology, and, i n f a c t , the goal of the thesis i s to describe any and a l l such techniques I discovered i n my study, but not to show how frequently s t a f f ' s application of the ideology i n the context of everyday work pressures constituted a threat to "good" patient care, however that may be "measured." The S o c i o l o g i c a l Literature Although a great deal i s known about the s o c i a l 15 features of c e r t a i n b i o l o g i c a l events (e_. g., blindness, death, etc.) and c e r t a i n t r a n s i t i o n a l states (§.. g., adolescence, aging, e t c . ) , l i t t l e i s known s o c i o l o g i c a l l y about c h i l d b i r t h and childbearing as a s o c i a l process. This i s not to say that c h i l d b i r t h has not been studied as an event. Anthropologists have been c o l l e c t i n g data on the s o c i o - c u l t u r a l features o associated with childbearing and c h i l d b i r t h f o r many decades. For the most part, the s o c i o l o g i s t s who have concerned them-selves with c h i l d b i r t h have been concerned to demonstrate quantitatively s i g n i f i c a n t relationships between medically defined phenomena and s o c i a l c h a r a c t e r i s t i c s of patients as they are perceived by s o c i o l o g i s t s . Numerous studies have shown that apparently s t a t i s t i c a l l y s i g n i f i c a n t relationships exist between the pathologies of pregnancy and b i r t h , pregnancy and b i r t h events and such s o c i a l c h a r a c t e r i s t i c s of patients as s o c i a l class, race, age and marital status." 1"^ As a r e s u l t , medical s o c i o l o g i s t s expect from the nature and d i r e c t i o n of these relationships that medical phenomena be c l a s s - r e l a t e d : (e_. g.,) higher socio-economic groups have lower frequencies of pathology than lower socio-economic groups. In focusing t h e i r attention on these studies of s o c i a l -medical r e l a t i o n s h i p s , researchers, with only a few excep-12 t i o n s , have ignored the s o c i a l s e t t i n g and the personnel within that s e t t i n g which have a d i r e c t bearing on the repro-ductive process. When t h i s commonly-occurring b i o l o g i c a l a c t i v i t y takes place within the confines of a hospital i t comes to involve the c l i n i c a l and s o c i a l a c t i v i t i e s of numerous h o s p i t a l personnel ranging from ward clerks and secretaries to gynecologists and o b s t e t r i c i a n s . "Having a baby," no matter how simple or complex b i o l o g i c a l l y , e n t a i l s a variety of occu-pational s p e c i a l i s t s engaged i n a concerted s o c i a l a c t i v i t y . In sum, researchers have generally taken f o r granted that the events of c h i l d b i r t h and prenatal care are tec h n i c a l or "objec-t i v e " outcomes determined by the "objective" b i o l o g i c a l condi-t i o n of the patient and, to a more li m i t e d extent, her " s o c i a l c h a r a c t e r i s t i c s " (as well as those of the medical s t a f f who "t r e a t " her) which are "external" to the organizational se t t i n g where these "natural" events occur, g. g., the patient and s t a f f ' s standing i n a s o c i o l o g i c a l l y - d e f i n e d s o c i a l s t r a t i f i c a -t i o n system. On the other hand, there have been a comparatively small number of medical s o c i o l o g i s t s who have provided f o r the organizationally situated character of "natural" events i n the h o s p i t a l . Mainly t h e i r analyses have drawn heavily from the following schools of thought i n sociology: ethnomethodology, 1 3 symbolic i n t e r a c t i o n , and dramaturgical an a l y s i s . With regard to events surrounding childbearing and c h i l d b i r t h , I have found the work of David Sudnow, an ethnomethodologist,^ p a r t i c u l a r l y s i g n i f i c a n t — s p e c i f i c a l l y , h i s discussion of how the p r a c t i c a l structure of occupational and organizational routines shape events i n the delivery room. His inte r e s t i n these events was generated by a general concern f o r death and dying as organizationally situated events. Thus, his focus i s 17 l i m i t e d f o r the most part to the organizational routines s t a f f develop to deal with natal " d i s t r e s s " and death i n the delivery room."*"'' I believe the works of another ethnomethodologist, Roy Turner, can also be seen as providing a useful a n a l y t i c a l framework f o r examining the organizationally situated charac-t e r of "natural" events, such as c h i l d b i r t h . For t h i s purpose I found most i l l u m i n a t i n g his analysis of how the outcomes of encounters between police and "offenders" may be s i g n i f i c a n t l y shaped by the p r a c t i c a l structure of the police's occupational r o u t i n e s . ^ In f a c t , i n t r y i n g to sort out and analyze the s a l i e n t features of the hospital a c t i v i t i e s I observed i n my f i e l d work, I was guided to a great extent by Turner's formula-t i o n of an ethnomethodological approach to studying events that occur i n professional and other occupational settings: . . . I have suggested that the properties of police work that I have discussed are generalizeable to other work set t i n g s . Indeed, I believe that ethnographic studies of professions and occupations, i d e n t i f y i n g , describing and analysing demand c h a r a c t e r i s t i c s and occupational routines, w i l l uncover s i g n i f i c a n t and invariant properties of stable s o c i a l arrangements that are taken f o r granted. In p a r t i c u -l a r , I believe that such studies are useful with respect to those occupations where established ideologies and lay b e l i e f systems encourage the view that p r a c t i t i o n e r s — e . g. physicians, s c i e n t i s t s , p s y c h i a t r i s t s , s o c i a l workers—do not, or "ought not" to shape t h e i r work a c t i v i t i e s i n accordance with such mundane considerations as the struc-ture of the work day, the v i s i b i l i t y of work, etc. . . . I am suggesting that ethnographic studies of science, medicine, etc., w i l l have as t h e i r pay-off not c r i t i q u e s and remedies, but some more fundamental understanding of how these a c t i v i t i e s are constituted i n the f i r s t place. My t h e o r e t i c a l i n t e r e s t i n advocating such studies, i s to d i s c l o s e , not the " s o c i a l influence upon," but "the s o c i a l structure of" the central events and a c t i v i t i e s of the professions and occupations. Like David Sudnow, I am advocating a concern with "the procedural basis of events," and "the concrete organizational foundations" of a c t i v i t i e s . To put i t another way, laymen possess common-sense knowledge of, and normative concerns with, the "technical" events and procedures of p r a c t i t i o n e r s — such events and procedures as "diagnosis," "arrest," "therapy," "treatment," "experiment," e t c . — a n d s o c i o l o -g i s t s are given to treat these as "context-free" matters, about which inquiry can be conducted without i n the f i r s t . , place c l a r i f y i n g such matters as organizational products. ' Also, i n t r y i n g to analyze the collected observations from my study of t h i s h o s p i t a l I found useful Donald H. Zimmerman's ethnomethodological ethnography of the work routines of intake and e l i g i b i l i t y s o c i a l workers. x o In p a r t i c u l a r , I was impressed with his discussion of how such p r a c t i c a l considerations as scheduling c l i e n t s (especially "bad c l i e n t s " ) and providing a competent performance i n the eyes of superiors ( i . e., what Turner termed "demand charac-t e r i s t i c s " ) led s o c i a l workers to modify a pr o f e s s i o n a l l y -supported i d e a l i d e o l o g i c a l approach to servicing and managing c l i e n t s . Also, I found useful h i s discussion of how experi-ence i n managing c l i e n t s also leads to some extent to the adoption or app l i c a t i o n (or not) of t h i s i d e a l approach to c l i e n t management (as opposed to a more work-located approach). Thus, i t was from Zimmerman's work that I drew the notion of two approaches to patient management and "care"—one pro-f e s s i o n a l l y and i d e o l o g i c a l l y i d e a l , the other located i n the everyday work s e t t i n g . From another ethnomethodologist, David Sudnow, I derived an in t e r e s t i n analyzing s t a f f ' s perspective i n terms of t y p i f i c a t i o n s of patients and events i n the hospital as 19 "normal events," which serve to organize t h e i r work routines so as to cope with demand c h a r a c t e r i s t i c s , e s p e c i a l l y the 19 scheduling of work. 7 Also, I found very useful Sudnow's b r i e f analysis of s t a f f ' s patient management techniques i n 20 d e l i v e r i n g "bad news" (or not) i n the delivery room. Thus, i n drawing from the l i t e r a t u r e and theory i n sociology I owe the greatest debt to the works of ethnomethod-o l o g i s t s : Roy Turner, Donald H. Zimmerman, and David Sudnow. Indeed, i t i s from t h e i r works that I drew my central theme: seemingly "technical" or "natural" events i n the hos p i t a l (e« g»> "prenatal care," "labor," and "c h i l d b i r t h " ) are shaped to a s i g n i f i c a n t extent by the s t a f f members' work routines (especially those involving patient management) which they develop to cope with the p r a c t i c a l structure (§.. g., demand ch a r a c t e r i s t i c s ) of t h e i r everyday work. In pursuing t h i s theme I w i l l follow a t h e o r e t i c a l approach which i s very s i m i l a r to that of Turner and Sudnow: I w i l l seek to analyze actual on-going i n t e r a c t i o n between hospital s t a f f members and patients i n terms of i t s con s t i t u t i v e , concrete organizational procedures and methods. This approach attempts to describe how f o r s t a f f members i n t h e i r everyday occupational routines patient management methods constitute a s i g n i f i c a n t part of the procedural d e f i n i t i o n of o b s t e t r i c s . In other words, I suggest that these heretofore undescribed methods to an impor-tant degree constitute "doing o b s t e t r i c s " f o r s t a f f members i n t h i s h o s p i t a l . The Hospital Setting Cit y Hospital i s a large general, private, acute care r e f e r r a l h o s p i t a l incorporated by the province around the turn of the century. I t s business a f f a i r s are managed by a board of volunteers ("trustees") who represent the governments of the Western Canadian province and c i t y i n which i t i s located, as wel l as a uni v e r s i t y medical school and the Hospital Corpora-t i o n i t s e l f (half of the board i s comprised of the l a t t e r ) . P o l i c i e s of the Hospital, as approved by the board of trustees, are administered by a s a l a r i e d d i r e c t o r . The Hospital has a t o t a l capacity of approximately 1,800 c h i l d and adult beds. I t s employee s t a f f exceeds 3,500. Approximately 900 doctors comprise the medical s t a f f . The graduate nursing s t a f f i s approximately 800 Registered Nurses. In the Hospital's t h i r t y - f i v e operating rooms approximately 45,000 operations are performed annually. More than 48,000 treatments are given i n the emergency department and more than 44,000 patients are admitted to City i n the course of a year. Approximately 40 percent are referred from areas beyond the c i t y i n which the Hospital i s located. An adult outpatient department gives diagnostic and treatment service to "low income" persons upon r e f e r r a l from a doctor or a welfare agency. About 61,000 patient consultations are conducted during the course of a year. Among the busiest of t h i s department's c l i n i c s are general medicine, dermatological, p s y c h i a t r i c , eye, obstetr i c s and gynecology. 21 One of the settings f o r my research i s the obstetrics and gynecology outpatient c l i n i c , which i s located i n the ground f l o o r of the obstetrics and gynecology b u i l d i n g . A Hospital publication describes i t s obstetrics department as . . . occupying a p o s i t i o n of eminence among medical i n s t i t u t i o n s , recognized as one of the foremost maternity centers. . . . Here the s k i l l s of the most able s p e c i a l -i s t s , performed with the aid of modern f a c i l i t i e s and services, assure the expectant mother of the f i n e s t medical and s u r g i c a l care. I t i s l i t e r a l l y the meeting place of about 3,200 newborns and mothers each year. In t h i s happy patient area there e x i s t s an understanding and an intimate r e l a t i o n s h i p between mother, nurse and child.21 (A f u l l d e s c r i p t i o n of the c l i n i c and the d e l i v e r y f l o o r s , s e t t i n g f o r my research, may be found at the beginning of Chapter I I , along with diagrams of the f l o o r plans of these two f l o o r s . ) Ci t y engages i n a large medical t r a i n i n g program which i t describes as.". . . a ranking educational program f o r pro-f e s s i o n a l and t e c h n i c a l personnel f o r s p e c i a l i z e d assignments i n the medical f i e l d — o n e of the great medical teaching 22 centers." * This program i s c l o s e l y associated with a school of medicine of a nearby large u n i v e r s i t y and an i n s t i t u t e of technology. More than 800 students from those two i n s t i t u t i o n s are enrolled i n courses f o r various types of tec h n i c a l s p e c i a l -t i e s as well as post-graduate medicine and surgery. City Hospital i t s e l f maintains a school of nursing with a student body exceeding 500 (one of Canada's l a r g e s t ) . Student e n r o l l -ment i n the above three i n s t i t u t i o n s i s representative of p r a c t i c a l l y every area of the globe, e s p e c i a l l y the Commonwealth countries. Of the Hospital complex of sixteen buildings the largest was b u i l t i n the l a t e 1950's and has an occupancy of 504 beds. It i s an ultra-modern ten story building with a t o t a l of eighteen operating rooms, including four emergency operating rooms located i n i t s emergency department. In stark contrast, next to i t i s the much smaller obstetrics and gynecology b u i l d i n g . I t i s a drab four story b u i l d i n g b u i l t i n the l a t e 1920's with an occupancy of 111 beds, plus 119 bassinets f o r new-born babies. (A more detailed d e s c r i p t i o n of t h i s building, s i t e of my research, may be found at the beginning of Chapter II.) The university's school of medicine maintains a research department at City, dealing p a r t i c u l a r l y with prob-lems of the new-born i n f a n t . In f a c t , i t was through the Hospital's a f f i l i a t i o n with the school of medicine that I gained access to the obstetrics and gynecology department. However, a high l e v e l administrator informed me, by way of orienta t i o n to t h i s department, that i t ( l i k e most departments i n the hospital) was primarily oriented to ser v i c i n g the health needs of the community, although he " l i k e s to support research" i n the obstetrics and gynecology department. Thus, at least i n the department which was the set t i n g f o r my f i e l d work, work routines were developed and maintained primarily to provide e f f i c i e n t s e r v i c i n g of patients and teaching, rather than to encourage and f a c i l i t a t e research ( p a r t i c u l a r l y that related to s o c i a l science). In the following section, describing my 23 data c o l l e c t i o n , I w i l l show how t h i s service and teaching orie n t a t i o n to some extent affected my access to t h i s s e t t i n g , p a r t i c u l a r l y the labor and delivery area. Methodology I n i t i a l l y , my choice of c h i l d b i r t h as a topic and non-participant observation as a method resulted from my reading Sudnow's b r i e f ethnographic description of doctor-patient 23 i n t e r a c t i o n i n the delivery room. J Also, my choice of an ethnographic method was strongly influenced by Roy Turner's study of po l i c e occupational routines ( b r i e f l y described above). In that paper he argues f o r an ethnographic method that t r i e s to provide as data a continuous and un-edited record or "videotape" of s o c i a l phenomena, i.e.., a method that t r i e s to describe and account f o r commonplace features of an actor's on-going organizational l i f e . A common s o c i o l o g i c a l response to these concerns (lay c r i t i c i s m s of "helping organizations"—J.E.F.) i s to seek to i d e n t i f y and make sense of the "variables" that might account f o r , g. g., police f a i l u r e to give a l l categories of c i t i z e n s equivalent treatments, whether as victims or suspects. As opposed to such an in t e r e s t I want to t r y to describe and account f o r some of the commonplace features of d a i l y police work that provide f o r lay c r i t i c i s m s . I r e a l i z e that t h i s w i l l disappoint at least two sets of readers, those who look f o r redeeming s o c i a l s i g n i f i c a n c e i n s o c i o l o g i c a l d e s c r i p t i o n s — o f the kind advertised i n such t i t l e s as Minorities and the, Police: Confrontation  i n America—and those who look f o r s o c i o l o g i c a l data to be cast into the moulds of c l a s s i c a l issues, such as the explanation of the growth of "informal" practices within a context of "formal organizations." Nevertheless, I must endorse Jack Douglas's characterization of s o c i o l o -g i s t s ' practice of substituting phenomena of t h e i r own construction f o r those of common-sense everyday l i f e and then studying t h e i r own ad hoc phenomena as i f these constituted " r e a l i t y . " They have done t h i s i n part to 24 avoid the complexities and "biases" of common-sense terms, but the study of t h e i r ad hoc r e a l i t y has simply created another l e v e l of complexity: since they have s t i l l wanted t h e i r studies to be ultimately related to everyday l i f e they have had to s h i f t back and f o r t h between t h e i r ad hoc  phenomena and the everyday phenomena, constructing post hoc  systems of t r a n s l a t i n g devices and other devices. As I see the application of Douglas's remarks to studies of the p o l i c e , neither the social-problems nor the t r a d i -t i o n a l t h e o r e t i c a l approaches have adequately resolved the fundamental procedural issue of how t h e i r constructs are related to the "everyday phenomena" of socially-organized p o l i c e a c t i v i t i e s . To put i t metaphorically, such studies proceed by the assembly of "snapshots" of the s o c i a l world: i t i s not hard, f o r example, to assemble snapshots demon-s t r a t i n g police "prejudice." Of course, my concern here i s not to argue that "police o f f i c e r s are not prejudiced," any more than i t i s to a f f i r m such a statement. To continue with the metaphor, my concern, rather, i s to suggest that a continuous and un-edited videotape of s o c i a l phenomena requires quite d i f f e r e n t constructs f o r adequate explana-t i o n than those that may s a t i s f y data consisting of a selected assembly of snapshots. These are complex issues, of course, and I am a f r a i d that I must leave them at t h i s point with just one i l l u s t r a t i o n . My own f i e l d observations could r e a d i l y have produced a snapshot of a juvenile o f f i c e r t a l k i n g to or apprehending a young Negro, such that "preju-dice" would be f a i r l y w e ll evident. But then i f the opera-t i o n of "prejudice," or the a t t r i b u t i o n of "negative a t t i -tudes towards Negroes" to the p o l i c e , i s to be raised to the l e v e l of an explanation of police behavior, what are we to say concerning another datum which only a continuous movie or videotape record could disclose—namely that the very same juvenile o f f i c e optionally organized an evening's p a t r o l i n such a way as l a r g e l y to stay out of concentra-tions of Negro population, choosing instead to p a t r o l white neighborhoods? 24 In sum, i n choosing a method f o r t h i s thesis research, I f e l t , l i k e Turner, that nothing short of an attempt to observe s t a f f members' prenatal and childbearing procedures " i n motion" would s u f f i c e f o r an adequate study of these phenomena. In order to obtain a continuous, on-going view of s t a f f members' a c t i v i t i e s in. s i t u I attempted to integrate my research a c t i v i t i e s into the natural rhythm of a c t i v i t i e s i n the 25 hos p i t a l s e t t i n g by accompanying or "shadowing" them as they went about routine i n t e r a c t i o n with patients. In t h i s fashion, the primary control over what was observed would presumably be exercised by the normal work routines i n the s e t t i n g . The f i e l d of observations would consist, then, i n any and a l l a c t i v i t i e s and events encountered i n the course of tracking personnel. In gathering ethnographic observations f o r t h i s study I spent s i x months as a non-participant observer i n the out-patient c l i n i c and delivery f l o o r of the o b s t e t r i c a l and gyne-cology department of City Hospital, a large general h o s p i t a l s e r v i c i n g both "private" and "public" patients i n a large c i t y of Western Canada. B a s i c a l l y , the bulk of the time spent there was devoted to simply observing and recording i n t e r a c t i o n i n the three areas of the department where I found the most sustained contact between patients and s t a f f members and thus were scenes where patient management rout i n e l y occurred: the intake or waiting area of the outpatient c l i n i c located on the ground f l o o r of the obst e t r i c s and gynecology building, the cubicle area to the rear of the waiting area where pelvic examinations and medical interviews were performed, and the delivery rooms, the s i t e of e h i l d b i r t h s , which were located on the top or fourth f l o o r of t h i s b u i l d i n g . In these three areas I sought to get close to occasions where medical interviews were conducted, p e l v i c examinations performed, and babies delivered, record what transpired i n the behavior of s t a f f members and t h e i r i n t e r -actions with patients, and analyze some of the general features 26 of that behavior. I was introduced, by a high-level adminis-t r a t o r t o the personnel i n charge of these areas, as a "socio-l o g i s t studying the s o c i a l organization of c h i l d b i r t h i n the h o s p i t a l . " Gradually I became acquainted with most of the s t a f f members i n these areas. While I sat on the waiting benches i n the intake area, I was not required to wear a hos p i t a l uniform. At those times I usually dressed i n a sweater and slacks. When accompanying s t a f f while they per-formed the taking of medical h i s t o r i e s and the physical and pe l v i c examinations I was required to wear a white intern's jacket over a white s h i r t and t i e . While observing i n the delivery rooms, I was required to wear a s t e r i l e green s u r g i -c a l gown, cap, shoe covers, and a white face mask. The h o s p i t a l s t a f f dress made me less subject to questioning by s t a f f members; but occasionally patients would address a v a r i e t y of requests to me including asking directions to other parts of the h o s p i t a l and news of the condition of a r e l a t i v e who was a patient. However, there was a continually high turnover of student nurses and doctors from the nearby medical school with which C i t y was a f f i l i a t e d and from which i t drew a s i g n i f i c a n t amount of i t s labor supply. Normally a group of students would spend only s i x weeks i n each Department of the Hospital. Thus, sometimes i t was not possible to be introduced to a l l of them. As a r e s u l t , occasionally they would ask me tech n i c a l questions about anatomy and various gynecological diseases or request my assistance i n the cubicle area and the de l i v e r y room. They 27 apparently assumed from my intern's jacket or green s u r g i c a l gown that I was t h e i r superior i n authority and experience. When such occasions arose, I usually introduced myself as a research medical s o c i o l o g i s t studying the "treatment of o b s t e t r i c a l patients i n the h o s p i t a l . " The student would then usually s h i f t his questioning to my research or request the aid of "another" s t a f f member. Occasionally, I would accede to the request f o r aid with a minor task i n order to further make my presence a natural part of the scene, a f t e r introducing myself. Sometimes I would be compelled to aid i n some minor task without the opportunity to introduce myself. For example, on one occasion while I was standing by i n the de l i v e r y room a patient who was just about to de l i v e r started to bleed from a puncture wound made i n her arm by an intraveinous i n j e c t i o n . The busy, somewhat disturbed student nurse grabbed my hand and forced me to hold a piece of cotton over the wound u n t i l i t stopped bleeding. Again, most of my time was spent watching and l i s t e n i n g . When possible to do so unobtrusively, I took almost l i t e r a l notes i n a small book which was carr i e d between the covers of a medical hi s t o r y f o l d e r . I t r i e d to capture as complete a " t r a n s c r i p t " of the on-going t a l k and behavior as possible, excluding only minor technical remarks such as, "pass me the sponge." Most of my information i s based on these observations and on casual conversations I had with members of the s t a f f and patients. While being aware that my presence i n these areas may influence the s t a f f ' s t a l k and behavior, I f e l t that t h i s e f f e c t was probably mitigated to a s i g n i f i c a n t extent by the long periods of time I spent i n t h e i r presence, as well as by the f a c t that i n the c l i n i c and delivery room s t a f f usually were under a good deal of pressure to perform t h e i r tasks as quickly as possible, presumably making i t more d i f f i c u l t to a l t e r t h e i r performances f o r my b e n e f i t . Access While I experienced few problems i n gaining and main-t a i n i n g access i n the c l i n i c , the d e l i v e r y f l o o r was found to be more d i f f i c u l t . In t h i s section I would l i k e to t r y to account f o r t h i s difference i n a c c e s s i b i l i t y f o r the two-fold purpose of not only describing some of the features of gaining access to a " d i f f i c u l t s e t t i n g , " such as t h i s one, but also to reveal features of the s o c i a l organization of the h o s p i t a l , p a r t i c u l a r l y those that impinged on the c o l l e c t i o n of data. Also, while r a r e l y reported by ethnographers, t h i s kind of background information would seem to be of central concern i n determining what i s being reported. In other words, these access problems (or the lack of them i n some areas of the hospital) must be seen as part of the data co l l e c t e d and taken i n t o account i n any analysis of the data. F i n a l l y , as the reader w i l l see, these problems are not ones that can be solved with more extensive sampling or q u a n t i f i c a t i o n . The d i f f i c u l t i e s experienced i n access i n the delivery f l o o r had t h e i r o r i g i n when a high-level administrative nurse gave me permission to begin observing a c t i v i t y on that f l o o r . 29 At that time she admonished me not to t a l k to nurses on that f l o o r because "they are too busy." "After a l l , you're here to study the patients and t h e i r treatment and not the nurses." Then she said she was worried that I, a lay outsider, should be allowed to witness events i n the delivery room at a l l . I t r i e d to reassure her that I was simply going to record l i t e r a l l y what took place i n that area. However, apparently she was s t i l l not convinced of my o b j e c t i v i t y and competency as an observer: But you aren't a medical person. So, you won't understand what's r e a l l y going on. A l o t of things go on i n the delivery room only the medical s t a f f r e a l l y understand. You won't know how to co r r e c t l y interpret the r e a l meaning of what goes on up there. At t h i s point she said she was very busy and terminated the appointment I had with her. During my subsequent observations i n the delivery room I t r i e d to follow her instructions about not t a l k i n g to nurses. I did so by confining my i n t e r a c t i o n as much as possible to doctors, interns and medical students. However, i n the close confines of the delivery rooms the b a r r i e r I t r i e d to erect between myself and the nurses began to break down. There the assistant head nurse took the i n i t i a t i v e by asking about my research. Because she had the task of supervising other nurses during the delivery she was often free from the on-going a c t i v -i t y to t a l k to me. Within the close quarters of the delivery room we occasionally found ourselves the only "spectators" i n the delivery a c t i v i t y . As a r e s u l t , I f e l t some pressure (and presumably she did, too) to esta b l i s h a conversation. As i t turned out, she had attended some classes i n sociology and 30 anthropology. Apparently f o r t h i s reason she was eager to learn from me how I as a researcher perceived the delivery a c t i v i t y . Also, she would often proffer information on the nurses' rou-t i n e s i n the supervision of patients i n labor and the s o c i a l science l i t e r a t u r e dealing with s t a f f - p a t i e n t r e l a t i o n s h i p s . Next, other nurses began i n i t i a t i n g conversations with me about what I was recording i n my note pad and t h e i r own views about the f l o o r ' s organization and routines. They appeared to be curious about the a c t i v i t i e s of a r e l a t i v e "stranger" i n t h e i r midst. Once they ascertained my s p e c i f i c purpose f o r being there they often t r i e d to "help" me by of f e r i n g b i t s of "gossip" about the f l o o r ' s a c t i v i t i e s . Nevertheless, I s t i l l t r i e d to avoid i n i t i a t i n g conversations with the nurses. However, given the close quarters of the delivery rooms and central hallway (see diagram of the f l o o r plan, page 59) and the fa c t that they had learned my name (and I, th e i r s ) i t became increasingly d i f f i c u l t to keep my interactions with them to a minimum. Dur-ing t h i s time, however, the Head Nurse of the f l o o r (in charge of administrative tasks), who had already been apprised of my ro l e i n the hos p i t a l , remained aloof and cool to my presence on the f l o o r . She did not t r y to i n i t i a t e i n t e r a c t i o n with me. When the period of my observation on the delivery f l o o r was about h a l f over the high-level administrative nurse had me ca l l e d into her o f f i c e . There she admonished me that I was not to "talk to the nurses so much." "You're supposed to be study-ing the patients' relationships with s t a f f — n o t the s t a f f . " I 31 agreed to continue to t r y to follow her i n s t r u c t i o n s . However, following t h i s warning, the f l o o r Head Nurse was occasionally absent f o r several days at a time. During her absences the assistant nurse (and others) became more aggressive i n t h e i r attempts to "help" me by o f f e r i n g me b i t s of "gossip." On one such occasion they discussed with me a caesarian section where the baby almost died at b i r t h . When the Head Nurse returned a f t e r t h i s occasion, she n o t i f i e d me that the high-level administrative nurse had t o l d her to t e l l me that I was not supposed to come up to the delivery f l o o r any more. When I subsequently discussed with the high-level administrative nurse the reasons f o r my dismissal she t o l d me that the patients' privacy has to be protected and that the nurses had complained about my presence i n the delivery room. Plus, she said, We don't gossip about patients, especially when they are Hospital s t a f f . The patient whose baby had problems i n the c-section was s t a f f . But you are not to think of i t as being dismissed at a l l . I t ' s just that we think you must have enough by now to get an o v e r a l l picture of the delivery f l o o r . That's a l l we agreed to i n the f i r s t place. (In f a c t , we had never discussed the length of my observations on that f l o o r . ) Because I f e l t I had enough observations f o r an adequate des c r i p t i o n of the delivery f l o o r , and due to my f r o s t y reception from the Head Nurse, I did not t r y to renegoti-ate access to that f l o o r . Later, when I discussed with the delivery f l o o r nurses the reasons given to me f o r being dismissed and being l i m i t e d as to whom I could t a l k to on the f l o o r , they said that they had not heard any complaints about my presence from members of the nursing s t a f f . On the other hand, they suggested that the " r e a l reason" f o r the l i m i t a t i o n and ultimate dismissal was that the nursing administrators (including the Head Nurse of the d e l i v e r y f l o o r ) were concerned at that time with the fa c t that the Hospital was undergoing a review of i t s e f f i c i e n c y and budget by the Hospital's trustees. In f a c t , they informed me that just two weeks p r i o r to my i n i t i a l appearance i n the delivery f l o o r a "time and motion" e f f i c i e n c y "expert" had been taking notes while "shadowing" s t a f f members, much as I had done. The interns who were on duty also gave me t h i s theory when I discussed with them the reasons f o r my dis m i s s a l . Further, these s t a f f members' theory that the administrators were p r i -marily concerned with the on-going " e f f i c i e n c y review" appeared to be supported to some extent by the f a c t that several months a f t e r my dismissal the p r i n c i p a l newspapers of the c i t y reported that a number of nurses had been discharged from City Hospital as a r e s u l t of the " e f f i c i e n c y review." One way to understand the negative reactions of the high l e v e l administrative nurse to my presence i n the delivery f l o o r i s to make use of the notion that members of society i n t h e i r i n t e r a c t i o n with other members employ categorization devices and associated expectations about behavior i n order to make sense of the s i t u a t i o n and to guide t h e i r own actions i n 25 the exchange. ' When people who do not know each other are placed i n a p o s i t i o n of i n t e r a c t i n g , we might assume that they are going to t r y and f i n d out what the other wants or i s doing. I t may be that one way of checking on who a person i s and what he wants i s to make use of information already at hand about people who seem to be l i k e him. I f the person does not belong to a category that the other possesses information about and he has to handle what he sees as p o t e n t i a l l y dangerous informa-t i o n , i n t e r a c t i o n may be both problematic and s t r e s s f u l . The observer i s present by design to f i n d out what i s going on and the administrative s t a f f may want to l i m i t what i t i s he hears and sees. These s t a f f members may be concerned not to make information available to the observer that l a t e r can be used against them.^ What I am arguing i s that the reason that some of the administrative nursing s t a f f did not seem happy about my presence i s due to the f a c t that they were not sure about the " r e a l " purpose of the research and t h e i r problem of f i n d i n g out what was the r e a l purpose was predicated on associating me with a category of persons about whom they "knew" something. One way of solving the problem would be to see i f I could be assimilated to any of the s o c i a l types who are "normally" around the Hospital. For example, i n the c l i n i c the adminis-t r a t i v e s t a f f also were not sure how to regard a s o c i o l o g i s t being i n the h o s p i t a l . Apparently they saw me as making some kind of study they did not understand. However, a year before my appearance i n the c l i n i c a fourth-year medical student had done a study there of unwed mothers' psychological reactions to 34 pregnancy. In so doing he was aided by the s o c i a l worker, who interviewed the unwed mothers who came to the c l i n i c f o r pre-natal care. I believe as a r e s u l t of t h i s past experience with the presence of a person doing behavioral research (an experi-ence which was lacking i n the de l i v e r y f l o o r ) , the s o c i a l worker quickly "took me under her wing" and other s t a f f members assumed that I was i n some way a f f i l i a t e d with her. Thus, I believe that the a v a i l a b i l i t y of the category of "behavioral researcher" to t y p i f y or assimilate the otherwise enigmatic t i t l e of s o c i o l o g i s t greatly f a c i l i t a t e d access to the c l i n i c . On the other hand, the nursing administrator's apparent use of the category " c r i t i c a l lay observer" (perhaps even some kind of " e f f i c i e n c y expert") who, as she puts i t , ". . . won't know how to c o r r e c t l y interpret the r e a l meaning of events. . . " t o resolve the problem of making sense of a puzzling researcher who wants to "shadow" s t a f f members during a period of budgetary and e f f i c i e n c y review probably contributed to my access problems i n the delivery f l o o r . Other ethnographic studies of o b s t e t r i c a l and/or gyne-c o l o g i c a l services appear to support my view of the importance of categorization of the researcher by s t a f f during the conduct of f i e l d work. For example, William Rosengren found that the lack of c l e a r l y defined categorization by s t a f f presented an obstacle to doing his f i e l d study. . . . During the f i r s t two or three evenings, the most pronounced obstacle to both accurate observation and acceptance by the personnel was the f a c t that from t h e i r point of view we had neither legitimate status nor meaning-f u l r o l e s i n the h o s p i t a l . Simply, people wondered what we 35 were doing there and how they should r e l a t e themselves to us. I n i t i a l l y , many of the p e r s o n n e l — p a r t i c u l a r l y the s t a f f nurses—seemed to think that we were new externs (medical students). And perhaps because of t h i s we were occasionally c a l l e d upon by the nurses to a s s i s t i n a subordinate fashion with some of the minor tasks prepara-tory to d e l i v e r y . Others seemed to f e e l that we were "inspectors" from the National I n s t i t u t e of Neurological Diseases and Blindness. For ourselves, we remained mum on the issue. The f i r s t d e f i n i t i o n of us by the s t a f f gave us meaningful r o l e s but no status. The second gave us legitimate status but no meaningful r o l e . As observers, therefore, we were caught up i n an almost i d e a l contradic-t i o n of status and r o l e . The dilemma was gradually resolved: F i r s t we were given a kind of status, primarily by being allowed to observe high-status private o b s t e t r i -cians and t h e i r patients. We were then provided with a meaningful r o l e , from the point of view of the o b s t e t r i c a l team, by helping them with some of the observations and recordings required by the National Collaborative Study (of B i r t h Defects—J.E.F.) which the team members found burdensome to do themselves.27 Joan Emerson i n her study of gynecological examinations i n a medical school also found that being categorizable by s t a f f as having a (as Rosengren terms i t ) "meaningful r o l e " v i s a v i s l i f e - a s - u s u a l i n the hospital greatly enhanced her a b i l i t y to gain information. Like Rosengren, she found that a more participant r o l e (acting as a nurses' aide) increased her accep-tance by s t a f f members. Possibly i f I, too, had had some f a m i l i a r "meaningful r o l e " whereby s t a f f (but e s p e c i a l l y the administrative nurses) found me a p o s i t i v e a i d i n t h e i r every-day work routines, then the ambiguity of my research a c t i v i t y may have been overlooked i n favor of my "contribution" to easing the work load i n the delivery f l o o r . However, I suspect that the problems I encountered with p a r t i c i p a t i n g i n "gossip" may have been much more d i f f i c u l t to solve or prevent. For example, l i k e myself, Emerson found that 36 refusing to j o i n i n the "gossiping" among s t a f f members resulted i n a " b a r r i e r " to gaining rapport and acceptance. . . . At the onset of the research the observer had the po l i c y of not giving information or opinions about any subject ( s t a f f , patient or v i s i t o r ) to any other subject, unless i t were a matter of carrying messages or something which came up i n the observer's r o l e as nurses' aide. The b a r r i e r s created by the observer's r e f u s a l to contrib-ute "gossip" about patients (and v i s i t o r s ) seemed f o r -midable enough to suggest that such a p o l i c y was too r i g i d when the observer was a participant to the degree that she was, and by the time the observer arrived on the medi-ca l ward she participated circumspectly i n the gossip (and occasionally "technical reports") about patients. Recording Observations In attempting to take almost verbatim notes I t r i e d to p o s i t i o n myself i n the three areas so that t h i s recording a c t i v i t y would not become a focus of attention f o r subjects being observed and thereby disrupt the normal on-going i n t e r -a c t i o n . In the c l i n i c waiting room the benches where waiting patients sat usually were f a i r l y crowded with patients and t h e i r male companions. I usually sat at the end of the waiting bench next to the wall on the side of the bench next to the S o c i a l Worker's " o f f i c e " (see the f l o o r diagram at the beginning of Chapter I I , page 58) to take advantage of t h i s crowd to reduce the v i s i b i l i t y of my presence and note-taking a c t i v i t y . As a r e s u l t , usually the waiting patients and t h e i r companions did not seem to take p a r t i c u l a r notice of my presence and rapid recording of s t a f f - p a t i e n t i n t e r a c t i o n s . In the p e l v i c examination area of the c l i n i c I wore a white coat while accompanying f i v e or s i x third-year medical 37 students and a teaching resident or o b s t e t r i c i a n when the medical history, general physical examination and the p e l v i c examination are performed. During t h i s period of contact with the patient, a student normally records i n d e t a i l the patient's h i s t o r y and notes her blood pressure and other observations derived from the physical and p e l v i c examinations. As a r e s u l t , my own recording a c t i v i t y f o r the most part went unnoticed by a l l p a r t i c i p a n t s . S i m i l a r l y , from the time patient enters the delivery f l o o r , s t a f f (usually the nurses) occasionally record t h e i r observations of the patient's progress i n labor. In f a c t , i n a corner of the delivery room at the head of the delivery table i s located a small writing shelf, where they p e r i o d i c a l l y record observations on labor progress and the delivery process. (See diagram of d e l i v e r y f l o o r at the beginning of Chapter II, page 59.) During my observations I stationed myself at that record-ing shelf, where I was f a i r l y well removed from s t a f f members' work. Usually my note-taking seemed to go unnoticed by s t a f f , p a r t i c u l a r l y when they were bu s i l y engaged i n labor coaching and i n the delivery process. However, when there was a break i n the a c t i v i t y , occasionally a nurse would ask what I was so busy recording. I would then show her my notes and a discussion of my research would ensue. Generally, I t r i e d to avoid taking notes i n the h a l l -ways of the areas because there i t seemed to a t t r a c t attention from s t a f f members (not so, p a t i e n t s ) . I t provoked t h e i r i n q u i r i e s as to my credentials f o r being there (as a possible 38 "newspaper man") by those s t a f f members who had not been introduced to me. Thus, when I observed s t a f f - p a t i e n t or s t a f f -s t a f f i n t e r a c t i o n i n the hallways I had to duck into an unoccu-pied examination cubicle, a lab room, the doctor's lounge ( i f i t were unoccupied), or the lavatory to record my observations. Consequently, before my observations i n the hos p i t a l were complete, I had i d e n t i f i e d various niches i n the ecology of the c l i n i c and delivery room f l o o r s which would provide at least a temporary b a r r i e r behind which I could retreat to take notes. In conclusion, the methodological problems I encountered i n t r y i n g to capture a complete picture of work routines without the aid of a tape recorder or videotape machine are informative of not only how to do such an ethnography, but also the s o c i a l and ecological organization of the hospital v i s a v i s writing and note-taking by s t a f f members as a normal, l i f e - a s - u s u a l , located a c t i v i t y . The quotations that appear i n t h i s thesis to i l l u s t r a t e features of s t a f f members' work routines i n the hospital come d i r e c t l y from my f i e l d notes. The only alt e r a t i o n s made to the o r i g i n a l notes involve t h e i r grammatical structure. S p e c i f i c -a l l y , i n some cases I was so busy t r y i n g to record what I was observing that I neglected to provide clear sentence and para-graph breaks i n the o r i g i n a l f i e l d notes. As additional sources of data f o r t h i s t h e s i s , I w i l l draw on published and unpublished descriptions of labor and del i v e r y room i n t e r a c t i o n by patients who have t r i e d to d e l i v e r t h e i r babies without anesthesia, i . e., what are loosely t y p i f i e d 39 by s t a f f as "natural c h i l d b i r t h " patients. Most of the groups and organizations that provide t r a i n i n g to prepare these patients usually require a " b i r t h report" from each woman to assess how successful they were at doing without anesthesia, as well as to learn various hospital's treatment routines and how to cope with them, i f necessary.3° Approximately 120 reports from patients i n the East and Western United States and England were analyzed to discover what management tech-31 niques were employed i n various h o s p i t a l s . In most cases the methods I observed at City were also described by the reports of the "natural c h i l d b i r t h " patients. Thus, descrip-tions from these reports w i l l be used as a source of corrobo-r a t i n g or supporting data. An additional source of supporting data were found i n the non-fiction published accounts of experienced private obstetricians.-^ Since they are written f o r a non-professional audience, they provide clear, detailed descriptions of actual i n t e r a c t i o n between doctors and patients i n the private o f f i c e s where medical interviews are conducted and pe l v i c and physical examinations performed, as well as i n labor and delivery rooms. F i n a l l y , I would l i k e to conclude t h i s section by expressing my gratitude f o r the cooperation extended to me by the s t a f f members and administrators at City Hospital i n allow-ing me to accompany them i n t h e i r routine a c t i v i t i e s and answer-ing my naive questions. In accord with promises I made to them, unfortunately, I am unable to thank individuals by name or i d e n t i f y the i n s t i t u t i o n d i r e c t l y . For the same reasons of 40 c o n f i d e n t i a l i t y and anonymity, the names of s t a f f members and patients have been changed or deleted from the reported observa-tions . Organization of the Thesis The thesis i s organized so as to give a detailed anal-y s i s of the three areas i n City Hospital where I found the most sustained i n t e r a c t i o n between s t a f f members and patients. Thus, each of three chapters analyzes the organization of the s t a f f members' work routines, p a r t i c u l a r l y patient management tech-niques, f o r a p a r t i c u l a r area. Analysis of the areas w i l l be presented i n the same order as they are encountered by the " t y p i c a l " o b s t e t r i c a l patient as she progresses through each stage of her organizational career: f i r s t the work routine i n the C l i n i c waiting room or intake area (Chapter I I I ) , then the cubicle or p e l v i c examination area (Chapter IV), and f i n a l l y the organization of work routines i n the d e l i v e r y room (Chapter V). Before presenting these three chapters, I w i l l , i n Chapter I I , provide the reader with a b r i e f run-through of the routines i n the three areas to give a general overview of the s t a f f treatment practices that w i l l be dealt with i n subsequent chapters. Also, i n the second h a l f of Chapter I I , I w i l l begin to provide some analysis of intake area work routines by showing how the organization of s t a f f ' s work influences the "organiza-t i o n of embarrassment" f o r the patients, i . how the pressures of processing a large patient case load i n a short 41 time leads to "neglect" by s t a f f of i d e o l o g i c a l l y prescribed proprietous treatment of patients, many of whom are unwed and concerned to manage the v i s i b i l i t y of t h e i r stigmatized status (unless, of course, such proprietous "protective" routines are costless of time, energy, e t c . ) . In Chapter I I I , I w i l l describe other patient manage-ment routines i n the intake area (and to a l e s s e r extent those i n the cubicle area) and s t a f f ' s view of themselves as having a mandate to i n s t r u c t and to lay the whole routine of pre-natal care on patients, regardless of t h e i r situations and views. Many patients' reactions to s t a f f ' s treatment here and i n other areas can index t h e i r character as "troublesome" from the s t a f f ' s viewpoint. In other words, i n t h i s Chapter, I w i l l t r y to show that there are systematic attempts to coerce patients to "shape up" so that i n the always-oriented-to f i n a l stages (labor and d e l i v e r y ) , they w i l l (hopefully) be "good patients." Also, we w i l l see s t a f f protecting standardized r o u t i n e s — e . g., requests f o r a female doctor get treated as organizationally d i s r u p t i v e . In t h i s Chapter, too, I w i l l attempt to show how the s o c i a l worker i n the C l i n i c i s occupationally trained, as part of the (medical) "team," to look ahead to the baby's "fate" a f t e r b i r t h — i s s u e s of father's employment, adoption, etc. Here, and with doctors i n the cubicle area too, the medical shades o f f into concerns with "model middle-class family arrangements," and s t a f f i n both areas seem to treat t h e i r mandate to enforce these f o r granted. Chapter IV deals with patient management techniques I 42 found i n the cubicle area where pe l v i c examinations, general prenatal physical examinations, and prenatal lectures are given to o b s t e t r i c a l patients. Here, I w i l l t r y to demonstrate how work exigencies such as work scheduling and providing a v i s i b l y competent performance r e s u l t i n only the occasional implementation of the ideals of the medical ideology ( i n c l u d -ing the "necessity" to "teach" patients, t r e a t t h e i r " i n d i v i -dual" problems, and give proprietous care) i n regard to patient management techniques; an approach to patient "care" and the teaching of students I term the "technical approach" (as. opposed to the academically-located "patient as person" medical p h i l o s -ophy or approach which supports the more consistent implementa-t i o n of i d e o l o g i c a l ideals i n everyday work routines). Since medical students do the bulk of the work i n t h i s area, I w i l l pay p a r t i c u l a r attention to analyzing t h e i r organizational problems, work orientations, concerns with "getting through" prenatal interviews and general examinations i n a v i s i b l y competent manner, etc. Some of the supervisory contact i s oriented to "making physicians" of medical students. In t h i s process, supervising physicians may give "pep-talks" containing i d e a l " i d e o l o g i c a l " components on the "patient as person" approach, as I have termed i t , but seem l a r g e l y to ignore s t u -dents' p r a c t i c a l work problems. In other words, i n these d i d a c t i c sessions, the "technical approach" (the medical philosophy, generally of an i m p l i c i t nature, which i s most commonly followed by Residents and medical students i n the cubicle area and delivery room, as well as by s t a f f i n the 43 intake area) to patient management may be down-graded as a medical philosophy, but students have to come to terms with the demand c h a r a c t e r i s t i c s of the s i t u a t i o n (scheduled work and v i s i b l e competence) once they get to the cubicles. Chapter V documents the intransigence of labor and delivery as "raw materials" f o r organizational programming and the patient management work routines developed to cope with the natur a l l y d i f f i c u l t features of these processes i n terms of the demand c h a r a c t e r i s t i c s of scheduling them as work and providing a v i s i b l y competent performance while "aiding" these processes. Also, I w i l l t r y to show i n t h i s Chapter how the ethnographic method adopted f o r use i n my research i s p a r t i c u l a r l y useful f o r revealing features of work routines, including management techniques and the "problems" or "complications" they cause o b s t e t r i c a l patients i n labor and d e l i v e r y . The e f f i c a c y of t h i s research strategy w i l l be contrasted with a s t r u c t u r a l survey approach to theory and method which imposes the research-er's organizationally a l i e n view of events i n the hos p i t a l as r e s u l t i n g from extra-hospital attributes and processes of s t a f f and patients (e. g., s o c i a l c l a s s , s o c i a l psychological a t t i -tudes, b e l i e f s , etc.) and thereby often produce demonstrably spurious analysis of such organizational events as labor and d e l i v e r y . 4 4 FOOTNOTES 1 . Margaret Mead, "Families and Maternity Care Around the World," B u l l e t i n of the American College of Nurse-Midwifery," VIII (Spring, 1 9 6 3 ) , 6 - 7 . 2 . Elizabeth Hosford, "The Maternity C y c l e — A Time of Challenge," B u l l e t i n of the American College of Nurse-Midwiferv, XII (May, 1967TT 4 7 - 4 8 . 3 . See Robert N. Wilson and Samuel W. Bloom, "Patient-Practitioner Relationships," i n Howard E. Freeman, Sol Levine, and Leo G. Reeder, eds., Handbook of Medical Sociology ( 2 n d ed.; Englewood C l i f f s , New Jersey: Prentice-H a l l , Inc., 1 9 7 2 ) ; also see Benjamin D. Paul, "Anthropologi-c a l Perspectives on Medicine and Public Health," i n Jerome K. Skipper and Robert C. Leonard, eds., S o c i a l Interaction  and Patient Care (Philadelphia: J . B. Lippincott Company, 1 9 6 5 ) . 4 . Wilson and Bloom, "Patient-Practitioner Relationships"; see also Paul, "Anthropological Perspectives." 5 . E l i o t Freidson, "Managing Patients," i n E l i o t Freidson and Judith Lorber, eds., Medical Men and Their Work (Chicago: Aldine, Inc., 1 9 7 2 ) , pp. 2 0 2 - 2 0 4 . 6. Anonymous M.D., Confessions of a Gynecologist (New York: Doubleday and Company, 1 9 7 2 ) , pp. 3 1 3 - 3 1 5 . 7 . By "demand c h a r a c t e r i s t i c s " I follow Turner's formulation of those " s i t u a t i o n a l and contextual features which persons engaged i n everyday routines orient to as governing and organizing t h e i r a c t i v i t i e s . . . " See Roy Turner, "Occupational Routines: Some Demand Characteristics of Police Work," paper presented to the C.S.A.A., Toronto, June, 1 9 6 9 ; see also Egon Bittner, "The Police on Skid Row: A Study of Peace Keeping," American S o c i o l o g i c a l Review, XXXII (October, 1 9 6 7 ) , 6 9 9 - 7 1 5 ; and Martine Orne's paper "On the S o c i a l Psychology of the Psychological Experiment," American Psychologist, (November, 1 9 6 2 ) , pp. 7 7 6 - 7 8 3 . 8. David Sudnow, Passing On (Englewood C l i f f s , New Jersey: Prentice-Hall, Inc., 1 9 6 7 ) ; Erving Boffman, Asylums (Garden City, New York: Doubleday Anchor, 1 9 6 1 ) ; Aaron V. Cicourel, The S o c i a l Organization of Juvenile Justice (New York:"John Wiley, 1 9 6 8 ) ; Don H. Zimmerman, "Tasks and Troubles: The P r a c t i c a l Bases of Work A c t i v i t i e s i n a 4 5 Public Assistance Organization," i n D. A. Hansen, ed., Explorations i n Sociology and Counseling (Boston: Houghton-M i f f l i n , 1 9 6 9 ) . 9. Margaret Mead and Niles Newton, "Cultural Patterning of Prenatal Care," i n S. A. Richardson and A. F. Guttmacher, eds.,Childbearing: I t s S o c i a l and Psychological Aspects (New York: Williams-Wilkins, 1 9 6 7 ) , pp. 1 4 2 - 2 4 5 . 1 0 . R. I l l s l e y , "The S o c i o l o g i c a l Study of Reproduction and Its Outcome," i n Richardson and Guttmacher, eds., Childbearing: pp. 7 5 - 1 4 2 . 1 1 . D. Baird, "Influence of S o c i a l and Economic Factors on S t i l l b i r t h and Neonatal Death," Journal of Obstetrics and Gynecology B r i t i s h Empire. LII, 2 1 7 - 2 3 4 ; L. Brown, "Social and A t t i t u d i n a l Concomitants of I l l n e s s i n Pregnancy," B r i t i s h Journal of Medical Psychology. XXXV, 3 1 1 - 3 2 2 ; E. Crump, "Relation of B i r t h Weight i n Negro Infants to Sex, Maternal Age, Parity, Prenatal Care and Socio-economic Status," Journal of P e d i a t r i c s . LI, 6 7 ^ - 6 9 7 . 1 2 . William Rosengren and S. DeVault, "The Sociology of Time and Space i n an Obstetrical Hospital," i n E l i o t Freidson, ed., The Hospital i n Modern Society (New York: Free Press, 1 9 6 3 ) , pp. 265-292; Sudnow, Passing On; Joan Emerson, "Behavior i n Public Places: Sustaining Definitions of R e a l i t y i n Gynecological Examinations," i n Hans Peter D r e i t z e l , ed., Recent Sociology. No. Two: Patterns of  Communicative Behavior (New York: Macmillan. 1 9 7 0 ) . pp. 7 4 - 9 7 ; James M. Henslin and Mae A. Biggs, "Dramaturgical Desexualization: The Sociology of the Vaginal Examination," i n James M. Henslin, ed., Studies i n the Sociology of Sex (New York: Appleton-Century-Crofts, 1 9 7 1 ) , pp. 243-272; Prudence Mors Rains, Becoming an Unwed Mother (Chicago: Aldine, 1 9 7 1 ) . 1 3 . See, e. g., E l i o t Freidson, The Profession of Medicine (New York: Random House, 1 9 7 0 ) ; Sudnow, Passing On; Thomas J . Scheff, On Being Mentally 1 1 1 (Chicago: Aldine, 1 9 6 6 ) . 1 4 . Sudnow, Passing On. see the section e n t i t l e d , " L i f e and Death: A Special Case of Interdependence," pp. 1 0 9 - 1 1 6 . 1 5 . By "ethnomethodology" I follow Turner's formulation found on p. 7 i n Roy Turner, Ethnomethodology: Selected Readings (Baltimore: Penguin Education, 1 9 7 4 ) : . . . I have attempted to represent the variety of research concerns and strategies which today pass as ethnomethodology. The subsuming of these works under that r u b r i c i s my r e s p o n s i b i l i t y , and I have been 46 guided c h i e f l y by p r a c t i c a l professional c r i t e r i a : I think i t i s safe to say that a l l of these authors would be regarded by " t r a d i t i o n a l " s o c i o l o g y - i t s e l f a gloss f o r a set of diverse e n t e r p r i s e s — a s p r a c t i -tioners of the "school". . . .In short, what ethno-methodology now amounts to i s to be located i n the research output of i t s p r a c t i t i o n e r s . . . . Turner subsumes the works of the following s o c i o l o g i s t s (among others) under the rubric of ethnomethodology: H. Garfinkel, Dorothy Smith, Egon Bittner, A. V. Cicourel, David Sudnow, Don H. Zimmerman, Roy Turner, and Harvey Sacks. 16. I b i d . 17. Ibid., pp. 16-18. 18. Zimmerman, "Tasks and Troubles: The P r a c t i c a l Bases of Work A c t i v i t i e s i n a Public Assistance Organization," 19. David Sudnow, "Normal Crimes: S o c i o l o g i c a l Features of the Penal Code i n a Public Defender's O f f i c e , " S o c i a l Problems. XII, 1965. 20. Sudnow, Passing On. 21. This publication was a small pamphlet, "The City Hospital Story," r e a d i l y available i n the waiting rooms and reception areas of the Hospital. From t h i s document I drew the s t a t i s t i c s which I produce i n t h i s section. 22. I b i d . 23. Sudnow, Passing On. 24. Turner, Ethnomethodology:« pp. 2-3. 25. This formulation i s based loosely on Harvey Sacks' formulation as found i n h i s unpublished doctoral d i s s e r t a -t i o n : "The Search f o r Help: No One to Turn To," University of C a l i f o r n i a , Berkeley, 1966. 26. This s i t u a t i o n may be seen as having properties s i m i l a r to those reported by Orne, M i l l s and Reicken with regard to small group research. They report that subjects do not play a passive r o l e i n research but bring into play the same s o c i a l s k i l l s they do i n other s i t u a t i o n s . Clearly t h i s also applies to f i e l d as well as experimental research. Orne, "On the S o c i a l Psychology of the Psychological Experiment; Thdodore M. M i l l s , "A Sleeper Variable i n Small Groups Research: The Experimenter," P a c i f i c S o c i o l o g i c a l Review. (Spring, 1962), pp. 21-28; 47 Henry W. Reicken, "A Program f o r Research on Experiments i n S o c i a l Psychology," Decisions, Values and Groups. Vol. II, edited by Norman F. Washburne (New York: Pergamon Press, 1962). 27. Rosengren, "The Sociology of Time and Space i n an Ob s t e t r i c a l Hospital," p. 270. 28. Joan Emerson, "Social Functions of Humor i n a Hospital Setting," (unpublished Doctoral d i s s e r t a t i o n , University of C a l i f o r n i a , Berkeley, 1963), pp. 352-353. 29. I b i d , p. 353. 30. The following are some of the "Birth Report Guidelines" f o r "natural c h i l d b i r t h " patients to follow i n describing f o r the natural c h i l d b i r t h organization t h e i r experiences i n giving b i r t h i n h o s p i t a l s . (Taken from p. 18 of Mary Kay Woodward. The Lamaze Method of C h i l d b i r t h Education  Student Manual (Fontana, C a l i f o r n i a : Preparing Expectant Parents, 19767. BIRTH REPORT GUIDELINES PLEASE—do i t as soon as possible, i n the h o s p i t a l , so i t doesn't get shunted o f f with the "sometime" things when memory may be l e s s v i v i d and accurate. This needn't be what you'd consider a "Literary M asterpiece"—just your own account of what happened—as clear, concise, and complete as possible. The true value of a b i r t h report rests i n the t e l l i n g of one very s p e c i a l "Birthday Story" by those who made i t so. (Husband's comments encouraged and greatly appreciated.) Please t r y to give a l i t t l e background concerning your becoming interested i n c h i l d b i r t h preparation . . . including comments of previous experiences i n c h i l d b i r t h . Follow as well as you can and f e e l to be h e l p f u l : your progress through labor; mentioning d i f f i c u l t and easy Earts (when and how long; 1st phase, 2nd or "Working abor" t r a n s i t i o n , expulsion—about how many contractions, pushes, etc...episiotomy?) T e l l of adaptation needed (when to use which breathing), f e e l i n g s then, other points which most impressed you, and might help someone i n a s i m i l a r s i t u a t i o n to better analyze her needs. Spotlight afterthoughts: yours, husband's, doctor's, ho s p i t a l s t a f f ' s (Try to get names of those p a r t i c u l a r l y h e l p f u l , understanding, and/or interested so that you can drop a note of appreciation l a t e r . ) How do you f e e l about recommending t h i s approach to others? Please include a 48 l i n e granting us permission to publish and/or quote any or a l l of your report, and sign i t . 31 . International C h i l d b i r t h Education. " B i r t h Reports," unpublished, Pomona, C a l i f o r n i a : Preparing Expectant Parents Library, 1967-1971; Elizabeth D. Bing, The  Adventure of B i r t h (New York: Simon and Schuster, 1970; Marjorie Karmel, Thank You. Dr. Lamaze (Garden City, New York: Doubleday Dolphin, 1965); Sheila Kitzinger, Giving B i r t h : The Parents' Emotions i n C h i l d b i r t h (New York: Taplinger Publishing Company, 1971). 32. Anonymous M.D., Confessions of a Gynecologist: also see William J . Sweeney, Woman's Doctor: A Year i n the L i f e  of an Obstetrician-Gynecologist (New York: William Morrow and Company, 1973)• 49 CHAPTER II WORK ROUTINES AND EMBARRASSMENT This chapter w i l l f i r s t provide a b r i e f run-through of the work routines i n the three areas of the hospital where I found the most sustained s t a f f - p a t i e n t i n t e r a c t i o n . The intent i s to give the reader a general overview of s t a f f treatment routines that w i l l be dealt with i n subsequent chapters. In the second h a l f of t h i s chapter, I w i l l begin the analysis of intake area work routines (which w i l l be continued to completion i n Chapter III) by showing how work exigencies allow only the occasional implementation of ideolo-g i c a l l y prescribed ideals of proprietous treatment of patients. The second h a l f of t h i s chapter, then, i n i t i a t e s the analysis of the e f f e c t of the p r a c t i c a l features of work routines on the implementation of professional ideals of patient care. This l a t t e r analysis w i l l be p a r t i c u l a r l y carried through i n Chapter IV (the cubicle area) and Chapter V (the labor and delivery areas). Overview of Routines The Outpatient C l i n i c of City Hospital provides gynecological, prenatal, and "well-baby" care, as well as s o c i a l service primarily to those who do not have or cannot afford a private physician. Members of the s t a f f t y p i f i e d the 50 patients who use the c l i n i c to consist of unwed g i r l s from the Home f o r unwed mothers, Indians from t r i b e s i n Western Canada, women whose husbands had deserted them or were unemployed or i n j a i l , women from prisons and juvenile h a l l s , p r o s t i t u t e s , "go-go g i r l s , " mostly unwed young "hippies," and a few st u -dents. For the purposes of providing some ethnographic back-ground on the intake and cubicle areas I would l i k e to follow the " t y p i c a l " or "routine o b s t e t r i c a l patient" through her i n i t i a l check-up routine i n the c l i n i c . Most of the prospec-t i v e patients were required to make an appointment f o r one of the weekdays on which the o b s t e t r i c a l c l i n i c s are offered: Monday, Wednesday, or Friday from 12:45 to 4:00 i n the a f t e r -noon. A l l patients are given a 12:45 appointment to allow time to process them before 2:00 when the residents and students a r r i v e to interview and examine the patients. After the patient a r r i v e s , the receptionist or the head nurse requests that she go to the " l a d i e s " to "empty her bladder" and "leave a speci-men." Then, since most patients do not have p r o v i n c i a l or private medical insurance, or s u f f i c i e n t income, the reception-i s t sends her to the o f f i c e of the " e l i g i b i l i t y s o c i a l worker" (see diagram on page 58) who helps them f i l l out an e l i g i b i l i t y statement to determine i f she q u a l i f i e s f o r p r o v i n c i a l aid to pay f o r her prenatal check-ups, medication, and delivery of the baby by a " c l i n i c " or " s t a f f " resident or i n t e r n . This completed form i s given to the s o c i a l worker who makes the f i n a l assessment of e l i g i b i l i t y and advises patients on employ-ment, housing, family and psyc h i a t r i c problems, as well as r e f e r r a l to an adoption agency or psychiatry outpatient department, i f necessary. After being interviewed by the s o c i a l worker i n her o f f i c e , the patient i s weighed and has a blood sample taken by the head nurse. F i n a l l y the head nurse c a l l s her name from her f i l e and a p r a c t i c a l nurse shows her to a cubicle and instructs her to undress and dress i n the gown. She usually s i t s on the examining table f o r f i f t e e n to twenty minutes before the medical student or resident appears through the curtains. T y p i c a l l y , he does not introduce him-s e l f and hurriedly asks her a serie s of questions on her and her family's past medical problems, as well as the history of her menstruation, any past pregnancies, and her frequency of sexual intercourse, and b i r t h control p r a c t i c e s . He then gives her a cursory, general physical examination. The nurse "puts her up" by placing her legs apart r e s t i n g on boards or " s t i r r u p s , " exposing the p e l v i c area. He performs the p e l v i c examination to check f o r uterine cancer, i n f e c t i o n s , venereal disease, symptoms of pregnancy, and the dimensions of the pe l v i c arch r e l a t i v e to the probable size of a baby at "term." Then the patient i s t o l d to get dressed. Afte r she i s dressed, the resident or student usually t a i l s her she i s i n good health and whether or not he thinks she i s pregnant. He writes her prescriptions f o r vitamins and irons and i n s t r u c t s her to return i n a month f o r a routine check-up. She returns to the rece p t i o n i s t ' s counter f o r another appointment. Usually, the rece p t i o n i s t r e f e r s her to the d i e t i t i a n ' s o f f i c e f o r dietary advice or to psychiatry outpatient i f the doctor recommends it."*" On the "term" or probable l a s t prenatal check-up before d e l i v e r y , another p e l v i c examination i s performed to check on the progress and d i s p o s i t i o n of the baby. At the conclusion of t h i s v i s i t the patient i s t o l d to c a l l the h o s p i t a l and come i n when her labor contractions are f i v e minutes apart. A large proportion, perhaps a majority, of the patients who d e l i v e r at C i t y are "private." However, a l l patients who a r r i v e i n labor have t h e i r g e n i t a l area shaved, given an enema, and a pelvic examination by an i n t e r n to determine whether her labor i s " f a l s e " ( i n which case she i s sent home) or " r e a l " ( i n which case she i s sent up to the fourth f l o o r ) . Her husband, i f he i s not to be present i n the delivery room, i s sent up to the waiting room on the t h i r d f l o o r . On the t h i r d f l o o r are twenty to t h i r t y private and semi-private rooms f o r obstetric patients (usually recovering from delivery) as well as gynecology patients. The second f l o o r consists of two open wards of f i f t y beds each, as well as a glass enclosed nursery f o r newborn babies. I f her cervix has been diagnosed as being l e s s than ten centimeters d i l a t e d , she i s put i n one of the four labor rooms on the d e l i v e r y f l o o r (see diagram on page 59 ). Her progress i n labor i s monitored by nurses on the f l o o r who c a l l her doctor when her cervix has reached eight to ten centimeters and diagnosed ready f o r one of the three delivery rooms down the h a l l from the labor rooms. She i s usually entering the "pushing" or second stage of labor when put on the delivery t a b l e , legs and abdomen draped with s t e r i l e sheets, and legs spread and strapped on s t i r r u p s i n the same po s i t i o n she assumed f o r a pe l v i c examination. Meanwhile, her doctor usually has arrived from his o f f i c e or another part of the h o s p i t a l . Depending on her progress, he may check i n with her f i r s t or go d i r e c t l y to the doctor's lounge on the fourth f l o o r where he changes into a green s t e r i l e gown. He then proceeds to the delivery room where an anesthetist has probably already begun giving the patient, who often i s i n pain and loudly com-plain i n g , doses of nitrous oxide through a mask. While she was i n the labor room the senior nurse on duty may supervise the administration of heroin (City i s one of the few hospitals l e f t with a supply of t h i s p a i n - k i l l e r ) or other anesthetic. I f the delivery and baby are expected to be routine and trouble-free, the doctor i s usually assisted by the intern, an anesthe-t i s t , and four nurses, two of which are students. I f the husband i s allowed to attend the delivery he i s f i r m l y t o l d to stay at the head of the delivery table and not get i n the s t a f f ' s way. The resident p e d i a t r i c i a n and h i s assistant (or a private s p e c i a l i s t ) usually are present with emergency r e s u s c i t a t i o n equipment f o r an expected troublesome d e l i v e r y or baby, such as i n cases of premature and Rh negative babies or a t i g h t p e l v i c arch. The members of the "delivery team" a l l take part i n shouting instructions to the patient on how to push " e f f e c t i v e l y , " as well as "encouragement" to sustain her pushing u n t i l the baby i s delivered. During t h i s second stage of labor, the doctor administers a l o c a l anesthetic and cuts an epesiotomy to increase the size of the vaginal opening so the mother w i l l not be "torn" when she f i n a l l y expells the baby. When the baby i s f u l l y expelled, the doctor announces i t s b i r t h by loudly and excitedly t e l l i n g the patient i t s sex. Often he w i l l also praise i t s health and attractiveness. The naked newborn baby i s often immediately held up f o r the patient to see. The baby i s then given a cursory physical examination by the senior nurse present, while the doctor has the patient expell the placenta and sews up the epesiotomy. When the nurse completes her examination of the baby she attaches a name tag to i t s wrist and wraps i t i n a blue or pink blanket, depending on i t s sex. She then usually presents i t to the patient, placing i t on a tray next to her so she can see i t or give i t to her to hold, depending on the patient's condition a f t e r d e l i v e r y . As with the doctor's b i r t h announcement, she and the other nurses then proceed to praise the baby's appear-ance and health and t r y to get the mother to do the same. I f the patient i s unwed and plans to give i t up f o r adoption (usually a " c l i n i c " patient) the doctor does not usually praise i t when i t arr i v e s , merely announcing i t s sex. In a s i m i l a r fashion, the nurses do not usually hand t h i s patient her baby or place i t on a tray, but ask f i r s t i f she wants to see the baby. I f the patient responds negatively, the baby i s quickly taken away af t e r being examined and wrapped. I f the patient wishes to see or hold i t the nurses r e f r a i n from p r a i s i n g or otherwise discussing the baby while she i s holding i t . A f t e r he f i n i s h e s sewing up the' epesiotomy the doctor again congratulates the patient and praises the baby ( i f the patient i s keeping i t ) before leaving to break the good news to the husband i f he has not been present f o r the d e l i v e r y . I f the doctor i s busy he may not go down personally to the t h i r d f l o o r but instead phone the head nurse on the t h i r d f l o o r and have her inform the husband. With regard to complications and a b i o l o g i c a l l y troublesome baby ("bad news"), the doctor makes a point of personally informing the husband. I f the husband i s at work or at home the doctor usually t r i e s to contact him by phone soon a f t e r the d e l i v e r y . In most cases where the delivery has been routine and trouble-free, the announcement to the husband i s b r i e f , something l i k e , "Congratulations! It's a boy! Your wife and baby are f i n e . Ok?" Meanwhile the patient i s l e f t alone i n the delivery room f o r an hour afte r the delivery f o r "observation" before being wheeled on a stretcher to one of the "recovery" beds on the second or t h i r d f l o o r s . She i s usually kept i n the hos p i t a l f o r three days afterwards while her doctor or the resident on duty checks the healing of the epesiotomy and her general recovery. 56 The Organization of Embarrassment While our " t y p i c a l " patient was i n the intake area p r i o r to being examined, s t a f f ' s i n t e r a c t i o n with her charac-t e r i s t i c a l l y displayed a pattern of non-privacy and non-c o n f i d e n t i a l i t y . T y p i c a l l y , researchers have attributed t h i s sort of treatment to the s t a f f ' s b e l i e f s and attitudes concern-ing the moral and economic " i n f e r i o r i t y " of the average " c l i n i c " patient. In other words, i t has been asserted that because s t a f f regard them as "poor specimens of humanity," they are "callous" and "careless" i n t h e i r treatment of them as opposed to middle class "private" patients. While these b e l i e f s may exist at City, I suggest that organizational features such as the ecology of the c l i n i c waiting room and the pressures of a large case load to be "processed" i n a short time probably are of equal or greater importance i n influencing the s t a f f ' s treatment of the " c l i n i c " patient. For example, on a " f u l l c l i n i c " day when most of the patients keep t h e i r appointments, the head nurse remains stand-ing behind the table by the scales where the patients' f i l e s are stacked. She seldom moves from that l o c a t i o n when there are a l o t of patients to be processed because from there she can e a s i l y look at one f i l e then another and summon patients to be weighed and have t h e i r blood taken. However, t h i s physical arrangement requires that she speak loudly or shout to the patients waiging on the bench and to the rece p t i o n i s t behind the counter. Also another important eco l o g i c a l feature 57 i s the close proximity of the benches on which the patients wait to the reception counter. This placement enables waiting patients to overhear most conversation at the counter unless the participants speak very q u i e t l y . Now I would l i k e to describe t h i s pattern of i n t e r a c t i o n more s p e c i f i c a l l y . When the nurse i s i n a hurry, she c a l l s a patient's name loudly, and before she cl o s e l y approaches the table she w i l l loudly t e l l her to "take o f f your shoes, you're going to be weighed." When she announces the weight she does so loudly so the rece p t i o n i s t can record i t i n her f i l e at the counter. The nurse w i l l also f a i r l y loudly praise or condemn the patient f o r a weight loss or gain. In reacting to t h i s , the patient w i l l look and blush a f t e r a quick glance at the waiting area to see i f anyone has taken notice of the nurse's announcement. Also, the head nurse w i l l loudly c a l l a name, and before the patient can get closer than ten feet to the table w i l l loudly i n s t r u c t her to "go empty your bladder and leave a specimen," or "go to the washroom and piss i n a paper cup." Patients often appear embarrassed at t h i s i n s t r u c t i o n and glance at the bench "audience" before going i n t o the "l a d i e s . " Apparently the head nurse i s concerned to have them quickly get i n and get out of the lavatory so she can send another patient to leave a specimen. With regard to taking blood samples, the nurse w i l l c a l l out a name and as soon as a patient begins to approach her table she st a r t s quickly walking back toward the "blood o f f i c e , " y e l l i n g to the patient hurrying to catch up something l i k e "Come, I want to take your blood!" Often s 2 "... —J _ ; , ._:..\.J.... I .-—Hit --i Z PC ••<$ > o o a i7 Hi — v - 7 (J o <-.t T» O v- cr 'a M- ct ."9 lT> LI )-'-73 V o o TO T" O CO .J i—,l4_i- U4 — t 1 h — — 4 _ t.' o »•*• ft H- K-ft cf-lBJ 1.1 ! (u 4 --ft \ ?,» . ra - M l i * . _ i i l l *s » —*-+— •J Bench y o m ' H £ Bench > O O »( CT fJ i •3 iH .7? j IB '.'<> J-1- i < C-1 i a •(-* * ' " i H - O o n • 3 sa j O H - ! • / - . • . O S 3 " T H>0 HJ>1 O H- W H -n n> a ore H , |-~ H > i r rt-*a ?! o i 3-1 § s: ro =1U jfable ( V o rc h p » <-!> 'i, P H - <a .a. 5 t - ^ r: C L O r V W * T — M 3 O o c o .-J Operating i T V ' 1 J — _ — t v 4--Nurses' Ltiundt^y | Lounge A -i U .1 i i •"f-;t-Bt-tT?rr ! O • 3 Operating HOOtfJ i Labor P.octn Labor Room n i r \ -I n t e r n ' a s l e e p i n g | Quarters Laboratory t- J HALLWAY My Usual Observation \ Location cording S h e l f i A Doctors Lounge D e l i v e r y P-COP •Head .Delivery Table -I i r I..A4 D e l i v e r y Room 'I oot l - l Resuscitate*' 1 A J -D e l i v e r y iloom H H r-Labor Room Labor Room "Mirror" .Pig. 2.•--Fourth F l o o r , O b s t e t r i c s ant: Gynecology B u i l d i n g D e l i v e r y ant? Labor F l o o r Coffae Room vO 60 patients, e s p e c i a l l y i f i t i s t h e i r f i r s t v i s i t , w i l l suddenly stop and reply with alarm, "Blood!", before continuing a f t e r her. F i n a l l y , a f t e r a patient has been examined, the head nurse checks the doctor's instructions i n her f i l e to see i f she should see the d i e t i t i a n or the p s y c h i a t r i s t . Again, she w i l l issue instructions loudly before the patient reaches her table: "You're overweight! See the D i e t i t i a n ! " ; or, "You need to see the p s y c h i a t r i s t ! Go to O.P.D.!" (the outpatient department f o r psychiatry). The recept i o n i s t , although her counter i s next to the benches, must ask "personal questions" about patients' finances to see i f they should be referred to the " e l i g i b i l i t y s o c i a l worker's" o f f i c e . I f she i s i n a hurry to get another patient into that o f f i c e she may just ask while a patient i s seated i f she i s on welfare or has medical insurance without f i r s t summon-ing her to the counter and shortening the distance between them: R.: (loudly) "Do you have medical insurance?" P.: "No." R.: "Are you working?" P.: "No." R.: "Is your husband working?" P.: "No." R.: "See Mrs. Brown, then." Also, the receptionist must, i n making an appointment f o r a patient, request the reason f o r i t so she w i l l ask the patient what her problem i s before giving her an appointment. 61 R.: "Do you have an appointment?" P.: "No." R.: "You w i l l have to make one. What's your problem?" P.: (very quietly but s t i l l e a s i l y overheard): "I think I have V.D." (she bows her head and giggles and then glances nervously at the people s i t t i n g at the bench who are sta r i n g at her) The receptionist must ask questions of the head nurse about patients who have just l e f t the c l i n i c or may s t i l l be i n the waiting area. I f she i s i n a hurry, she w i l l do so at a distance from behind her counter. Also included i n these exchanges are what normally would be considered "back stage" t a l k deriding or c r i t i c i z i n g patients. R.: "Miss Brown has c a l l e d Dr. Johns (an administrator)." Nurse: "Miss Brown i s a s t a f f patient and was t o l d to c a l l me, not Dr. Johns. So have her c a l l me. She i s a nuisance! She's a nuisance!" The s o c i a l worker also w i l l t r y to gather information about patients from the receptionist or the head nurse while they are being examined or a f t e r they have l e f t . I f she i s pressed f o r time, she may y e l l questions to them across the crowded bench area. S.W.: "Is A p r i l ok?" R.: "She just l e f t . " S.W.: "Is her head a l l r i g h t ? " (This patient had a head injury.) R.: "She said she was going to the head shrinker! Ha! Ha!" The residents and students who do the examinations are 62 also usually quite busy. So, when a patient leaves the cubicle without waiting to get the post-examination advice, the doctor w i l l come out to where she i s s i t t i n g i n the waiting area to advise her, rather than take the time to take the patient back to a cubicle, which i s often f i l l e d immediately a f t e r a patient leaves, i n any event. Dr.: "You've gained a l o t of weight. That's bad! You better get some 'water p i l l s ' and i r o n . Watch that i n f e c t i o n and t e l l your boy f r i e n d about those symptoms." The patient, who i s s i t t i n g at a crowded bench, frowns and looks down at the f l o o r . Patients usually t r y to manage the lack of privacy and c o n f i d e n t i a l i t y by coming close to s t a f f before speaking (e. g.) about why they came to the c l i n i c or to t e l l the head nurse that they cannot "go to the bathroom" when they are requested to do so. Often they then mumble or speak very quietly, glancing around them and back to the people at the bench. Also, when a doctor or nurse i s discussing t h e i r cases with them at the bench or counter, the patients w i l l t r y not to reply to questions or volunteer comments. When the reception-i s t or head nurse asked them questions from a distance, the patients w i l l not verbally respond, and instead gesture a "yes" or "no." Nurse: "Are you to be examined today?" P.: ( s i t t i n g at the bench, shakes her head up and down) Nurse: "Have you been i n there?" (Patient shakes her head "yes.") When the nurse made t h i s l a s t utterance, she pointed i n the d i r e c t i o n of the lavatory and kept moving her index f i n g e r up to her forehead as i f to scratch i t . Thus, she t r i e d to mask her pointing gesture so as to appear as not to be i n d i c a t i n g the lavatory. Here i s one of the instances where the head nurse used a verbal i n d i r e c t reference and a "gestural locator to the " l a d i e s . " They show that she was aware of the pro-p r i e t i e s surrounding speaking about elimination i n p u b l i c . Instances of t h i s sort of circumspection usually occurred when she and the rest of the s t a f f were not "too busy" and could look up from t h e i r records and f i l e s to establish face-to-face contact with a patient across the waiting room. In a s i m i l a r fashion, when not busy she would quietly t e l l a patient her weight and walk over to the receptionist's desk to quietly inform her, instead of loudly c a l l i n g out the weight. Also, she would then take time to wait u n t i l the patient reached her before accompanying her back to the "blood o f f i c e . " Many of the c l i n i c ' s o bstetric patients were unwed and apparently found the public character of the waiting room problematic i n terms of managing t h e i r appearance to conceal information or signs of t h e i r "flawed" character. I take i t that generally as v i s u a l evidence of pregnancy appears i n the form of a swollen abdomen, many unwed women f e e l that they fac an increasingly d i f f i c u l t task of reducing or concealing i n f o r mation about t h e i r unwed status which would render the increas ingly v i s i b l e bulge stigmatizing.-^ Apparently, these women assume the primary part of t h e i r personal front that a public audience attends to i n deciding marital status, i s the t h i r d f i n g e r of the l e f t hand where wedding rings are customarily worn. One method, therefore, f o r dealing with the assumed scrutiny of t h i s area i s to wear a wedding band, or other type of r i n g , on that finger i n order to "pass" i n public places as a wed pregnant woman. In f a c t , evidence that unwed pregnant women regarded the c l i n i c waiting room l i k e other public settings requiring "reputational work" or "stigma management" was found by the f a c t many of them wore such "passing devices." They seemed generally w i l l i n g to inform s t a f f of t h e i r " r e a l " status i n "backstage" areas such as the s o c i a l worker's o f f i c e and the d i e t i t i a n ' s o f f i c e , while making e f f o r t s to conceal evidence of i t i n the more public waiting area. Apparently t h i s device was somewhat successful because i n the waiting area even some of the s t a f f members assumed from the r i n g that the patient was wed, although once i n the "backstage"^" areas, often the patient would correct t h i s impression. The s t a f f members who were most frequently "taken i n " were new and inexperienced. They found these "mistaken" categorizations to be sources of i r r i t a t i o n and embarrassment. One type of s t a f f member, the d i e t i t i a n , more commonly made these faux pas because she usually spent only several weeks i n the c l i n i c before moving to another department i n the hospital f o r further t r a i n i n g . The following instance was re l a t e d to me by a d i e t i t i a n who found t h i s "mistake" to be a source of annoyance and i r r i t a t i o n . You can't t e l l by the r i n g i f she's married. This afternoon I made the mistake of c a l l i n g the father (of the ch i l d ) husband. This didn't disturb her though— she's only eighteen and immature—she's playing house. She's going to get married i n a month. Talks about the father, who she's l i v i n g with, a l l the time—Bob t h i s ! Bob that! Most of the patients who did not wear rings neverthe-le s s also showed that they were sensi t i v e to the c l i n i c as one of many public places where an audience ro u t i n e l y judges the moral standing of a v i s i b l y pregnant woman, i n terms of wed versus unwed status. The warrant f o r t h i s assertion can be found i n the f a c t that among those without rings the majority made some e f f o r t to reduce the v i s i b i l i t y of a r i n g l e s s t h i r d f i n g e r on the l e f t hand, i . , to observe some sort of " l e f t hand d i s c i p l i n e . " In other words, rather than make a more permanent appearance a l t e r a t i o n , wearing a r i n g , these women t y p i c a l l y engaged i n more temporary, or " s i t u a t i o n s p e c i f i c , " improvised passing a c t i v i t i e s and devices. Many of these e f f o r t s involved simply putting the l e f t hand i n a coat pocket and keeping i t there while i n the waiting area. For example, when required to f i l l out and sign forms at the receptionist's counter a patient would t r y to keep her l e f t hand i n her pocket while writing and handling papers with her r i g h t hand excl u s i v e l y . However, patients were sometimes chagrined and exclaimed "Oh!" or "Oh my!" when they remembered at the l a s t moment that they were left-handed. In these cases the patient would hurriedly f i l l out the form and scratch her signature and quickly jam her l e f t hand back into her pocket. While waiting to be examined these patients t y p i c a l l y t r i e d to do everything with t h e i r r i g h t hand, keeping t h e i r l e f t hand i n t h e i r pocket. This became awkward when t r y i n g (§.. g.,) to put a cigarette i n her mouth and l i g h t i t , or when t r y i n g to read a magazine with only one hand. Another common and more e a s i l y managed passing device involved constantly wearing gloves while i n the waiting area. When a patient was not wearing a coat, or at least one without pockets, or gloves, then she often engaged i n a passing a c t i v i t y wherein on enter-ing the area she holds her l e f t hand up to the side of her face away from the bench area as i f to scratch or rub her face. In doing t h i s she would keep facing straight ahead, not glanc-ing at the benches. Another technique involved "playing" with her hair with the l e f t hand on the side of her head away from the audience. I f the patient i s carrying packages, usually she clasped both hands t i g h t l y around the objects so the fingers of the ri g h t hand overlapped and concealed the fingers of her l e f t hand. When a patient without coat pockets or gloves was standing i n front of the counter or getting up and moving around the bench area to get, f o r example, an ash tray or magazine, she usually t r i e d to keep her l e f t hand i n constant motion by doing various a c t i v i t i e s such as touching the side of her face, scratching the side of her body, and "playing" with her h a i r . Presumably t h i s a c t i v i t y was intended to prevent the audience from focusing i t s attention on the r i n g 67 f i n g e r long enough to detect whether a r i n g was bring worn. On the other hand, I also observed that patients categorized by s t a f f as "Hippies" and "Indians" usually did not wear a r i n g or engage i n these improvised passing a c t i v i -t i e s . S t a f f and most patients consistently act as i f the entire membership of the bench audience shared t h i s concern f o r reputation. The s t a f f evidenced t h i s assumption of a shared orientation to the stigmatized character of unwed pregnancy i n t h e i r discreet attempts to, i n e f f e c t , "collabor-ate" with a l l patients i n constructing an image of them as "wed," i . although s t a f f presume they know the "t r u t h , " they,treat a l l unwed patients as "wed" while i n front of the waiting benches. The most v i s i b l e technique whereby s t a f f presume to help patients "pass" involves the way i n which they addressed them when summoning them to be processed and treated. The s o c i a l worker described t h i s method to me as follows: I c a l l a l l women "Mrs." when c a l l i n g them in t o the o f f i c e ; even though the women w i l l say they aren't married when they get i n the o f f i c e . I t protects them from embarrass-ment . When no -last name i s available, the s t a f f use an ambiguous form of address by c a l l i n g patients by t h e i r f i r s t names. Another i n t e r e s t i n g feature of the waiting room was the dress worn by v i s i b l y pregnant women. I observed many patients, p a r t i c u l a r l y the g i r l s from the Home, discuss the unaesthetic character of t h e i r appearance and dress while waiting to be examined. These patients tend to discuss t h e i r pregnancy i n terms of a "bulge" which was undermining t h e i r attempts to dress and appear " a t t r a c t i v e " i n non-pregnant terms of ideals of slimness and being able to wear short s k i r t s . To manage the aesthetics of t h e i r appearance, many wore f u l l - l e n g t h overcoats even i n f a i r weather and kept them on while i n the c l i n i c which served t o conceal the "bulge." Also, patients tended to describe other patients' dress i n terms of the extent to which i t showed a proper amount of "shame" f o r t h e i r "condition," considered d i s f i g u r i n g . Unlike other "primitive" cultures, the dominant perspective i n North America on the prop r i e t i e s of "appearing pregnant" involves rules on displaying the "bulge" too v i s i b l y , which i s con-sidered both "unaesthetic" and showing no "shame" f o r one's "condition." These pro p r i e t i e s were i n evidence i n the s t a f f ' s and Home patients' annoyed reaction to "Indians" and "Hippies" who often arrived wearing such dress as t i g h t Levis and tee shorts. In one case, a patient, c a l l e d a "Hippy" by s t a f f , came dressed i n hot pants and a t i g h t blouse which d i s -played a large proportion of her breasts and swollen abdomen. The s t a f f were very disturbed at how t h i s " i n t e r f e r e d " with the work of the male repairmen painting the c e i l i n g , so they quickly shunted her to one of the cubicles f o r a p e l v i c exam-in a t i o n without the usual processing and one and one-half hour wait. This patient provoked the complaint from the s o c i a l worker that she "didn't know where t h i s generation was heading" and "Some people don't care I" With regard to patients c a l l e d 69 "hippies," the s o c i a l worker explained that these " v i o l a t i o n s " were a r e s u l t of "moral breakdown" and "psychological maladjust-ment." On the other hand, she f e l t that the "Indians" were just c u l t u r a l l y " d i f f e r e n t and didn't know any better; but each generation i s learning." In any event, the above instances i l l u s t r a t e how s t a f f observe and enforce pr o p r i e t i e s and con-ventions with regard to dress and appearance against "deviant" subcultural groups. 70 FOOTNOTES 1. I f the patient has been diagnosed as not being pregnant, she i s n o t i f i e d of t h i s f a c t and she does not return to the c l i n i c . For the patient diagnosed as being pregnant, she i s given monthly cursory physical examinations u n t i l the l a s t month of her pregnancy, when she receives them weekly. After her i n i t i a l , more thorough, check-up she does not usually receive another p e l v i c examination u n t i l the probable l a s t prenatal check-up, unless she has some complaints or develops symptoms i n d i c a t i n g possible complications i n her pregnancy or problems with her health. 2. A common cause f o r a patient to sometimes come to the ho s p i t a l several times before f i n a l l y remaining and giving b i r t h i s her mistaking " f a l s e , " or Braxton-Hicks, contrac-tions f o r the actual onset of labor. These are intermittent, painless contractions of the uterus toward the end of pregnancy. 3. Erving Goffman, Stigma: Notes on Deviance and Management  of Spoiled Identity (Baltimore: Penguin, 1970). 4. Erving Goffman, The Presentation of S e l f i n Everyday L i f e (New York: Doubleday Anchor, 1959). 71 CHAPTER III PREPARING THE PATIENT: THE ORGANIZATION OF MORAL CONTROL IN THE INTAKE AREA In t h i s chapter, I w i l l describe other patient manage-ment routines i n the intake area (and to a l e s s e r extent those i n the cubicle area) and s t a f f ' s view of themselves as having a mandate to i n s t r u c t and to lay the whole routine of prenatal care on patients, regardless of t h e i r situations and views. Many patients' reactions to s t a f f ' s treatment here and i n other areas observed can index t h e i r character as "troublesome" from the s t a f f ' s viewpoint. In other words, i n t h i s chapter I w i l l t r y to show that there are systematic attempts to coerce patients to"shape up" so that i n the always-oriented-to f i n a l stages, labor and delivery, they w i l l (hopefully) be "good patients." Also, we w i l l see s t a f f protecting standardized r o u t i n e s — e . g., requests f o r a female doctor get treated as organizationally d i s r u p t i v e . In t h i s chapter, too, I w i l l attempt to show how the s o c i a l worker i n the C l i n i c i s occu-p a t i o n a l l y trained, as part of the medical team, to look ahead to the baby's "fate" a f t e r b i r t h — i s s u e s of father's employment, adoption, etc. Here, and with doctors i n the cubicle area, too, the medical shades o f f into concerns with "model middle-class family arrangements," and s t a f f i n both areas seem to 72 take t h e i r mandate to enforce these f o r granted. As I discussed i n the Introduction, medical s t a f f see i t as t h e i r moral r e s p o n s i b i l i t y to t r y to "teach" patients the medical perspective i n order to l i m i t infant mortality and reduce the eff e c t s of delivery on the newborn c h i l d . Likewise, i n the intake area, or waiting room, the s t a f f members ( s o c i a l workers, nurses, and receptionist) t r y to thus manage what they characterize as "ignorant" or " c u l t u r a l l y backward" patients, as well as those who adhere to non-medical or f o l k approaches to prenatal and natal events. Thus, the waiting room becomes f a i r l y frequently a scene of c r o s s - c u l t u r a l con-f l i c t wherein s t a f f members make i t t h e i r business to t r y to " r e s o c i a l i z e " or "teach" patients (regardless of t h e i r s i t u a -t ions and views) t h e i r " r e s p o n s i b i l i t i e s " toward the unborn c h i l d v i s a v i s medically prescribed routines of prenatal care and d e l i v e r y . For example, the s o c i a l worker related to me the follow-ing "incident" which i l l u s t r a t e s s t a f f ' s strong moral reaction and coercive approach to patients who i n s i s t on using "non-medical" techniques. Yesterday a hippy, from Midwest Province, and his wife, from New York, (I suspect her parents are sending her money) came i n with a baby delivered by the father. He was d i r t y , f i l t h y , long-haired, and smelled. The poor c h i l d . Disgusting! It had had no medical treatment so the baby's eyes swelled up and the skin was peeling. Otherwise, i t was t h r i v i n g . They came because they needed a doctor's signature to get the Department of S t a t i s t i c s to r e g i s t e r the b i r t h . When (the head nurse) t r i e d to feed the baby glucose formula, the mother knocked i t out of her hand—"The baby was going to be raised n a t u r a l l y ! " 73 We t r i e d to give advice on how to feed i t and care f o r i t s skin. But they wouldn't l i s t e n ! They hadn't taken the baby to the Well Baby C l i n i c (for post-natal care—J.E.F.) and didn't accept medical care i n general. They had read everything and knew what to do! They said they'd bring the baby back next week f o r a check-up. I f they don't, I'm going to n o t i f y the Adoption Agency and have the baby apprehended as a case of c h i l d neglect. I couldn't do i t immediately. As long as they brought i t to a doctor, i t can't be c l a s s i f i e d as neglect. I doubt i f t h e y ' l l bring i t back. Apparently what angered her was the lack of cooperation by the parents with s t a f f i n allowing them to give i t "pre-scribed" food, and an apparent lack of commitment on t h e i r part to the medical perspective, such that they would not be persuaded to follow the l e g a l l y sanctioned post-natal care routines. Instead, the "hippies" i n s i s t e d on being treated as self-taught experts with the same l e v e l of competence as the s t a f f members. As a r e s u l t , the s o c i a l worker implies that i f i t were not f o r t h e i r compliance with the " l e t t e r of the law" she would have had the baby "apprehended" immediately. The law requiring a doctor's signature before a b i r t h can be registered provides routinely f o r a l e g a l l y enforced meeting between medical s t a f f and lay parents which otherwise may not take place. Staff members take these encounters as opportunities to "check" on the parents' compliance with pre-scribed medical routines and to t r y to give "advice" to persuade them to see the moral necessity f o r the use of medical "expertise." F a i l i n g to coerce them morally, they have the authority under the law ( i . g., through the medical s o c i a l worker's authority) to have the baby seized and made a ward of 74 the court; i . g.., they thereby can resort to l e g a l l y sanctioned physical coercion to make medical care "available" to the new-born baby."*" However, with regard to prenatal (as opposed to post-natal) care, s t a f f lack the ultimate, l e g a l means of enforcing "proper care" of the yet unborn baby. Instead, they must r e l y s o l e l y on moral control of the patients through attempts to persuade them to adhere to medically prescribed ways of "becoming a mother" so that i n the always-oriented-to f i n a l stages (labor and delivery) they w i l l (hopefully) be "good patients." Such attempts at moral control could be e a s i l y overheard from the waiting room bench taking place between s t a f f and a patient i n the s o c i a l worker's " o f f i c e " since, l i k e a l l " o f f i c e s " i n the area, i t was merely a plywood enclosed cubicle and i t s "walls" did not completely extend to the c e i l i n g of the C l i n i c f l o o r . For example, i n the following instance, s t a f f were overheard t r y i n g to persuade a patient not to follow her intended course of just coming to C l i n i c f o r an i n i t i a l prenatal v i s i t to determine i f she i s pregnant, then not coming back f o r "check-ups" and having her baby i n a non-medical s e t t i n g . S o c i a l Worker: (sounding cross and impatient) "Why should we handle you through the c l i n i c ? The embarrassment of the blood t e s t and p e l v i c and you go up i n the s t i c k s where i t won't  do you any good! You're seventeen and t h i s i s your f i r s t baby. You should be where you can see a doctor every month. We're not going to handle you here at a l l i f you're just going to say goodbye! (The s o c i a l 75 worker leaves and returns with the head nurse and introduces her to the patient as an "expert who can give you some good advice." The head nurse repeats the same l i n e that the s o c i a l worker used e a r l i e r to t r y to persuade the patient. When the patient i s s t i l l not persuaded, the nurse brings a doctor into the " o f f i c e " and introduces him as one who w i l l be able to give her some advice. The doctor, too, t r i e s to persuade her to go "one way or the other" and repeats the s o c i a l worker's remark of either using the h o s p i t a l f o r a l l her prenatal care and delivery or be refused even an i n i t i a l prenatal check-up.)" Doctor: "Remember what can happen. One time such a natural c h i l d b i r t h took place where the husband and wife had studied a l o t of books and t r i e d to d e l i v e r t h e i r own baby. I t was healthy but dead due to t h e i r mishandling i t . " Patient: "I've seen a doctor who said i t ' s a l l r i g h t f o r me to go back i n the s t i c k s . " Head Nurse: "Don't take his advice!" S o c i a l Worker: "I recommend seeing a public health nurse at a nearby h o s p i t a l . A f t e r a l l what can we do when you don't care about yourself! We care more about you than you do! (Afterward she discusses the patient's case with me.) That patient i s one-quarter Indian and (the Head Nurse) had talked to her before, t e l l i n g her "either/or" (either she accepted ho s p i t a l care f o r her entire prenatal and natal period or would receive no service whatsoever—J.E.F.). This time we brought i n the "big a r t i l l e r y " (a doctor—J.E.F.) to t r y to persuade her. We'll have the public health nurse write to the ho s p i t a l near the Indian Reservation (where the patient l i v e s — J . E . F . ) . I harped at her so much because we didn't want to turn her away without service (which they did eventually do—J.E.F.). But she's so r i g i d about having children without medical attention!" Again, l i k e the b i r t h r e g i s t r a t i o n case, lay adherents of non-medical perspectives probably would t r y to avoid coming into contact with medical personnel except f o r these few s p e c i f i c services, over which they may be seen as having a monopoly: (e. g.) r e g i s t r a t i o n s of b i r t h s , diagnosis of pregnancy, or providing a general physical check-up. S t a f f t r e a t these i s o l a t e d encounters as occasions to "check" on patients' committment and compliance to medical routines and to attempt to morally persuade or "teach" them the value of medical care to meet t h e i r maternal " r e s p o n s i b i l i t i e s " to the unborn c h i l d . In t h i s case, apparently having f a i l e d to s o c i a l i z e and coerce her r h e t o r i c a l l y , s t a f f members resort to a frequently used management technique wherein they issue an "ultimatum" ( s t a f f characterizes t h i s as t e l l i n g such a patient " e i t h e r / o r " ) , t e l l i n g the patient that she w i l l not receive the service she sought on t h i s one v i s i t (e_. g., a diagnosis of pregnancy, or a general physical check-up) unless she consents to having a l l her prenatal and natal (and presumably post-natal) "care" put i n the hands of medical experts. In addition, s t a f f t r y to teach the patient the medical purpose f o r t h e i r issuing t h i s ultimatum. For example, here the s o c i a l worker i n her i n i t i a l remarks presumes that since the patient w i l l i n e v i t a b l y f i n d the i n i t i a l v i s i t p a i n f u l (the blood test) and embarrassing (the p e l v i c examination) she should therefore p a r t i c u l a r l y want i t to "do her some good" by making i t the f i r s t step i n the medical supervision of her entire prenatal and natal "career." In other words, the s o c i a l worker i s presumptively 77 treating i t as self-evident that the service the patient came for at the present time i s not in fact the service she really seeks, because i t must be tied to a sequence of medical "care" to constitute a "real service" for her. In sum, the social worker tries to teach her the medical purpose of the ultimatum so as to "inform" her that the present service she seeks i s "worthless." At the same time, this rhetoric j u s t i f i e s the ultimatum in terms of values and ideals to which the patient would presumably respond, i . g.., "doing her some good." After providing a rationale for not giving the service which the patient requests unless she cooperates, the social worker in her next remark tr i e s to persuade the patient on the grounds of the "medical facts" of her case. This justification for her participation in medical routines appears as an implied threat of troubles for a patient of her medical "type." ("You're seventeen and this i s your f i r s t baby. You should be where you can see a doctor every month.") This case illustrates how staff draw on their medical knowledge of normal types of "troublesome patients" as a resource to persuade patients to allow them to have control over their lives during the prenatal and natal periods. In the process, staff members usually do not explicitly specify what sort of medical troubles w i l l occur to what types of patients, nor the relative probabilities of these actually occurring in the case of the patient being thus managed. Presumably, such an "objective" evaluation would put the patient in a situation where she can, and i s allowed to, make an "informed" choice of how to conduct her l i f e during these events. Instead, by making i m p l i c i t threats of trouble s t a f f are not t r e a t i n g the use of prenatal care by the patient as a matter of choice. They treat i t as self-evident that any sane, reasonable woman would value t h e i r own and t h e i r baby's health, and, therefore, would heed such suggestions of possible trouble i n t h e i r case. They f e e l responsible to society f o r the welfare of the mother and c h i l d and t r y to manage a patient by, f o r example, making implied threats warranted by the "medical f a c t s " of a patient's case. They apparently assume that the patient does not have the r i g h t to r i s k prenatal and natal "complications." When a patient, as i n t h i s case, r e s i s t s the moral arguments and "either/or" threats of one s t a f f member, then often that s t a f f member w i l l bring i n "outside experts" who i n turn t r i e s to persuade her. Confronting the reluctant patient with an array of "experts" i n t h i s case leads to the most prestigious member of the management "team," the doctor, t r y -ing to scare or shock the patient with an anecdote of where a non-medical c h i l d b i r t h resulted i n the baby's death due to the "incompetence" of self-taught l a y "experts." The doctor's remark that the parents had "read a l o t of books" implies that the knowledge and s k i l l s required f o r safe c h i l d b i r t h are not to be found i n any source to which the patient may have access. What i s further implied i s that only medical s t a f f have the expertise necessary to ensure a safe delivery and that they 79 would not "mishandle" the patient's d e l i v e r y . As with attempts to persuade the patient to use medical prenatal care, s t a f f do not treat the method of c h i l d b i r t h as a matter of choice f o r the patient and merely t e l l her the technical p r o b a b i l i t i e s of the r e l a t i v e safety to her and her c h i l d of using d i f f e r e n t methods of c h i l d b i r t h . He cannot just advise that she go out and take her chances, while admitting that the h o s p i t a l s t a f f are not i n f a l l i b l e and that occasionally they "lose" a baby due to "mishandling," too. Instead, he t r i e s to shock her with an anecdote which implies that ex-hospital, "natural c h i l d -b i r t h s " e n t a i l a p r o h i b i t i v e amount of r i s k . The use of t h i s sort of anecdote presumably i s based on the s t a f f ' s assumption that every woman shares with them a high value with regard to the l i f e and welfare of the unborn baby, and, therefore, can be shocked into cooperating with them. When the patient shows she i s aware that health issues are involved by s t a t i n g she had a doctor sanction her choice of ex-hospital, natural c h i l d b i r t h , the head nurse i s quick to admonish her not to take his advice. The nurse i n so doing implies that her doctor must be wrong, and perhaps incompetent, without f i r s t asking who that doctor might be or what knowledge he has of her case. The s o c i a l worker counters her invocation of an authority to support her intended s t y l e of delivery by recommending another "expert" who, she implies, w i l l give her "good advice." Also, s t a f f are morally committed to prescribed medical routines to the extent that they w i l l charge "health BO workers" (a public health nurse) to "follow up" and continue to t r y to manage patients. Thus, the "management team" of "experts" aligned against the patient i n the C l i n i c i s to be expanded to include "experts" outside the Hospital i n the patient's everyday l i f e . F i n a l l y , the s o c i a l worker t r i e s to j u s t i f y sending her away without any service (except, perhaps, f o r a l o t of advice) by using the management techniques of shaming and morally censuring the patient. ("After a l l , what can we, do when you don't care about yourself!") S p e c i f i c a l l y , here the s o c i a l worker t r i e s to put the patient i n a p o s i t i o n of shame and moral censure by implying she has viol a t e d a " r u l e " of the service r e l a t i o n s h i p between doctor and patient wherein the patient i s morally e n t i t l e d to receive service only i f she cooperates with s t a f f when they are simply "trying to help her." Also, i n her f i n a l remark she implies that the patient's lack of cooperation constitutes a morally reprehensible lack of concern f o r her own (and presumably her unborn chi l d ' s ) welfare. ("We care more about you than you do!") In sum, the patient i s supposed to leave the C l i n i c blaming herself, not the s t a f f , f o r a lack of s e r v i c e — s i n c e i t i s her own r e f u s a l to "help h e r s e l f , " by cooperating, which renders her morally unworthy to receive that service. Thus, the s o c i a l worker t r i e s to leave the patient with the sense that her lack of compliance with prescribed medical routines r e f l e c t s on her own moral character rather than on the correctness of those routines. In the following example, s t a f f members (the s o c i a l worker and a resident) t r y to persuade a patient who has r e g u l a r l y accepted medical prenatal care, not to carry out her voiced intention of giving b i r t h i n a non-medical s e t t i n g . This case provides another example of the use of an "either/or" ultimatum (regarding further prenatal care which the patient seeks), with the accompanying j u s t i f i c a t i o n f o r r e f u s a l of further service involving an attempt to shame and censure the patient; plus, the management technique of t r y i n g to shock the patient with a description of the possible h o r r i b l e effects such a s t y l e of delivery may have on the newborn baby. S o c i a l Worker: "The welfare of the baby i s risked out there! What i f the baby i s born with a cord around i t s neck and needs oxygen?" Patient: "Those things won't happen. I want a midwife." S o c i a l Worker: "In t h i s day and age there aren't any except i n the northern remote parts of the province where they are used of necessity; and there's no choice. I f you don't care what happens to your baby, I can't do anything more f o r you." (The patient appears i r a t e and just turns around and leaves. They had been arguing i n front of the r e c e p t i o n i s t ' s counter.) Pr i o r to i s s u i n g the ultimatum, the s o c i a l worker e x p l i c i t l y appeals to the patient's assumed concern f o r her baby's wel-f a r e , and then t r i e s to shock the patient with a graphic d e s c r i p t i o n of a possible t e r r i b l e consequence f o r the baby i f she pursues t h i s course of action ("The welfare of the baby i s r i s k e d out there! What i f the baby i s born with a cord around 32 i t s neck and needs oxygen!") The patient counters by claiming the use of a midwife w i l l prevent r i s k i n g the baby's welfare. Nevertheless, the s o c i a l worker t r i e s i n a vague manner to d i s -c r e d i t midwives i n general as somehow i n f e r i o r to the service received i n a h o s p i t a l , without s p e c i f i c a l l y t e l l i n g her i n what ways they are d e f i c i e n t ; i . she does not simply t e l l her the objective p r o b a b i l i t i e s of a safe delivery at the hands of a midwife, but suggests that they are just a "necessary e v i l " i n some regions where h o s p i t a l i z a t i o n i s not a v a i l a b l e . Then, the s o c i a l worker proceeds to issue an ultimatum, imply-ing that the patient's choice of a midwife d e l i v e r y r e f l e c t s on her moral f i t n e s s as a mother and that t h i s means she i s no longer e n t i t l e d to the services of the C l i n i c ("If you don't care what happens to your baby, I can't do anything more f o r you.") Occasionally, patients refuse to p a r t i c i p a t e i n standardized C l i n i c prenatal routines because they e n t a i l breast and p e l v i c examinations by a male s t a f f member; i . e_., they see these events as requiring unacceptably immodest expos-ure and manipulation of t h e i r bodies. As a r e s u l t , such patients usually demand that a female doctor do the examina-tions before they w i l l cooperate and submit to an i n i t i a l o b s t e t r i c a l check-up. In response, s t a f f (since there are no female doctors i n the C l i n i c ) t r y to protect such a standardized routine and engage i n a concerted e f f o r t as a management team to t r y to persuade these patients that these widely held lay S 3 considerations are not relevant to a medical s e t t i n g where doctors may be male but they are "just doing t h e i r jobs"; i . g . , despite the obvious sexual overtones of disrobing i n front of, and being manipulated by, a strange male(s), patients are to see i t as e s s e n t i a l l y a non-sexual event. Usually, however, s t a f f members f a i l to persuade such a patient to accept " t r e a t -ment" from a male and often turn the patient away without ser-v i c e . For example, i n the following case s t a f f members do not take the patient into an " o f f i c e " to t a l k to her but instead u t i l i z e the area i n front of the receptionist's counter. I take i t that they remain i n t h i s area because they assume t h e i r remarks of r i d i c u l e and argument may be more e f f e c t i v e i f the patient could be made to f e e l p u b l i c l y shamed or embarrassed f o r causing a "disturbance" and as a r e s u l t "give i n " rather than have her views castigated i n p u b l i c . Also i l l u s t r a t e d i n t h i s case i s the management technique wherein s t a f f speak to each other about the patient i n front of her as i f she were not present, so as to provide few conversational s l o t s or openings f o r the patient to be able to reply to t h e i r charges. S o c i a l Worker: (to patient) "We t r y and oblige but we just don't have 'em (female d o c t o r s — J . E . F.)." Head Nurse: (to the S o c i a l Worker) "It's just r i d i c u l o u s ! She's wasting her time! Our doctors see a l l patients who walk i n the door unless they have t h e i r babies at home. So, we'd be spending a l o t of money f o r nothing!" S o c i a l Worker: (to the Head Nurse) "This i s j u s t r i d i c u l o u s ! She's twenty-one and he's twenty-four, yet she has an eighteen-year-old mind!" Head Nurse: (to the S o c i a l Worker) " I t disturbs me! This i s her second baby; and she made t h i s fuss with the f i r s t baby." Resident: (to the S o c i a l Worker) "This i s the mark of the generation gap and common-law marriage: when the young are r i g i d but the older more wiser and l e s s unbending." Head Nurse: (to Social Worker) "I don't understand i t ! " S o c i a l Worker: (to the patient) "How are you going to pay f o r i t ? ( t h e examination—J.E.F . J " Patient: "The Province Medical Plan." S o c i a l Worker: "You have to be i n the province three months to be e l i g i b l e . You'd better go back to Eastern C i t y , (to the Head Nurse) She's seven months along." (She sounds annoyed at t h i s f a c t . ) Head Nurse: (to the S o c i a l Worker) "This wastes a l o t of time and money (using a female d o c t o r— J . E.F.)! This i s her second baby, too. She's l i v e d common law f o r f i v e years! She claims (the s o c i a l worker's supervisor) promised her a female doctor! She never d i d ! " S o c i a l Worker (phones the supervisor): "I'm annoyed. (After completing the c a l l ) The supervisor says we have no female doctors." Patient: "Why did (the supervisor) promise me?" S o c i a l Worker: "Why do you need one?" Patient: "I do . . ."(The patient appears to be angry and leaves the C l i n i c . ) Although s t a f f treat the patient i n t h i s "nonperson" conversa-t i o n a l manner, occasionally they, nevertheless, complained to me a f t e r the patient l e f t that she would not l i s t e n to them and acted as i f s t a f f were not there. So c i a l Worker: (l a t e r discusses t h i s case with me) "We gave her a l o t ("bent" the e l i g i b i l i t y r ules on residence—J.E.F.); yet she wouldn't give i n on t h i s one thing! I f she 35 was sixteen or seventeen and having her f i r s t c h i l d , or an older woman who had been raped or had been drunk some night, then I could understand. But she i s twenty-one and no white l i l l y because she's been l i v i n g common-law f o r three years and has a one year-old c h i l d . She acted as i f (the Head Nurse) and myself weren't there when we t r i e d to t a l k to her. I think the c i t y i s going too f a r i n g i v i n g her what she wants. Her and her guy have been here (i n the province—J.E.F.) two weeks and are on welfare. They should send them back to Eastern C i t y . Also, she brought i n a (her) c h i l d of that age who disrupted everything and we had to take care of him which r e a l l y annoyed us when she wouldn't cooperate. I don't know what her angle i s . Perhaps she just wants a private physician which i s expensive. How-ever, every woman who comes int o the Hospital with a gynecologist's or an obstetrician's care has a p e l v i c and other examinations to v e r i f y her state of pregnancy, done by an i n t e r n — t h a t ' s t h e i r job! And that patient didn't even know what family planning was!" Despite the f a c t that she knows that the patient has already been promised a private female doctor by her supervisor ("the c i t y " ) , the s o c i a l worker nevertheless i n i t i a l l y t r i e s to convince the patient to submit to an examination by a male doctor on the grounds that the C l i n i c lacks female s t a f f f o r t h i s purpose ("We t r y and oblige, but we just don't have 'em.") For her part, the head nurse i n i t i a l l y simply t r i e s to r i d i c u l e and d i s c r e d i t her request f o r a female doctor as superfluous ("It's just r i d i c u l o u s . She's wasting her time.") Then she t r i e s to normalize the C l i n i c ' s routine wherein males do a l l the examinations, implying that the patient should cooperate since a l l other patients do accept such "care" 36 ("Our doctors see a l l patients who walk i n the door unless they have t h e i r babies at home. So, we'd be spending a l o t of money f o r female doctors f o r nothing!") The s o c i a l worker then j o i n s the head nurse i n debunking her request by asserting that her (assumed) plea f o r modesty does not b e f i t her "age" or l e v e l of "maturity"; i . only a "teenager" or younger patient may appropriately demand such consideration ("This i s just r i d i c u -lous. She's twenty-one and he's twenty-four; yet she has an eighteen year-old mind!") Likewise, the nurse invokes the f a c t that t h i s i s her second baby to imply that a patient of her "experience" may not l e g i t i m a t e l y demand ("making a fuss") that such p r o p r i e t i e s be observed. Next the doctor t r i e s to debunk her r e f u s a l to cooperate by t r e a t i n g i t as a symptom of a general " s o c i a l problem" (the "generation gap") and as a sign of her poor moral character ("common-law marriage"). Apparently the patient i s to draw the conclusion that his generalization applies to her and, therefore, hear the terms "young" and "common-law marriage" as r e f e r r i n g to h e r s e l f . Then the s o c i a l worker t r i e s to issue an i m p l i c i t ultimatum wherein the patient should leave the C l i n i c without service since t e c h n i c a l l y she does not q u a l i f y f o r medical welfare, and presumably because she w i l l not cooperate with s t a f f members. However, she quickly rescinds t h i s t a c t i c because the patient i s seen by her super-v i s o r as too f a r advanced i n her pregnancy to t r a v e l to the province where she would qualify and should, therefore, be granted the extra welfare support required f o r a female doctor, i f t h i s i s the only way to have her receive prenatal care ("You have to be i n the province three months to be e l i g i b l e . You'd better go back to Eastern C i t y . . . She's seven months along.") Next, the head nurse also invokes the i l l e g i t i m a t e status of her r e l a t i o n s h i p to her "husband" to imply she lacks s u f f i c i e n t moral standing to l e g i t i m a t e l y demand that proprie-t i e s surrounding immodest exposure be observed ("This wastes a l o t of time and money! This i s her second baby, too. She's l i v e d common-law f o r f i v e years!") Then the nurse switches the focus of her attack from her lack of legitimate grounds to make such a request to the f a c t that the patient has invoked the support of the supervisor i n i n s i s t i n g on her demand f o r a female doctor. Having f a i l e d to persuade the patient by d i s c r e d i t i n g and r i d i c u l i n g her request, s t a f f switches topics to next t r y to undermine the authority the patient has used to counter t h e i r arguments. The head nurse t r i e s to do t h i s by claiming the patient has l i e d about the supervisor's promise of a female doctor ("She claims the supervisor promised her a female doctor. She never did!") The s o c i a l worker c a l l s the supervisor's o f f i c e to t r y to gain some (apparent) evidence that she i s l y i n g . She does t h i s knowing already that because of the patient's advanced stage of pregnancy that the super-v i s o r has "bent" the e l i g i b i l i t y r u l e s and promised a female doctor, too. Over the phone the s o c i a l worker, i n f a c t , con-firms that t h i s i s the case, but she nevertheless t e l l s the 88 patient that the supervisor t o l d her that the services of a female doctor cannot be provided. However, the patient apparently has not been f u l l y convinced by t h i s telephone ruse because she points out the inconsistency which tends to under-mine the s o c i a l worker's i m p l i c i t claim that the supervisor does not support her request ("The supervisor says we have no female doctors.") Patient: "Why did (the supervisor) promise me?") Rather than answer the patient's counter question and t r y to defend her contrived claim that the supervisor does not support the patient's request, the s o c i a l worker once again switches t o p i c s , t h i s time to the patient's motives f o r making her request, i . g . . , she t r i e s to make the patient account f o r them i n public while standing i n front of the waiting benches. However, the patient evades the question ("Why do you need one?") Patient: "I do . . . .") Apparently, the patient w i l l not allow h e r s e l f to be thus "trapped" i n t o making a p o t e n t i a l l y embarrassing public confession of her need f o r modesty. Thus, throughout the i n t e r a c t i o n , s t a f f continuously switches topics of conversation as the patient appears not to be persuaded by f i r s t one argument and then another: the lack of female doctors i n the C l i n i c , normalizing "care" by male doctors, invoking her "age" and previous h o s p i t a l i z a t i o n , invoking the "generation gap" and her lack of r e s p e c t a b i l i t y , her lack of t e c h n i c a l e l i g i b i l i t y f o r welfare, and, f i n a l l y , t r e a t i n g the motives f o r her request as problematic and p u b l i c l y accountable. F i n a l l y , i n her remarks to me afterwards, the s o c i a l worker makes i t clear that s t a f f p a r t i c u l a r l y t r i e d to persuade t h i s patient to cooperate and accept male "care" because they f e e l the supervisor ("the c i t y " ) i s being "too permissive" (" I think the c i t y i s going too f a r i n giving her what she wants.") In other words, these management e f f o r t s , normally employed with "modest" patients, are increased i n t h i s case because the supervisor (because of the patient's advanced stage of pregnancy) supports the patient's request; i . e., the supervisor usually does not subscribe to the C l i n i c s t a f f ' s view that any patient, almost regardless of the state of pregnancy or other circumstances, i s deemed " i n e l i g i b l e " f o r Welfare support and C l i n i c care i f she refuses to p a r t i c i -pate i n those routines which have sexual overtones. S i m i l a r l y , a private o b s t e t r i c i a n r e l a t e s how i n deal-ing with "modest" patients, rather than engaging i n lengthy arguments with the patient (as i n the C l i n i c ) , he b r i e f l y t r i e s to r o u t i n i z e the p e l v i c examination as "standard procedure," and teach the patient that i t i s medically required procedure before issuing an ultimatum wherein she must accept the pro-cedure from himself, a male, or else be refused any service whatsoever as "his patient." Again, i n the C l i n i c t h i s , too, i s a commonly used approach i f various r h e t o r i c a l moral appeals f a i l to persuade the patient (unless, of course, the patient can e n l i s t the support of the s o c i a l worker's supervisor). I t may seem in c r e d i b l e that i n t h i s day and age some women absolutely refuse to undergo pelvic examinations, but each month perhaps one or two of such supermodest types v i s i t my o f f i c e and do just that. The t i p - o f f doesn't come u n t i l 90 a f t e r the p r e l i m i n a r i e s — t h e history taking—when I say, "Now, my nurse w i l l take you to the examining room. Please take o f f a l l of your clothes, except your shoes. She w i l l give you a robe." Usually, with t h i s kind, there i s a l i t t l e gasp. "But, Doctor, I never have—I mean, you don't need to examine me completely do you?" Just how does she think I can e s t a b l i s h the condition of her innards otherwise? By radar? I t r y to explain that a, complete physical, including a p e l v i c , i s standard medical procedure. At one time I would present a l l of the arguments f o r the process but t h i s , I discovered, was l a r g e l y a waste of time with the woman who i s gripped by i n h i b i t i o n s stronger than l o g i c . Now I simply point out that an examination i s necessary and I can't accept the care of a patient without i t . "But, Doctor," i s the usual re p l y . "Can't you just give me some tests? There's nothing wrong with me—I just want to know whether or not I'm pregnant." The cause i s l o s t . I repeat that I can't accept her as a patient. There i s no charge. Blushing, her face t i g h t and righteous, she leaves. Perhaps i n the inte r e s t of enlightment I should draw out the super-shy types more f u l l y , but I'm a f r a i d the task i s one f o r a psychologist, not a busy o b s t e t r i c i a n whose working hours already stretch too long. And I w i l l admit that I'm not objective about the prudery that so long held back the development of gynecology and o b s t e t r i c s . Well into the eighteenth Century the idea that a physician should inspect a respectable woman's "privates" or attend her i n c h i l d b i r t h was considered immoral; the f i e l d was l e f t to the granny midwives who no doubt acquired mechanical s k i l l but l i t t l e science. . . . When I think of the needless suffering and l i v e s l o s t because of r i d i c u l o u s l y overdeveloped modesty, I confess I have l i t t l e time f o r people who s t i l l per-petuate such i d i o t i c a t t i t u d e s . Besides the medical s t a f f and s o c i a l worker, the rece p t i o n i s t also engages i n attempts to persuade patients to see the importance of a medically supervised regimen of pre-natal care. These attempts are p a r t i c u l a r l y evident when a patient comes to her counter a f t e r having missed a p r i o r appointment f o r a routine prenatal check-up, such as i n the 91 following case. Patient: (hands an appointment s l i p to her) "I missed an appointment l a s t Wednesday." Receptionist: (very sternly) "Why?" Patient: (shakes her head s l i g h t l y ) " I t ' s not important." Receptionist: "Why?" Patient: "I f e l t good anyway and . . . " Receptionist: (cuts o f f her utterance i n mid-sentence and begins scolding her) "Doctors think these check-ups are very important and should be kept!" Patient: "But the l a s t time they just asked me i f I f e l t f i n e so . . ." Receptionist: (interrupts her utterance again) "But you have to be checked every week! (the patient i s i n her l a s t month of pregnancy—J.E.F.) Okay. Now we'll check you today, (sternly and impatiently she says) Go to the lavatory and s i t down! (Afterwards the rec e p t i o n i s t t e l l s me: We generally have a l o t of women miss appointments and not be examined f o r weeks or months at a time)." Apparently, i f and when patients do cooperate and agree to have regular prenatal care i n the C l i n i c , many nevertheless f a i l to see the importance of such frequent check-ups. I take i t that t h i s i s a r e s u l t of the f a c t which I discussed i n the Introduction that many patients place l i t t l e or no value on "preventive medicine" i n general. These patients see the use of medicine as warranted only i f "symptoms" or "troubles" begin to obviously i n t e r f e r e with t h e i r everyday l i f e and occupational capacity. Thus, f o r these patients medicine takes on a "repair function" when the body begins to be unserviceable or cause noticeable discomfort. In other words, as long as they " f e e l 92 f i n e " i n the present they see no need f o r medical care which i s intended f o r the purpose of "preventive maintenance" of t h e i r bodies. However, usually the receptionist does not l e t a missed appointment "pass" without some e f f o r t to make the patient account f o r her "transgression," sanction her f o r i t , and t r y to persuade her to see the importance of scheduled prenatal check-ups. The patient, h e r s e l f , apparently assumes that keep-ing appointments i s treated by the re c e p t i o n i s t as a sanction-able matter since she manages her response so as to avoid giving her motive, which turns out to be seen as indeed sanctionable by the re c e p t i o n i s t ("Why?" Patient: "It's not important.") However, the receptionist does not t r e a t t h i s as an adequate accounting f o r her motives and repeats her question, "Why?" When the patient gives her motive, the receptionist responds by using a commonly-used management method of interrupting or 3 "cutting o f f " her explanation i n mid-sentence. ("Why?" Patient: "I f e l t good anyway and . . . " Receptionist: "Doctors think these check-ups are very important and should be kept!") I take i t that the use of t h i s method r e f l e c t s s t a f f ' s assumption that patients do not have equal r e c i p r o c a l conversa-t i o n a l r i g h t s to speak and be heard by s t a f f , i . e_., t h e i r t a l k and questions can be ignored or "cut o f f " by s t a f f without t h e i r being able to legitimately sanction s t a f f members, but the opposite does not leg i t i m a t e l y hold f o r the s t a f f members' t a l k and questions to the patient. The re c e p t i o n i s t uses t h i s method again when the patient t r i e s to protest the v a l i d i t y of her 93 reason f o r missing an appointment. (Patient: "But the l a s t time they just asked me i f I f e l t f i n e , so . . ." Receptionist: "But you have to be checked every week!") I assert that t h i s may be a commonly-used method of doing scolding wherein s t a f f , acting as management agents, ask a patient f o r the reason f o r a "transgression" and then "cut o f f " or not give a p o l i t e or f u l l hearing to the patient's account before taking t h e i r next turn i n the conversation. Although the receptionist has e x p l i c i t l y asked the patient f o r her reasons f o r missing an appointment, her scold-ing remark implies that whatever reason the patient may f e e l to be adequate i s i n f a c t not v a l i d or important since "she i s not an expert or an authority" l i k e the doctors who "know what i s best f o r her." ("Doctors think these check-ups are very important and should be kept!") Also, i n t h i s remark the receptionist implies that she believes that no matter what reason the patient may give, the r e a l reason i s that the patient does not see the e s s e n t i a l importance of s t r i c t l y adher-ing to a medically supervised prenatal regimen of "care." Thus, evidently she i s r e l y i n g on an assumption of what t y p i c a l l y or normally motivates absenteeism (a difference i n c u l t u r a l per-spective) i n order to scold her presumptively without f i r s t l i s t e n i n g to a l l of the patient's reasons. In the second interru p t i o n of the patient's account, the receptionist apparently i s t r y i n g to teach the patient that how she f e e l s i s i r r e l e v a n t — i t i s a matter of the normative character of 94 the medical routine ("But you have to be checked every week!"). In other words, I take i t that here she i s reminding the patient of one of the rules of the C l i n i c , implying that the patient should treat them (the rules) as normative matters binding on her behavior. In addition to t r y i n g to persuade patients to accept medically supervised prenatal care and c h i l d b i r t h , s t a f f mem-bers t r y to teach patients to "properly" organize t h e i r l i v e s i n preparation f o r parenthood, including t h e i r f i n a n c i a l and marital a f f a i r s , as well as t h e i r housing s i t u a t i o n . The s o c i a l worker, espe c i a l l y , t r i e s to control by moral per-suasion patients' occupational and marital l i v e s so as to ensure a "sound" future f o r the baby. Most of t h i s attempted management occurs when the s o c i a l worker i s interviewing the patient to gather information to determine e l i g i b i l i t y f o r Welfare, and to f i l l out the S o c i a l P r o f i l e sheet i n the patient's medical history f i l e . Instead of merely asking questions i n a straightforward manner about the patient's s o c i a l and f i n a n c i a l circumstances and recording her responses, often she turns the interview into a d i d a c t i c session wherein she i n i t i a l l y asks presumptuous "leading" questions (and r h e t o r i c a l questions), apparently intended to encourage the patient to i n f e r the existence of moral and " s o c i a l " problems i n her l i f e and then o f f e r s "advice" about what the patient and her "hus-band" could (intended to be heard as "should") do about these "pressing" problems. In other words, the s o c i a l worker, by her 95 choice of topics and manner of questioning, t r i e s to get the patient to see that her f i n a n c i a l or marital s i t u a t i o n con-s t i t u t e s a set of "problems" f o r which the patient i s morally responsible so that when she f i n a l l y offers her advice i t i s more l i k e l y to be heeded by the patient as morally binding on her behavior. (The patient enters the s o c i a l worker's o f f i c e and s i t s down.) So c i a l Worker: "Are you pregnant?" Patient: "I don't know yet." So c i a l Worker: "Where are you from?" Patient: . So c i a l Worker: "I never heard of i t . Is i t small?" Patient: "Yes." So c i a l Worker: "Is i t near Midwest Ci t y ? " Patient: "No." Soc i a l Worker: "Do you have any health problems?" Patient: "I've had mono." So c i a l Worker: "You're pretty sure! Ha! Ha! Did you want to get pregnant or did i t just happen?" Patient: "Oh. I wanted a baby." So c i a l Worker: "Has your husband worked during the l a s t s i x months?" Patient: "No." Soc i a l Worker: (looking at the face sheet information before her) "He hasn't had any work since he came to t h i s c i t y ; and he has two years of college? Is he not motivated?" Patient: "I don't know." Soc i a l Worker: "He could get a job on campus and you, too. I can see why the Adoption Agency (where he t r i e d to f i n d work—J.E.F.) didn't want to hire him. He hasn't a degree!" I take i t that the question concerning whether she wanted to get pregnant i s intended to check out how "welcome" t h i s baby i s . I t i s phrased i n such a way as to imply that f o r a preg-nancy to be "welcome" i t must be r a t i o n a l l y planned. In f a c t , the patient i n her response shows she has heard the intended question to be the d e s i r a b i l i t y of the baby and not merely the l i t e r a l one of whether the pregnancy was planned; i . e_., she responds to the intended or "leading" character of the question. Next, note that the s o c i a l worker does not merely record the "No." response to her question about her husband working but instead uses the information on the face sheet completed by the s o c i a l worker's assistant to provide a warrant to ask a presumptive and accusatory question about her husband's "apparent" lack of motivation. ("He hasn't had any work since he came to t h i s c i t y ; and he has two years of college? Is he not motivated?") In the process, she presumptively suggests that both she and her husband are to blame (due to a lack of motivation) f o r not being employed and then offers the advice that both she and her husband seek employment on a nearby college campus. When the s o c i a l worker encounters these patients with "problems" i n the waiting room on subsequent check-ups, she often "follows up" on her e a r l i e r management attempts i f , f o r example, the patient's husband s t i l l i s unemployed or t h e i r l i v i n g quarters are s t i l l seen to be "unsatisfactory" with chastisements and reminders of the necessity of getting o f f welfare i n order to be able to pay f o r the new baby. In the following example the s o c i a l worker happens to encounter a patient i n front of the receptionist's counter when she returns to the C l i n i c f o r a routine prenatal check-up. S o c i a l Worker: "Hi, Mary. How are you?" Patient: "Fine." S o c i a l Worker: "What? No baby, yet?" (The patient i s i n the l a s t stages of pregnancy—J.E.F.) Patient: "I've moved." So c i a l Worker: "What's your new address?" (The patient t e l l s her.) "Is i t a house or an apartment? How many rooms?" Patient. "Two." Soc i a l Worker: "Two bedrooms, furnished?" Patient: "Yes." S o c i a l Worker: "Your husband working yet?" Patient: "No." So c i a l Worker: (frowns) "What! No job!" Patient: "He can't f i n d one." So c i a l Worker: (angry tone of voice) "Are you l i v i n g i n a hotel l i k e l a s t time?" Patient: "Yes." Soc i a l Worker: "Are you going to keep the baby?" Patient: "Yes." 93 S o c i a l Worker: "What about clothes f o r the baby?" Patient: "I don't know yet." S o c i a l Worker: (sounding annoyed) "Just how do you expect to pay f o r a l l t h i s ? Out of Welfare? l o u know that money comes out of my_ pocket, too!" At the news that the husband i s not working yet she gets angry and begins denigrating t h e i r l i v i n g s i t u a t i o n . Also, t h i s news apparently makes the " f i n a n c i a l future" f o r the baby more problematic so she brings up the topic of adoption and reminds the patient of the expense entailed i n buying baby clothes. She t r i e s to point up the importance of her husband f i n d i n g a job by pointing out the patient's f i n a n c i a l r e s p o n s i b i l i t y . ("Just how do you expect to pay f o r a l l this?") Since the husband has not yet found a job, the s o c i a l worker presumes that they are planning to l i v e on Welfare; so, she implies that Welfare w i l l not be adequate f o r t h i s purpose. Also, she claims the patient i s taking money from her personally when she accepts Welfare. Thus, the s o c i a l worker implies that taking Welfare at a l l i s immoral because i t involves f o r c i n g her and other taxpayers to pay f o r the patient's and her family's support. In addition to these e f f o r t s observed i n the waiting area, I found that occasionally the doctors i n the pe l v i c examination, or cubicle area included s i m i l a r management attempts i n t h e i r interviews with the patient. Resident: "You've been pregnant before?" Patient: "No." 9 9 Resident: "How old are you?" Patient: "Seventeen." Resident: "Where are you from?" Patient: "North C i t y . " Resident: "Where do you go to school?" Patient: "I have been working." Resident: "How long?" Patient: "One year." Resident: "Did you get pregnant i n North C i t y or come over here?" Patient: "I don't know when I got pregnant." Resident: "Does your husband work?" Patient: "No." Resident: "How much do you make?" Patient: "Three hundred d o l l a r s a month." Resident: "Where i s your husband going to get work?" Patient: "I don't know." Here the doctor apparently t r i e s to show the patient that i n order to r a i s e a c h i l d both she and her husband are going to have to work. He does not t e l l her t h i s e x p l i c i t l y , but simply leaves i t up to her to draw t h i s conclusion from h i s presumpt-uous question, "Where i s your husband going to get work?" In another case, a resident uses the same management technique of asking presumptuous "leading" questions. Resident: "What kind of work do you want?" Patient: "I don't know." Resident: "You should see the s o c i a l worker." (Later i n the interview the resident shows he has read the patient's f i l e which states her husband works as a f i l l i n g s t a t i o n attendant.) "How i s your husband getting along at the gas station?" Patient: "Okay." Resident: "Chance of anything better?" Patient: "I don't know." Resident: "As long as you are not a f r a i d to go out of town, he can get better wages." Here the resident introduces the topic of her f i n a n c i a l s i t u a -t i o n by a presumptuous question which assumes she desires to (and indeed should) go to work. He then asks a "leading" question about her husband's success on his current job. I take i t that he already believes that t h i s job has "undesir-ably" limited p o s s i b i l i t i e s f o r increased income, which he presumes they need, and therefore i s not seriously interested i n how successful he i s but just wants to "set up" or provide f o r the relevance of his next presumptuous question, "Chance of anything better?" This question provides a way of showing the patient that her husband should be more ambitious without having to e x p l i c i t l y admonish her to t h i s e f f e c t . His f i n a l remark suggests he has gathered from her responses (and probably already suspected) an apparent lack of ambition on the part of her husband. However, instead of merely sta t i n g his advice i n a straightforward manner ("There's more opportunity out of town."), he formulates i t as a mild cajole or coaxing which challenges her to move out of town so he can advance 101 occupationally ("As long as you are not a f r a i d to go out of town, he can get better wages.") Besides t r y i n g to manage the prospective parents' f i n a n c i a l , occupational, and housing situations, s t a f f often b u i l d i n t o t h e i r questions concerns f o r the permanency of the parental r e l a t i o n s h i p and the consequent legitimacy of the yet unborn baby. Such a d i d a c t i c approach apparently i s intended to allow the patient to draw her own conclusions as to the need to be future-oriented and to provide f o r the permanency (and r e s p e c t a b i l i t y ) of the family r e l a t i o n s h i p . The follow-ing excerpt from an interview between a pregnant patient and the s o c i a l worker provides an example of the use of t h i s method of presumptuous questioning. S o c i a l Worker: "How long have you l i v e d common-law with your guy?" Patient: "Six months." So c i a l Worker: "Are you on Welfare?" Patient: "No." S o c i a l Worker: "What does he do?" Patient: "He's a carpenter." S o c i a l Worker: "What does the future hold? Do you think y o u ' l l get married?" Patient: "I don't know." Apparently the s o c i a l worker wants the patient to see hers e l f as involved i n an "impermanent" r e l a t i o n s h i p and implies that t h i s requires changing f o r the future and that the patient should consider (or has considered) marriage as a possible future course of action. 102 F i n a l l y , I would l i k e to conclude t h i s chapter with a discussion of how c l i n i c s t a f f i n the waiting room (and cubicle area) endeavor to persuade patients to adhere to a medically prescribed prenatal dietary regimen. For example, when the head nurse weighs patients on every v i s i t , she does not merely record t h e i r weight on t h e i r medical hi s t o r y charts and t e l l them what they weigh; she also includes a loud, p u b l i c l y stated moral censure i f they have gained any weight, and loud approba-t i o n i f they have l o s t any weight ("You've l o s t a pound! Good g i r l ! I am proud of you!") Apparently the nurse sees her rou-t i n e task as including attempts to persuade patients to see the importance of l i m i t i n g weight gain by c o n t r o l l i n g t h e i r d i e t s f o r the "sake of the baby's health," and to avoid "complications" during pregnancy. However, from my observa-tions t h i s appeared to be a chronic, irremediable "problem" f o r her (and the res t of the s t a f f ) because i t i s the r e s u l t of cr o s s - c u l t u r a l differences between them and patients. For example, while patient's waited at the benches many of t h e i r conversations dealt with such topics as eating, t h e i r f a v o r i t e foods, and t h e i r large appetites. Apparently many patients did not regard the gestation period as being governed by medicalized food r u l e s , but instead as a period where they continued t h e i r pre-pregnancy dietary habits. This c u l t u r a l difference r e s u l t s i n the common occurrence of the following sort of attempt at persuasion at the weighing s c a l e . Head Nurse: "You've gained three pounds! That's too much even f o r an I t a l i a n who eats spaghetti!" 103 (The s o c i a l worker happens to be walking by and overhears t h i s exchange. Without i n v i t a t i o n , she offers her advice.) S o c i a l Worker: " I t a l i a n who eats spaghetti, eh? You better cut downI" As with managing patients with regard to other c r o s s - c u l t u r a l issues, the s o c i a l worker often spontaneously "teamed-up" with the head nurse against a patient when the occasion seemed to req u i r e i t . Here the head nurse uses the commonly-used method o f t i e i n g a sanction f o r weight gain to a presumptive charac-t e r assessment of the patient; e_. g., she may draw on the commonly held assumption (among C l i n i c s t a f f ) that patients with " I t a l i a n " surnames often continue t h e i r pre-pregnancy, " t y p i c a l l y I t a l i a n , " d i e t s which include medically prohibited l a r g e amounts of starch. In other words, s t a f f members often draw on shared ethnic t y p i f i c a t i o n s of patients i n doing sanctioning, which are assumed to be related to the normal dietary v i o l a t i o n s assumed to be indicated by weight gains. Thus, i n sanctioning patients, s t a f f members t y p i c a l l y make two sorts of presumptions: (1) Any weight gain i s the patient's moral r e s p o n s i b i l i t y and due to her v i o l a t i o n of dietary norms. (2) These v i o l a t i o n s are the r e s u l t of patient's adhering to her ethnic (or r e l i g i o u s ) subcultural dietary habits. When a patient does not exhibit any e a s i l y recognized signs of a p a r t i c u l a r ethnic a f f i l i a t i o n , the head nurse may just presumptively accuse the patient of some general v i o l a t i o n (e» £•> "over-eating") of dietary rules i f she has gained any weight. Head Nurse: "You gained four pounds! You've been 104 over-eating!" In some cases of t h i s type, censure and admonition may be more i n d i r e c t l y expressed and include a vague threat of (presumed) undesirable effects on the patient's aesthetic appearance i f she does not discontinue her (presumed) v i o l a -t i o n s . For example, i n the following instance the head nurse weighs a t a l l patient and whistles gently before announcing her weight. "153 pounds! You better slow down or you are going to be a very b i g lady." Apparently the head nurse assumes that a lay patient may be more concerned f o r her appearance than any medical s i g n i f i c a n c e of gaining weight. Besides t r y i n g to manage patients when they are weighed, the head nurse often monitors patients' conversations while they wait on the benches f o r references to "bad food habits" and often interrupts t h i s t a l k with sanctions or reminders of the necessity of observing medical dietary r u l e s and l i m i t i n g the amount of weight gained during t h e i r pregnancy. She engages i n these management attempts p a r t i c u l a r l y with the " g i r l s " from the Home f o r unwed mothers because they s i t on the benches nearest the scales where she spends much of her time. For example, during one C l i n i c session the patients discuss plans f o r how they w i l l celebrate Halloween (including the "smuggling" i n t o the Home of t h e i r f a v o r i t e — t h o u g h "prohibited"—foods) i n the Home. Patient: (to the group of patients) "What are we going to do f o r Halloween?" 105 Head Nurse: "Are you going " t r i c k or t r e a t ? " Patient: "I don't know." Head Nurse: "Maybe y o u ' l l get bigger than!" A common account ( s t a f f c a l l them "excuses") the head nurse hears when patients t r y to explain the reason f o r weight gains i s that a "spe c i a l occasion," l i k e a holiday or birthday, "required" her to "over-eat" and v i o l a t e the medically pre-scribed d i e t . Also, she assumes that such events do i n f a c t frequently r e s u l t i n sanctionable weight gains. Thus, here she anticipates the possible "adverse" e f f e c t s of such an event and i n d i r e c t l y warns them to be aware of the possible sanction-able r e s u l t s (an "unattractive" weight g a i n — " y o u ' l l get bigger then!") of engaging i n " v i o l a t i o n s " of the prescribed d i e t that these holidays r i t u a l l y e n t a i l . Besides discussions of " r i t u a l eating," a common topic of conversation among the waiting Home patients i s t h e i r f a v o r i t e foods and what they are going to eat a f t e r the C l i n i c session, including going to a nearby drug store f o r various ("prohibited") fountain t r e a t s . Often the head nurse w i l l cut in t o these conversations and sanction t h e i r repeated r e f e r -ences to eating and food. The following i s an example of t h i s sort of management attempt: (The patients are discussing how hungry they are and the food they intend to eat a f t e r the session, when the head nurse interrupts with a question f o r the group.) Head Nurse: "What did you have to eat today?" Patient: "Nothing." Head Nurse: "That's r i g h t ! You don't eat on C l i n i c day! That's why you're always t a l k i n g about food!" The head nurse evidently was already aware that many patients do not eat on " C l i n i c day" i n order to t r y to compensate f o r t h e i r "transgressions" during the res t of the week and to at le a s t temporarily reduce t h e i r weight, so as to avoid being sanctioned by C l i n i c s t a f f or even being h o s p i t a l i z e d f o r possible "complications" due to weight gained during the pregnancy. In other words, she probably already knows the answer to her question, "What did you have to eat today?" even before she asked i t . Thus, instead of issuing a s t r a i g h t -forward sanction f o r t h e i r "devious" or " i r r e g u l a r " dietary pr a c t i c e s , she "traps" the patients into a "confession" of abstaining from food by asking an apparently innocuous "lead-ing" question i n order to "set up" or warrant her sanctioning remarks, "That's r i g h t ! You don't eat on C l i n i c day! That's why you're always t a l k i n g about food!" This case also i l l u s t r a t e s the f a c t that apparently s t a f f not only want the patients to control t h e i r dietary habits but also t h e i r t a l k to each other about food; perhaps on the grounds that "careless" or "indulgent" t a l k i s seen to undermine any possible " p o s i t i v e " e f f e c t that s t a f f ' s manage-ment e f f o r t s might have had on them. On the other hand, i f and when s t a f f over-hear the patients discussing the medical "dangers" of various types of foods during pregnancy they usually do not t r y to j o i n the conversation. Thus s t a f f 107 usually interrupt only to issue a reprimand (e. g., ". . . you're always t a l k i n g about food!") when patients are discuss-ing how hungry they are or "prohibited" sorts of food, which are also the patient's f a v o r i t e s . In sum, apparently s t a f f see the patients' conversations as part of the management process and therefore monitor i t to control i t and provide f o r a continuity between the s t a f f ' s s o c i a l i z a t i o n t a l k and the content of conversational exchanges between waiting patients. After the patients have a l l been weighed and properly sanctioned ( p o s i t i v e l y or negatively), they wait on the benches to be instructed by the head nurse to go back into the cubicle area "to see the doctor." During t h i s period, the rec e p t i o n i s t , whose counter i s near the Home patients' bench, w i l l remind the waiting patients of t h e i r r e s p o n s i b i l i t y to "watch t h e i r weight." The following case i l l u s t r a t e s the method by which she does t h i s reminding. (The r e c e p t i o n i s t leans over the counter, looks at the Home patients, and loudly asks the group the following question.) Receptionist: "Who has gained a l o t of weight today?" Patients: (Many patients giggle nervously and they respond with a chorus of:) "Not me! Not me! Not me!" I take i t that here the recep t i o n i s t i s not t r y i n g to monitor or sanction any one individual's weight gain, but instead i s doing what a school teacher does when she asks her class at the beginning of the session, "Who has done the homework assignment?" In other words, she i s r e l y i n g on what she assumes w i l l be a large number of p o s i t i v e responses (e_. g., a chorus of "Not me," or f o r the teacher, "I have!") to have the e f f e c t of making whoever has not been "good" f e e l shamed or sanctioned. Apparently, she i s t r y i n g to "follow-up" the head nurse's moral treatment of p a r t i c u l a r individuals with t h i s t a c t i c of using the "group" to provide a public setting so that those patients that have not gained (or have l o s t ) weight may have some sense of "recognition" (or "reward") f o r t h e i r "achievement", whereas the "bad" patients who have gained weight are not allowed to leave the waiting room without t h i s one l a s t reminder of t h e i r " v i o l a t i o n s " of the r u l e "weight gains are prohibited." Like the head nurse i n the waiting area, s t a f f i n the cubicle area assumed any weight gain was the r e s p o n s i b i l i t y of the patient, and treated i t as presumptive evidence that she had " v i o l a t e d " rules about "watching her weight" and adhering to a d i e t . As a r e s u l t , they sanctioned any weight gain and debunked any reason the patient gave f o r the assumed " v i o l a t i o n " of the d i e t , or a weight gain, as being "excuses"— implying she had d e l i b e r a t e l y sought to "transgress." T y p i c a l l y , these reasons, or "excuses," involved celebrations and holidays where eating i s regarded an i n t e g r a l part of, or r i t u a l l y required, i n such events. Despite the doctors' lectures and subsequent sanctions f o r "transgressions" during check-ups, patients frequently arrived i n the C l i n i c a f t e r 109 these events with what s t a f f saw as "sanctionable" weight gains. In other words, many patients s t i l l regarded the prescriptions and proscriptions governing these events as taking p r i o r i t y over medical dietary r u l e s . Thus, t h i s provided a common issue f o r c r o s s - c u l t u r a l c o n f l i c t i n routine prenatal check-ups. Resident: "Hi! How are you?" Patient: "This i s the big month, eh?" (Her ninth month of pregnancy—J.E.F.) "At l a s t . I gained three pounds." Resident: "Tisk! Tisk! Are you watching your weight?" Patient: "I t r y , but we had a birthday celebration." Resident: "I keep hearing those excuses a l l the time!" (Later i n the examination) "Here are some sleeping p i l l s . " (She had complained of not being able to sleep.) "Take one. This weight! Y o u ' l l watch i t ! " In the following case a Resident treats a patient's observably obese condition as presumptive evidence of her not "staying" on the d i e t and as grounds to sanction her f o r w i l l f u l l y r e s i s t i n g the dietary advice, i . g.., being "stubborn." He then follows t h i s e f f o r t with a "scare story" s i m i l a r to that used by s t a f f to t r y to manage patients i n the waiting area and cubicles who voice t h e i r intentions to have t h e i r c h i l d i n a non-medical s e t t i n g . Here the resident i s accompanied by several students. Resident: "How's your health?" Patient: "Okay." Resident: "She's had a urine analysis, have you?" (He looks at the hemoglobin count on her chart.) "Have you had iron?" Patient: "No." 110 Resident: (to the students) "Why hasn't she been given any iron?" (He grabs a handful of her abdomen and asks the students) "What's t h i s ? " (The students appear surprised and puzzled at his question.) Student: "Fat and stretch marks." Resident: (to the patient) "Stay on your d i e t ! No starches or grease!" (The patient laughs nervously, and he responds) "This i s no game! Don't be stubborn! We're not playing any games! Too much weight put one g i r l i n the ho s p i t a l and caused disposal of her baby and l i v e r damage." He ph y s i c a l l y sanctions her by roughly grabbing a handful of the offending " f a t , " and displaying i t to the students as such seems to be an attempt to "shame" the patient. In other words, he takes advantage of the teaching s i t u a t i o n to treat the " f a t " as a teaching object ("What's t h i s ? " ) , thereby using the stu-dents as an audience with which to "shame" or degrade her as being "over-weight." The patient then laughs nervously, apparently from embarrassment at being thus "displayed." How-ever, the resident interprets t h i s laugh as meaning she i s being "smart," or making l i g h t of his admonitions. As a r e s u l t , he proceeds to presumptively sanction her f o r not adopting the prescribed attitude on the importance of weight control, i . , t r e a t i n g i t as a "game." ("This i s no game!") Next, he t r i e s to impress on her that t h i s i s "serious b u s i -ness" by r e l a t i n g an anecdote of the "troubles" experienced by another patient who gained too much weight during pregnancy. As with the management of "natural c h i l d b i r t h " patients, s t a f f I l l members do not treat the patient's d i e t or the weight she gains as a matter f o r her choice. As a r e s u l t , they do not simply t e l l patients t e c h n i c a l p r o b a b i l i t i e s of the r e l a t i v e safety of d i f f e r e n t dietary practices or varying amounts of weight gains to them and t h e i r o f f - s p r i n g , and permit them to make decisions about these matters. Instead, they t r y to shock patients with anecdotes which imply that serious harm to them and t h e i r babies in e v i t a b l y follows from not following the pre-scribed dietary regimen. Presumably, the use of t h i s type of story i s based on the s t a f f ' s assumption that any woman would share t h e i r great concern f o r l i f e , and, therefore, would be shocked into compliance with the regimen. Above a l l , s t a f f appear to f e e l responsible to society f o r the welfare of the unborn c h i l d , and consequently t r y to persuade the patient to give up her apparent "stubbornness" and view i t as a l i f e and death matter. 112 FOOTNOTES 1. However, i t i s quite unusual for the Social Worker actually to use this r i g h t to make the baby the ward of the court. Typically, in gaining the compliance of "recalcitrant" parents, the threat of doing this i s sufficient. Further-more, even i f parents continue to resist, the Social Worker usually does not exercise her right unless the baby exhibits "serious effects" from their "negligent" treat-ment. 2. Erving Goffman, Asylums (Garden City, New York: Doubleday Anchor, 1961). 3. Bruce Katz has described how doctors in two-party therapy conversations may use the management technique of inter-rupting or "cutting off" a patient's utterance in order to sanction him or emphasize a point. See Bruce Katz, "Conversational Resources of Two-Person Psychotherapy" (unpublished Master's thesis, University of British Columbia, Vancouver, B.C., 1971). 113 CHAPTER IV IMPLEMENTING A MEDICAL IDEOLOGY IN PRENATAL WORK ROUTINES This chapter deals with patient management techniques I found i n the cubicle area where pel v i c examinations, general prenatal physical examinations, and prenatal lectures are given to o b s t e t r i c a l patients. Here I w i l l t r y to demonstrate how work exigencies such as work scheduling and providing a v i s i b l y competent performance r e s u l t i n only the occasional implementa-t i o n of the ideals of the medical ideology (including the "necessity" to "teach" patients, treat t h e i r " i n d i v i d u a l " prob-lems, and give proprietous care) i n regard to patient manage-ment techniques; an approach to patient "care" and the teaching of students I term the "technical approach"—(as opposed to the academically-located "patient as person" medical philosophy or approach which supports the more consistent implementation of i d e o l o g i c a l ideals i n everyday work r o u t i n e s ) . Since medical students do the bulk of the work i n t h i s area, I w i l l pay p a r t i c u l a r attention to analyzing t h e i r organizational problems, work orientations, concerns with "getting through" prenatal interviews and general examinations i n a v i s i b l y competent manner, etc. Some of the supervisory contact i s oriented to "making physicians" of medical students. In t h i s process, 114 supervising physicians may give "pep t a l k s " containing i d e a l " i d e o l o g i c a l " components on the "patient as person" approach, as I have termed i t , but seem large l y to ignore students' p r a c t i c a l work problems. In other words, i n these d i d a c t i c sessions, the "technical approach" the medical philosophy, generally i m p l i c i t , which i s most commonly followed by residents and medical students i n the cubicle area and d e l i v e r y room, as well as by s t a f f i n the intake area to patient manage-ment may be down-graded as a medical philosophy, but students have to come to terms with the demand c h a r a c t e r i s t i c s of the s i t u a t i o n (e_. g., work scheduling and v i s i b l e competence) once they get to the cubicles where they a c t u a l l y work with patients. Taking the Medical History In the City Outpatient C l i n i c , the bulk of the prenatal and gynecological pelvic examinations are performed by t h i r d year medical students. They take the medical history by i n t e r -viewing the patient, do a general, cursory examination, and f i n d a resident to supervise t h e i r doing of the " i n t e r n a l examination." The "history" form i s f i l l e d out by the student on the patient's f i r s t v i s i t and i s used by students and r e s i -dents on subsequent check-ups. A " p e l v i c " i s done on the f i r s t v i s i t to take a Pap smear, check f o r gynecological problems, as well as assess the p e l v i c bone structure f o r i t s adequacy i n allowing a vaginal d e l i v e r y . Another " i n t e r n a l " i s ro u t i n e l y performed shortly before the estimated delivery date to assess the expansion of the uterus and check f o r any additional 115 gynecological problems. A " p e l v i c " may be given on one of the intervening routine monthly check-ups i f the patient complains of vaginal troubles, or problems are detected with regard to the fetus. There are usually only two residents on duty, plus an intern , to supervise eight curtained cubicles. As a r e s u l t , students do most of t h e i r work unsupervised. Even when the resident attends the p e l v i c , he i s usually quickly c a l l e d away to another cubicle, allowing l i t t l e time to "teach." However, the students are there to learn, so they l e a r n primarily "by doing." The only formal teaching session occurs on the t h i r d year students' f i r s t v i s i t to the c l i n i c . On those occasions, usually four or f i v e students appear i n the waiting area at 1:00 and wait f o r the teaching o b s t e t r i c i a n , Dr. B a r t l e t t , who arr i v e s around 1:20 to d e l i v e r a lecture i n one of the seminar rooms on the second f l o o r . Following the "orientation l e c t u r e , " the doctor and students, as a group, do an i n i t i a l o b s t e t r i c a l v i s i t , including the pelvic examination. These lectures deal with how to do pe l v i c examinations, physiology, and the general operation of the c l i n i c . Much of these d i d a c t i c sessions con-s i s t of "pep-talks" concerning lack of patient cooperation due to the c r o s s - c u l t u r a l character of t h e i r encounters with patients, as well as " t i p s " on how to manage them. Dr. B a r t l e t t : "This i s an outpatient gynecology and o b s t e t r i c a l c l i n i c . The patients consist of those who aren't r e c e i v i n g (for some reason) private care. Some by choice l i k e the c l i n i c , and regard Gity as t h e i r "doctor." On the other hand, some are down and out. Some are i n trouble with the law and come from j a i l . Unmarried g i r l s are 116 from the Home, and a l o t of Indians who have no resources of t h e i r own. O b s t e t r i c a l patients come i n d i r e c t l y to the o b s t e t r i c a l c l i n i c . Gynecology patients can be referred from the Outpatient Department. The patients get pushed around by the bureaucracy. There aren't enough doctors to give care, and what's more important, the care i s not con-s i s t e n t — d o c t o r s think d i f f e r e n t l y — t h e y see a d i f f e r e n t doctor each time. Patients sometimes f e e l they don't need care. Be t h i s as i t may. We have obstetrics (whether a problem to the patient or not) and they need care. The g i r l (patient) has got ideas of doctors as being made of iron; so, when you t e l l them about watching t h e i r d i e t s , they may be convinced. She doesn't l i k e needles and wonders i f she can avoid them; damned i f s h e ' l l l e t us. The disadvantage of the c l i n i c i s that a l o t of patients know they can get away with weight gains; and they don't have to stand f o r any arguments about i r o n either; or else they can go elsewhere. In private practice, she pays her money and comes, so she decides to follow i n s t r u c t i o n s . So, we need to e s t a b l i s h a good r e l a t i o n s h i p between doctor and patient to use the peculiar authority of the doctor to get them to accept treatment they may not l i k e . An i r o n needle i r r i t a t e s , stings, unless by expectation i t hurts. A l o t of g i r l s have tatoos which are done by i r o n needles, and getting these done doesn't hurt the g i r l , anyway. Doctors are on pedestals to people. People think they earn too much and are wealthy S.O.B.s. Yet, they think they pack authority and can use i t . But doctors can only use i t i f they use t h e i r t o o l s : t h e i r behavior and dress." Here B a r t l e t t emphasizes the differences between the private and c l i n i c patient. He points out how the c l i n i c r o utinely has patients that require "arguments" by a s t a f f w i l l i n g to exert t h e i r "authority" (moral control) to transform them int o 117 "proper" mothers-to-be who are future-oriented and allow t h e i r l i v e s to be governed by a prenatal medical regimen. He makes an e f f o r t to "debunk" lay resistance to needles as being founded on unwarranted fears ("expectations") or "scare s t o r i e s . " He admonishes them to see such resistance "for what i t i s " and exert t h e i r authority to overcome i t (as did the head nurse i n the intake area). He exhorts them to establish a "good r e l a t i o n -ship" with the patient so that t h e i r "peculiar authority" can be used to get the patient to cooperate, despite her b e l i e f s and "expectations." He implies that such a r e l a t i o n s h i p i s contingent on the s k i l l f u l management of t h e i r dress and behav-i o r v i s - a - v i s the patient. The primary "moral" of t h i s i n i t i a l part of the lecture seems to be that " i f we are going to make good mothers-to-be out of these 'poor 1 patients the r e l a t i o n s h i p we e s t a b l i s h with them i s as important as technical s k i l l s . " During the rest of h i s lecture he usually becomes more s p e c i f i c as to the c r o s s - c u l t u r a l "problem" areas, as well as the aspects of "dress and behavior," to be managed to establish a r e l a t i o n s h i p i n which moral control may be exerted over the patient. Dr. B a r t l e t t : "Any patient responds to how you t r e a t them; and you respond to how the patient treats you. I f the patient gets f l i p p a n t and saucy, you do too. You should respond d i f f e r e n t l y and not t r y to get back at the patient i f she's impolite. You have to know your own r e l a t i o n s h i p to the patient to know how to assess your r e a c t i o n . Whether the patient uses drugs, smokes, your emotional r e l a t i o n -ship to the patient. This r e l a t i o n s h i p e f f e c t s your putting an accurate assessment 118 on the (physical and " i n t e r n a l " examination) chart. B a s i c a l l y , i t ' s communication: keep i t open i n the following way. F i r s t , be f r i e n d l y without being too f r i e n d l y , or f a m i l i a r . Second, use the milk of human kindness. Remember, they lacked the things we had; and don't forget how you are t r e a t -ing them. Talk to them as persons. Keep careless t a l k and laughter to a minimum. The patient i s paranoid, and assumes i t applies to her. This i s es p e c i a l l y true as each examination booth can be overheard, so you see i t tramped on a l l the time. Despite t h e i r low economic status, the patient i s frightened because they often have never undressed i n front of a man, so i t ' s impor-tant to close o f f the booth. So, treat the patient as a s i s t e r and learn to do things s k i l l f u l l y so you hurt her l e s s . Keep your hands and stethoscope warm. Move slowly and accurately. I f you hurt the patient, apologize, and l e t 'em know you're a human being." (A lecture a f t e r doing the p e l v i c as a group) Dr. B a r t l e t t : "One thing you have to do i s to establish rapport with a patient. This one we just examined i s cooperative. No problems. But you have to be able to t a l k to anyone whether they have bad breath, bad teeth, or make a face l i k e an ugly person, or i s snotty with you. This i s es p e c i a l l y important f o r the vaginal (examination)•" His talk s point out how medical personnel t r y to organize the events surrounding prenatal care into non-sexual occasions. However, i t i s a management problem because through and through, i t has obvious sexual overtones. He warns them to avoid sexual implications. He t r i e s to get them to adopt his model of the patient as an "unfortunate s i s t e r " whereby "even though you treat them l i k e c a t t l e i n the c l i n i c , t r e a t them as doctors." He admonishes them to understand "unfortunates" and develop the l a s t l i t t l e refinements of c i v i l i t y , privacy, 119 and modesty to est a b l i s h a "good r e l a t i o n s h i p " whereby t h e i r (the patients') behavior may be contro l l e d . Their behavior i s supposed to be i d e a l , since they are on a pedestal now. He gives them these "pep-talks," even though he assumes they have these attitudes already. His t a l k s c l e a r l y assume t h i s since he e x p l i c i t l y t e l l s them how to be praiseworthy v i s - a - v i s professional i d e a l s ; but he does not have to i n s t r u c t them to have the "right a t t i t u d e , " i . e_., "treat maternity as hon o r i f i c and sacred." Thus, he c l e a r l y shows he does not have to s o c i a l i z e them out of a "lay non-medical" perspective, but can assume "proper" pre-professional s o c i a l i z a t i o n . In sum, he does not explain why they should adopt these techniques, but instead commands them to be ready to perform them and "pay l i p - s e r v i c e " to the values embodied i n the "medical" perspec-t i v e . In his lectures, B a r t l e t t charges them to observe pro-f e s s i o n a l p r o p r i e t i e s of modesty by reducing the number of pelvic examinations, using the methods of draping, and having a nurse present. Such attempts at managing sexual overtones serve, according to the doctor, to gain the cooperation of the patient, as well as preventing those overtones from becoming grounds f o r impugning the competence of the doctor. Dr. B a r t l e t t : "During the active labor period, a f t e r the patient has been admitted to the h o s p i t a l , nurses lean a l o t on r e c t a l exams to see how the cervix i s d i l a t i n g and the baby i s coming. This i s not the best way to assess labor. Patients hate i t . I t hurts. Nurses depend on i t , and do i t too often. They don't use common sense: whether there i s 120 a bloody show, how often and strong are the contractions, and how the membranes are. Only i f she gets a l o t of pain, do your exam. Three vaginal exams are a l l you need. Use f i n g e r s — t h e y give a more accurate f e e l ; and i t ' s more comfortable f o r the patient. I t ' s the nurses' custom not to do vaginals. Nursing schools do medicine on an authori-t a t i v e , a r b i t r a r y basis; plus, the nurses' books say not t o . People believe i t ' s l i a b l e to cause i n f e c t i o n i f you use your hand; but she probably had a b i g ding i n her twenty-four hours before, anyway. Always use u t t e r politeness. Don't be rude and h o i t y - t o i t y . Expose adequately, but not unnecessarily, and respect modesty. You should have a nurse attending, i f i t ' s a young g i r l . Don't usually do an exam-inat i o n unless t h i s i s the case. Otherwise, I've been i n practice 15 years and never had an accusation. I t ' s a waste of time to always have to f i n d a nurse and have one present. Besides, you can't do anything nasty down i n that farm. You hear every-thing. When the g i r l i s being put up i n the s t i r r u p s , you don't have to leave, but i t ' s a matter of courtesy. The patient and you have to get down i n an undignified position; and there i s n ' t enough room to work." He poses his approach as "common-sense," as opposed to "authori-t a t i v e , a r b i t r a r y " medicine; whereby, students are to r e l y on ad hoc judgment of the progress of labor to " i n d i v i d u a l i z e " the number and timing of examinations. He invokes a view of the normal o b s t e t r i c a l patient and her sex l i f e to debunk the s t y l i z e d text-book approach. However, he does not use the dictionary term ("intercourse") to r e f e r to t h i s presumably normal "contamination," but a more "crude," f o l k sexual r e f e r -ence ("big ding"). This lecture i l l u s t r a t e s how s t a f f i n t h e i r backstage t a l k routinely exhibit the non-medical or lay view of p e l v i c examination and d e l i v e r y events as having obvious 121 sexual and prurient character. I found that when he wanted to emphasize or graphically describe some aspect of the pe l v i c examination, he employed these non-dictionary references, apparently as a pedagogical device. At the same time, he strongly admonishes them to control sexual implications i n the front stage by "being p o l i t e , " l i m i t i n g exposure, and having a nurse present to act as chaperone. He seems to assume there i s v a r i a t i o n among patients as to t h e i r " s e n s i t i v i t y " to sexual overtones and, consequently, tendency to confront a doctor with them i n the form of an e x p l i c i t accusation. He warns them to vary t h e i r techniques of reducing sexual overtones according to shared categories of normal types of patients; e_. g., a "young g i r l " requires a "chaperone" nurse. For other types of patients, he asserts i t i s "a waste of time," at least p a r t i a l l y because of the e s s e n t i a l l y public character of communication i n the cubicles. In i n s t r u c t i n g students on how to conduct the medical his t o r y interview, B a r t l e t t gives p a r t i c u l a r attention to that section of the hist o r y form c a l l e d the "sex-marital inquiry." Dr. B a r t l e t t : "For the sex-marital inquiry you should learn to ask personal questions. Know yourself and don't do i t f o r vicarious reasons. Ask only the questions, and don't appear to take a vicarious i n t e r e s t . Learn how to get the information out of her. You'll have a scared seventeen year-old, and y o u ' l l ask her whether she's having i n t e r -course. You should learn to establish rapport to get the information, so pass over these questions casually, so neither she, nor you, gets embarrassed. Don't ask i f she's been pregnant before, since s h e ' l l automatically and d e f i n i t e l y say no. Conduct a systematic inquiry so the marital and preg-nancy answers w i l l appear to be given r o u t i n e l y as part of the whole interview. You're going to get a c e r t a i n amount of misinformation; and you have to learn to minimize i t as best you can. You want to know the chances of getting pregnant. She may t e l l you she had a period two weeks ago, but i t may not be a period. You have got to f i n d out i f she screws, Ha! Ha! or has intercourse. T e l l 'em no information i s going to be blabbed around. T e l l 'em, I want to do the r i g h t thing by you; and that t h i s i s not a time to be playing games. T e l l 'em i t ' s not a time to be r e t i c e n t , and that s h e ' l l be c h i s e l l i n g only h e r s e l f i t i t ' s not the t r u t h . She w i l l say a few times a while back, or on a regular basis, or a few times a week. Get the information! Learn to be ultraobservant!" His lecture reveals that s t a f f are aware that the "medical h i s t o r y " may be another c r o s s - c u l t u r a l issue f o r the patient and doctor. The patients seem to believe that "there's us and the la-de-da doctors." Consequently, t h e i r responses to such questions reveal that they t r e a t them not so much as medical events of purely technical import, but as governed by proprie-t i e s that non-medical or "normal" scenes of inquiry carry. Accordingly, they w i l l organize t h e i r responses so that they f a l l within the accepted p r o p r i e t i e s ; e.. g., they w i l l not t e l l s t a f f about t h e i r sex appetites (implied i n the question on rate of intercourse), e s p e c i a l l y i f they are great. B a r t l e t t seems to take i t f o r granted that the normal, or " t y p i c a l , " patient w i l l assume that i f they give an "out-rageous" response to such i n q u i r i e s , the doctor w i l l not t r e a t i t so much as a medically i n t e r e s t i n g f a c t , but as a disreput-ably poor phenomenon. Because of t h i s management process, he 123 warns, the patient w i l l be shaping information. Nevertheless, B a r t l e t t sees i t as an important r e s u l t of his i n s t r u c t i o n that students be able to get "accurate" information to f i l l out the history and physical examination forms. This requires not only that they manage the p e l v i c examination as a non-sexual event to get the patient to relax and cooperate, but also manage the sexual overtones of the "medical h i s t o r y " so that the patient w i l l t r e a t "personal questions" as they presumably do the r e s t of the medical inquiry, i . §,., as purely t e c h n i c a l questions asked "for her own good." However, he makes i t clear that these questions are d i f f e r e n t f o r the s t a f f , a l s o . He implies that they, l i k e the patients, w i l l f i n d them to be of prurient i n t e r e s t and provoke embarrassment. Thus, although these are doctors-in-training, he assumes that t y p i c a l l y they share with patients the view that such i n q u i r i e s are through and through sexual events. He warns them that i f sexual overtones are to be managed f o r the patient, then they must also manage t h e i r own presentations and not ask questions spontaneously, which might reveal to the patient what she believes already: s t a f f do not t r e a t such i n q u i r i e s i n purely t e c h n i c a l ways. Ba r t l e t t ' s sexual jokes (". . . ask her i f she 'screws,' ha! ha! . . .") i n the backstage teaching se t t i n g suggests that not only students, but he, too, t r e a t s these as more than t e c h n i c a l matters. Normally, part of the orientation lecture i s also devoted to i n s t r u c t i n g students on the necessity of managing 124 t h e i r appearance and behavior to conceal or reduce the v i s i b i l -i t y of information as to t h e i r student status i n order to "pass" as doctors. They are admonished to work to gain the patient's t r u s t i n t h e i r competence, including engaging i n "passing devices," whereby, they may avoid appearing ignorant i n answering a patient's questions and appearing "studentish" i n dress and manner. Dr. B a r t l e t t : "The purpose of the c l i n i c i s to give the student contact with patients. Here he i s regarded as a doctor. He dresses, behaves, and i s addressed as a doctor. The students sta r t out scared; and the patients are scared, too. The students don't have to be. You have a r e s p o n s i b i l i t y as a teacher and student to watch to see i f you have a respec-table appearance. Some groups of patients, I wonder i f i t makes any difference to them. Whether a patient w i l l t r u s t a d i r t y , smelly person i s a matter of question, but i t i s the image of the doctor to wear a white coat, s h i r t , and t i e , and be clean. Learn and help the patient. Don't be too studentish with them. I f they ask questions, answer them i f you can. I f you can't, then s h i f t d i r e c t i o n to ward o f f questions. Use a l i n e of patter as a device to d e f l e c t questions. Refer to each other as doctor. A l o t of patients know you're students. Some think you're young doctors. But most patients won't ask d i r e c t l y , so c a l l each other doctor. The doctor-patient r e l a t i o n s h i p i s a matter of two people: there may be d i f f e r e n t ideas i n the minds of patient A and B, but they won't question the doctor as long as he appears competent. I f you get stuck (during the examination), come to me. You should develop your own glibness; such as " l e t ' s t a l k about that l a t e r , " or "Dr. B a r t l e t t can better answer that." Develop your own system. I'd l i k e to be there f o r the p e l v i c examination only." B a r t l e t t usually just mentions i n passing that some patients w i l l believe they are young doctors. Apparently, i t would not 125 be as pedagogically effi c a c i o u s f o r students to take f o r granted that t h e i r credentials f o r doing medicine would automatically be established with most patients. I f students assumed they already had the patient's t r u s t i n t h e i r competence, presum-ably t h i s would allow them to focus e n t i r e l y on the technical aspects of treatment which they are learning and not devote energy developing the r o l e of a "competent doctor," who "treats the patient as a person," which B a r t l e t t prescribes. In other words, B a r t l e t t describes the t y p i c a l patient as skeptical,of t h e i r credentials and demanding a show of competence so they w i l l see t h e i r task as more than developing and sharpening t h e i r t e c h n i c a l s k i l l s , i . "helping" the patient and not merely "learning" from her. Thus, B a r t l e t t appears to use "passing" as a "competent" doctor as a pedagogical device with regard to his "patient as person" approach. As w i l l be d i s -cussed, t h i s contrasts with the pedagogical and treatment approach of the " t e c h n i c a l l y oriented" residents, who also do some of the orie n t a t i o n lectures and f i r s t - v i s i t p e l v i c exam-inations with the students. Despite B a r t l e t t ' s "pep t a l k s , " students (and residents) do not seem to employ his "patient as person" approach i n t h e i r routine encounters with patients i n the c l i n i c . Here he complains about t h i s "neglect" i n a lecture to students. Dr. B a r t l e t t : "The b i g disadvantage of c l i n i c care i s that no one takes an i n t e r e s t i n the patient as a person. Also, one doctor t e l l s them one thing—another, another t h i n g . F a i r l y good technical care, but on a personal basis, not so good. Anyone who i s having 126 her f i r s t c h i l d i s worried and needs and wants to t a l k ; but everybody here i s i n here and out to coffee as f a s t as they can." His t a l k implies that the students should not l e t themselves be "swept up" i n the organizational routine wherein s t a f f simply t r e a t the technical problem the patient brings to the c l i n i c so that they can l i m i t t h e i r work day to provide ample l e i s u r e . In other words, students are to hear these complaints as r e f e r r i n g to a c t i v i t i e s they should not be engaged i n , and not merely as a c r i t i c i s m of the c l i n i c ' s routine. He complains that t h i s "technical approach" predominates i n treatment i n the c l i n i c , with the r e s u l t that s t a f f routinely do not implement "patient as person" ideals of the medical ideology and make an e f f o r t to l i s t e n to "lay fe a r s " and s o c i a l i z e patients into the medical view of c h i l d b i r t h as "natural, normal, and routine." Besides the s t a f f ' s concern to provide f o r a lim i t e d work day, another demand c h a r a c t e r i s t i c which makes implementing B a r t l e t t ' s i d e o l o g i c a l ideals d i f f i c u l t f o r students (and r e s i -dents) i s the f a c t that a v i s i b l y competent performance on t h e i r part depends on t h e i r completion of the hist o r y and the physical examination i n twenty minutes to h a l f an hour. A " f u l l c l i n i c " means over f o r t y patients w i l l have to be seen i n two hours. To meet t h i s two hour deadline, students are expected by super-v i s i n g residents to devote as l i t t l e time as possible to each patient. The saliency of t h i s time pressure i n the students' outlook on t h e i r performance may be i l l u s t r a t e d by the comments of a student to a nurse as he steps outside of a cubicle during 127 an examination. Student: "Is there a lot more to go?" Nurse: "Yes, but not a whole bunch." Student: "It's slowing down then. I was wondering i f I was taking too much time." To further i l l u s t r a t e the saliency of work-load pressures in the orientation of the staff, I would like to relate the following description given me by one resident of the nurses' task back in the cubicle area: "We look to them to get r i d of 'any garbage' and line up patients so the doctors make maximum use of the time." Also, i f students do not deal with cases quickly, then they are often chastised for "taking so long" by the resident; and the head nurse keeps "checking" with them to ask, "Are you done yet? I need this cubicle." Also, Bartlett, himself, warns them to be quick and not try to do more than a "reasonable" examination. Dr. Bartlett: "The complete history and physical has to be done in a reasonable time: half an hour at most. It i s only sufficient to see i f something i s a disease, and refer her to someone else. Establish reasonable health and find the history of obstetrics and maternity. See what she needs. Get here early and get your examination done early." The effect of this work-load pressure is that students, rather than probe patients' responses for "accuracy," or try to establish "rapport" and socialize or give advice, simply try to "get through" the interview and physical examination as quickly as possible, before Bartlett or a resident arrives to supervise the "internal" examination. As a result, the 128 structure of the medical hi s t o r y and physical examination form guides the student's i n t e r a c t i o n with the patient. Students t r y to rush patients through the various topics on the form to f i l l out a complete form i n the a l l o t t e d time. In t h i s regard, B a r t l e t t , himself emphasizes the importance of an accurate, completed form as the primary task f o r students i n the c l i n i c . Dr. B a r t l e t t : " I t used to take eight hours f o r a medical student to do one patient, and do a l l the t e s t s , and the doctor would be down on you i f they didn't get done. The older order has changed, and you have the advantages and disadvantages of the new order; but b a s i c a l l y a l o t hasn't changed. The trouble i n medicine i s not what people don't know, but they don't do i t . Anyone can f i l l out a form, but they don't do i t . You've got to develop a system and do i t , i f you're to be a conscientious doctor." This i s b a s i c a l l y a moral appeal to students to honor medicine and t h e i r duty to i t s e t h i c a l tenets to persuade them not to follow the current c l i n i c practice of "sloppy" and "careless" h i s t o r y taking. In the c l i n i c , I found l i t t l e accountability f o r poor completion of forms because students work i n the c l i n i c f o r only a month before moving to another Department i n the H o s p i t a l — p l u s the f a c t that a l l s t a f f s c r i b b l e i l l e g i b l y t h e i r signatures on the forms. Besides, s t a f f are usually too busy to trace and sanction the offender. Thus, i t i s only through such moral appeals that B a r t l e t t can hope to reduce the incidence of such "carelessness." On the other hand, while i n s t r u c t i n g students to attend to work-load demands and competent form completion, he nevertheless reminds them that the patient i s a person with "needs" f o r s o c i a l i z a t i o n or advice as well as "help" with her " s o c i a l s i t u a t i o n . " Dr. B a r t l e t t : "The patient comes to us f o r help; and you can't just f i l l out forms and l e t them go. Often r e s p o n s i b i l i t y i s shelved, and people stop thinking and just f i l l out forms. You have to t e l l them about t h e i r health and give them some advice." In t h i s regard B a r t l e t t made the following "complaint" to me. The students don't ask s o c i a l questions and are le s s thorough than they should be. I t ' s these darn forms! I want to get them at t h i s stage (beginning of t h e i r t h i r d year); so t h e y ' l l incorporate more of the s o c i a l side of medicine l a t e r . Thus, while he exerts moral pressure on students to observe ideals of the "patient as person" approach, the organizational and work exigencies, including the forms, to which he also "orients" them provide the p r a c t i c a l contingencies s e t t i n g the l i m i t s within which i t may be accomplished. He presents i t as a moral requirement of them as doctors to manage such " p r a c t i c a l pressures" so as to discharge t h e i r "duty" to treat "non-technical needs," such as "teaching" patients about t h e i r "health." He sees i t as important that he provide moral educa-t i o n early; presumably, before they become s o c i a l i z e d and "wise" i n the c l i n i c - l o c a t e d "technical" approach, which defines the patient as a set of symptoms to be treated and a "medical past" to be recorded. As B a r t l e t t asserted e a r l i e r , i t appeared that his id e o l o g i c a l l y - p r e s c r i b e d i d e a l model of the patient as a "younger s i s t e r " and his "patient as person" approach was not the everyday work-located t y p i f i c a t i o n of the patient, or routine approach, employed by residents and students i n the 130 c l i n i c . His view of the setting-specific, or "technical," approach i s shared by the social worker in the intake area. She related to me the following contrast between the consultant and the residents: "Dr. Bartlett, the consultant, i s especially concerned with the person; the residents only refer to the body condition i n room ." When Bartlett i s not available, several residents do the orientation v i s i t with the third year students. One of the students remarked to me on the differences between one teaching resident, Dr. Sands, and Bartlett. He suggests that staff's "technical approach" i s reflected in their pedagogical technique and orientation, especially when they, as a group, treat or examine a patient. Here they have just observed while Sands inserted a f e t a l monitoring device into the uterus of a laboring, loudly complaining patient in the delivery room. Student: "I characterize Dr. Sands as technically oriented. He asks a lot of technical questions of the patient. He asked a lot of technical questions of us today; even while the patient was in pain in the delivery room. Dr. Bartlett asks fewer questions. He i s more concerned with communi-cating a bedside manner and just getting the students accustomed to c l i n i c care. Dr. Sands asks us for a lot of numbers. He's a lab technician. What's the use of knowing a l l these numbers?" Like the social worker, this student f e l t that residents do not deal with the "refinements" ("bedside manner") of treating patients as much as Bartlett does. Basically, staff seem more concerned with simply diagnosing, f i l l i n g out forms, and treat-ing whatever complaints the patient brought to the c l i n i c , with 131 le s s time or e f f o r t devoted to "teaching" patients the medical ideology. In t h i s regard, James Henslin i n his analysis of the "sociology of the p e l v i c examination" observes that, generally, women's outpatient c l i n i c s have been described by patients as settings where t h e i r concerns f o r modesty and moral respect have not been observed by medical s t a f f , unlike private prac-t i c e . Here he reports on the reactions of c l i n i c patients i n general• Sometimes doctors are "less gentle" with such patients and "less concerned" about the patient's f e e l i n g s during the examination. Henslin had t h i s reported to him by women on welfare concerning the "coldness" and "callous-ness" of doctors performing vaginal examinations i n public health settings, while Biggs (his co-author) has observed t h i s same "behavior" i n a public health c l i n i c . 1 I am not interested i n adding to the often-made invidious comparisons between c l i n i c and private p r a c t i c e . Henslin's data, along with the observations of B a r t l e t t and others i n the c l i n i c , i s presented to indicate that an approach other than the i d e a l "patient as person" i s employed by t h i s c l i n i c ' s s t a f f , and probably i n other c l i n i c s as w e l l . B a s i c a l l y , i t i s not my intent i n t h i s thesis to "muckrake" and reveal the "deplorable t r u t h " about t h i s maternity service. Such c r i t i c -isms can already be found i n the medical and s o c i a l science l i t e r a t u r e designed to "reform" or "improve" c l i n i c and h o s p i t a l care. Besides, doing t h i s sort of irony cannot qualify as an adequate s o c i o l o g i c a l analysis because i t s t a r t s from value premises or standards as to what i s "good, considerate care." In the l i t e r a t u r e , such yardsticks of "adequate" or 132 " i d e a l " care t y p i c a l l y remain i m p l i c i t , and probably can be applied to any treatment s e t t i n g to "discover" or "analyze" patient care as "inadequate" or "careless" and, therefore, departing from those i d e a l s . These i d e a l standards usually are based on the "patient as person" ideals embodied i n the medical ideology, assumed to be i n greater a p p l i c a t i o n i n private p r a c t i c e . On the other hand, my only i n t e r e s t here i s to t r e a t t h i s "patient as person" approach as i t s e l f a peda-gog i c a l l y located view to be described as to i t s features, p a r t i c u l a r l y as i t en t a i l s c e r t a i n patient management methods. In no way do I intend to use i t , as have other researchers, as a common-sense value perspective with which to construct a "th e o r e t i c a l approach" to "uncover" c l i n i c routines, and thereby be able to describe the many ways that a public c l i n i c "depersonalizes" or otherwise "abuses" the patient as a "tech-n i c a l " or "teaching" object, i n contrast to the proprietous treatment presumed to be available i n private p r a c t i c e . Again, I wish to make no such invidious comparisons, but instead to describe adequately the two d i f f e r e n t approaches to patient care as they reveal d i f f e r e n t techniques of patient management. Two Approaches to Patient Care As the student's remarks to me suggest, residents i n t h e i r teaching concentrate on the "technical side" of the c l i n i c a l v i s i t s , paying only " l i p - s e r v i c e " to "patient as person" i d e a l s . This focus i s apparent i n t h e i r orientation v i s i t s with patients. For example, here Sands lectures students 133 while conducting a routine check-up, where just a physical examination and an assessment of the progress of the pregnancy are performed. Doctor: "Be sure and ask the patient the date of the l a s t menstrual period. This could be embarrassing i f she knows and you make a mistake i n pre d i c t i o n . In the interview, ask about the most common i l l -nesses, e s p e c i a l l y i n reproductive age g i r l s , such as hypertension, instead of heart disease. Ask about diabetes. Pregnancy w i l l p r e c i p i t a t e diabetes, i f so . . • (to the patient) Just f o r a few minutes, okay? (Patient laughs nervously.) Ask about her family h i s t o r y . Ask about ease of previous d e l i v e r i e s . I f i t was quick, then you may have a d e l i v e r y before she gets to the hospi-t a l . Economics may influence the s i t u a t i o n as to whether a patient can come back frequently, and whether she can afford transportation. You should act as a s o c i a l worker, and not t r e a t her just as a pregnant g i r l . Even as a s p e c i a l i s t you should be able to cope with any family problems. You should know when to get her to the h o s p i t a l , and i f she's l i k e l y to have a short labor period. (Students begin f e e l i n g the patient's abdomen f o r the baby's position.) I t ' s l i k e a chunk of meat. You know how much one pound i s by f e e l i n g ; so when you are on night duty at Metropolitan (hospital) f e e l them and watch to see how close t o labor they are. The baby i s usually within a pound; but i t ' s not easy to t e l l . I f the baby i s not engaged by the t h i r d trimester, then chances of placenta previa, or f e t a l malpresentation, or there i s an obstruction i n the passageway, or a tumor on the baby, (to the patient) Just a few more minutes, okay? (Sands does not look f o r the patient's response to t h i s question, nor does he wait f o r one, before continuing his lecture.) (He l i s t e n s f o r the f e t a l heartbeat rate and says to the patient) Fine. Okay. Everything's a l l r i g h t . " Patient: "No sleep." Dr.: "Do you have trouble sleeping? (He does not pursue the t o p i c introduced by the patient.) Come back i n one week. (Before the patient i s formally dismissed, he continues lecturing.) I f the patient gains four pounds a week f i n d out about her dietary intake. Low income groups subsist on too much macaroni and bread. 134 A doctor should suggest other things that are cheap. Since she's I t a l i a n , (the patient l y i n g on the table) she l i k e s pasta; but she l i k e s salads, too, so get her to substitute. Don't take i t f o r granted. Know why she i s n ' t eating the ri g h t things. You may have to go through the d i e t i n d i v i d u a l l y . Patients have to be guided by t e l l i n g them e x p l i c i t l y what to do. Teen-agers are hard because they l i k e s a l t . So i f you take something away, give something back, l i k e a baby. Have the d i e t i t i a n give her a d i e t she can follow. I f not, have her follow a doctor's d i e t . " An obvious feature of t h i s teaching method i s that no attempt i s made to delay or schedule d i d a c t i c t a l k around the contact with the patient. B a r t l e t t , on the other hand, r e s t r i c t e d such t a l k mainly to the "backstage," p r i o r or subsequent to the interview and examination. Sands' remark, "Just f o r a few minutes, okay?", I take i t , i s his attempt at "saving face" and j u s t i f y i n g the use of the patient as a teaching object. I t constitutes an "exclusion device" whereby the patient i s n o t i f i e d that she i s not to "butt i n . " I t serves to show the patient that she need not be a l i s t e n e r and, i n f a c t , i s not one. This device i l l u s t r a t e s one method whereby a patient's conversational r i g h t s may be lim i t e d so that she may be treated as a passive object f o r conversation among s t a f f . Despite the fa c t that Sands protests the i d e o l o g i c a l l y prescribed i d e a l of tr e a t i n g patients as a s o c i a l worker might, he, himself, treats t h i s patient as only a "pregnant g i r l " and r e f e r s to the fetus as a "chunk of meat." Also, he does not devote any part of his t a l k to persuading students to observe pro p r i e t i e s surround-ing sexual overtones and "hurting" the patient, as B a r t l e t t does. A minimum of i n t e r a c t i o n takes place between he and the 135 patient, to the extent of not following up on the problem of "no sleep" which she introduces, apparently because he i s concentrating more than B a r t l e t t on the teaching function i.e.., regarding patient contact as an occasion to teach and learn, primarily, rather than "help" or give advice. Also, his model of the patient seems to be that of a "baby," rather than a "younger poor s i s t e r , " who needs authoritative guidance to be managed to conform to medicalized food r u l e s . Unlike B a r t l e t t , he does not emphasize gaining "rapport" with the "poor" patients who are nevertheless "human," as a management strategy. Rather, he provides them with ethnic and status t y p i f i c a t i o n s which they are to use as taken f o r granted resources to guide the patient to observe prenatal regimens. Such a character analysis as grounds f o r management to follow the d i e t regimen resembles that used by the head nurse and s o c i a l worker i n presumptively sanctioning weight gains i n the waiting area of the c l i n i c . E a r l i e r I asserted that c l i n i c s t a f f do not observe or lecture on the "courtesies" that B a r t l e t t espouses and p r a c t i c e s . As a d d i t i o n a l support f o r t h i s generalization, I would l i k e to consider another resident's "pep-talk," orienting students p r i o r to t h e i r s t a r t i n g to do h i s t o r i e s and examinations on t h e i r own. Resident: " . . . You should do cases on your own except f o r the vaginal. We'll (the residents) come around and see how you are doing and do a b i t of teaching. In the l a s t group of students, one of them pressed on the c l i t o r i s with the index f i n g e r while i n s e r t i n g a speculum; and 136 we frown on that here. You are to c a l l me, or other residents, i f you have problems, then the intern, or the head nurse, i f none of us are about. Yo u ' l l get most of your i n t e r e s t i n g cases here, not i n the ward. Most of the c l i n i c learning w i l l be here. There i s a b i g variety of cases here. Some of the patients are not very i n t e l l i g e n t and are not able to follow i n s t r u c t i o n s , but you have to be patient. Also, you might have to t a l k down, no, not t a l k down, but lower yourselves so you can t a l k on t h e i r l e v e l . A vaginal w i l l be done on the f i r s t v i s i t , and as they near term, to see i f the baby i s a l l r i g h t . We do vaginals on gynecology patients as the case warrants i t . " The resident seems primarily concerned with persuading students to be interested i n coming down to the c l i n i c from the wards. He does t h i s by emphasizing the advantages of the c l i n i c patients as teaching objects. Apparently he assumes (and uses the assumption as a pedagogical resource) that students are primarily interested i n learning from the patients, not helping them, as B a r t l e t t exhorts them to do, so he stresses t h i s aspect of the c l i n i c . On the other hand, unlike B a r t l e t t , he makes only passing reference to the importance of managing sexual implications and communicating or "teaching." He only warns them against the more gross and provocative sexual a c t i v i t y , not with exercising i n t e r a c t i o n a l control to prevent sexual connotations from even a r i s i n g . Also, i n discussing manage-ment approaches, he shows that he shares Dr. Sands' model of the patient as a "baby" who needs authoritative guidance or " i n s t r u c t i o n s . " While he t r i e s to "repair" the apparent impropriety of t h i s view (". . . no, not t a l k down . . . . " ) , he s t i l l makes i t clear where the c l i n i c patient stands i n 137 r e l a t i o n s h i p to the s t a f f (". . . lower yourselves so you can t a l k on t h e i r l e v e l . " ) In practice, i n hi s routine treatment of the patients, t h i s resident, l i k e Sands, i s less circum-spect than B a r t l e t t i n preventing sexual implications from a r i s i n g . These residents, themselves, f o r example even i n v i t e d these implications by t e l l i n g patients at the beginning of the pe l v i c examinations to "spread t h e i r legs," whereas B a r t l e t t normally asks the patient to " l e t your legs f a l l apart" or "move your legs wider." To further support my contention that Dr. Sands and other residents only "pay l i p - s e r v i c e " to i d e o l o g i c a l "patient as person" i d e a l s (". . . you should be able to cope with any family problem . • . " ) , I would l i k e to consider another teach-ing occasion with a patient. Dr.: "There are two dates f o r her l a s t normal menstrual period i n her f i l e : February 1 and nine. The problem with her i s that four weeks' discrepancy i s important. I f you take the f i r s t date, she's overdue beyond 42 weeks. We would not be happy with her. I f i t ' s the second date, then f i n e , (to patient) What date do you think i s correct?" Patient: "I don't know because I stopped taking p i l l s and my period was i r r e g u l a r . " Dr.: "So i t ' s es p e c i a l l y important to get the uterus s i z e at the f i r s t v i s i t . The desc r i p t i o n i n her f i l e i s not good because i t just says that the s i z e i s consistent with the February 9 date and does not give a description of the uterus. I t ' s important to know i f she's past due because y o u ' l l have to d e l i v e r her here. Due i n one week, or past due." Patient: "For one week I have had pains; but they're not regular. I know labor pains. I may be wrong on a l l the dates." Dr.: "A few days wouldn't make that much dif f e r e n c e . 138 (feels patient's stomach) The baby's head i s n ' t engaged. So we'll have to do a vaginal examination to examine the cervix to see i f i t ' s ripening." Patient: "I get pains when I go to the bathroom." Dr.: "Do you take i r o n p i l l s ? " Patient: "I have them but I have been away from home." Dr.: "You're not sick with them?" Patient: "No." Dr.: "Any complaints?" Patient: "Just these pains. They're not as strong as labor pains." Dr.: (patient has been wearing panties) "Take o f f your Eanties. (Sands does a pel v i c examination.) I t ' s ard to t e l l . You probably have one or two weeks yet. But even a f t e r the baby i s born, you can only t e l l more or l e s s . I t w i l l t e l l you before what date you got pregnant." Patient: "Can you t e l l the day when I got pregnant? I want to know who the father i s . " Dr.: "A blood t e s t could determine i t ; but i t would cause a f i g h t and l i t i g a t i o n i n court." Patient: "My husband l e f t on February 15; and I want to know i f I could have got pregnant before then." Dr.: "I won't say f o r sure. You should t e l l your regular Dr., Dr. G. (a resident), to take care of that when you're delivered." Patient: "Can I bring my husband to the c l i n i c ? He has accepted the baby; but we just want to know who the father i s . " Dr.: "Let the doctor do that l a t e r . We don't l i k e to get into that much d e t a i l about the blood type." Patient: "How can I f i n d out about the blood type?" Dr.: ( i r r i t a t e d ) "I don't want to take care of that now. (Afterwards I asked Sands why he did not want to go into i t . He seemed "very defensive" i n replying that even though the husband seems to accept i t , 139 he's l i a b l e to s t a r t a f i g h t before the delivery, or leave when the baby's i d e n t i t y i s known. I just don't l i k e to handle these matters, anyway." Sands' remark, " . . . the description i s not good. . .," may be intended as a c r i t i c i s m of c l i n i c s t a f f , but the patient may hear i t as a negative diagnosis. He apparently i s so involved i n his lecture that he may not hear the ambiguity i n h i s t a l k . This faux pas shows that he, l i k e other residents, focuses primarily on the teaching function and treats the patient as a set of symptoms. The patient brings up her pains three times i n the examination, but t h i s i s ignored, apparently because he i s so busy teaching students and persuading the patient of the need to take i r o n p i l l s . The patient's answer to h i s inquiry on whether she i s taking i r o n shows she hears i t as not merely intended to c o l l e c t information, but i n f a c t dealing with a sanctionable t o p i c , the adherence to a medical regimen. Thus her response ". . . 1 have been away from home. . ." seems intended to avoid a reprimand. Neither the resident nor the students leave when the patient i s "put up" i n the s t i r r u p s by the nurse. Unlike B a r t l e t t , most s t a f f do not lecture on or observe t h i s "courtesy." Also, his command to "take o f f your panties" i n front of him and the students r e f l e c t s the f a c t that c l i n i c s t a f f are l e s s circumspect than the teaching consultant i n avoiding or not i n v i t i n g sexual implications. In an e a r l i e r l e cture, Sands had t o l d students they "should act as a s o c i a l worker" and "be able to cope with any family problems," but I claimed that t h i s was merely paying " l i p - s e r v i c e " to "patient as person" i d e a l s . I believe there i s i n t h i s examination an example of why my assertion i s correct. I n i t i a l l y , he just wants to e s t a b l i s h an estimated date of impregnation i n order to do a routine c a l c u l a t i o n of her due date and evaluate the normalcy of her pregnancy. However, he cannot ascertain i t f o r c e r t a i n , so he t e l l s the patient that she should wait u n t i l the d e l i v e r y to estimate the date of impregnation. The patient, nevertheless, presses him f o r an estimation, explaining her motive i s to resolve a "family" matter, i . e_., a question of paternity. He answers that he w i l l not do the necessary blood t e s t of the fetus i n utero because i t would in e v i t a b l y cause a disruption of the family. I take i t that here he i s using his common-sense knowledge of paternity cases to "scare" the patient. He does not f i r s t inquire into the d e t a i l s of her r e l a t i o n s h i p to her husband and his "attitude" to the baby before predicting the outcome i n her case, but instead poses a troublesome outcome as a c e r t a i n t y . Thus, as with those patients planning a "natural c h i l d b i r t h " i n a non-medical set t i n g , s t a f f ' s primary concern i s not with presenting the "objective" f a c t s and p r o b a b i l i t i e s of a patient's p a r t i c u l a r case, but with sanction-ing and shocking them into pursuing a medically prescribed course of ac t i o n . "My husband l e f t on February 15 . . . " i s the i n d i r e c t way the patient admits to having sex with someone other than her husband. However, Sands already assumed t h i s i n his attempt to "scare" the patient. When the patient i s 141 not swayed by t h i s management approach, he claims the c l i n i c d i v i s i o n of labor dictates she delay her request f o r her "regular doctor" at delivery, with the organizational reason that a teaching group just does not l i k e to "go into such d e t a i l . " Thus, he t r i e s to avoid the possible inference that he i s simply being a r b i t r a r y or negligent by invoking the d i v i s i o n of labor and thereby claiming she has just asked the wrong doctor. Immediately afterwards, he admits he just does not l i k e to handle these sort of family matters. Thus, I assert that t h i s treatment of the patient's request f o r a paternity determination supports my view that he only "pays l i p - s e r v i c e " to ideals of the "patient as person" approach, rather than dealing with "family matters," as he exhorted students i n his orientation l e c t u r e . Another example of the c l i n i c s t a f f ' s approach to the patient as a "technical object" may be found i n t h e i r lack of "team d i s c i p l i n e " ^ when they voice differences of opinion about the d i s p o s i t i o n of a patient's case i n front of her. Apparently, they are accustomed to monitoring each other's cases while i n the cubicle and o f f e r i n g advice to each other. They are used to a great deal of consultation as part of t h e i r learning experience with the patient. On the other hand, the more experienced teaching consultant, B a r t l e t t , usually r e s t r i c t s t a l k to the backstage before or a f t e r the contact with the patient; plus, with his experience, he seldom consults with the more junior s t a f f . 142 In the following instance, one of the residents s t i c k s his head between the curtains of the cubicle while B a r t l e t t i s doing a p e l v i c examination. The resident offers h i s advice on the a d v i s a b i l i t y of doing the p e l v i c at t h i s v i s i t with t h i s p a r t i c u l a r patient, r e f l e c t i n g the general c l i n i c view of only examining and t r e a t i n g patients as i t i s absolutely necessary i n order to reduce the amount of time spent with each patient. To t h i s end they e s t a b l i s h "rules of thumb" of when to do " p e l v i c s . " In t h i s case, the resident t r i e s to provide f o r the most e f f i c i e n t use of time by reminding B a r t l e t t of such a " r u l e . " Resident: "There i s no point i n doing a p e l v i c at t h i s stage i n the game. There's no point i n doing t h i s examination so e a r l y — s e v e n days afte r missing her period." Dr. B.: "John, i t makes f o r a good comparison on the next v i s i t , as one way to test f o r pregnancy by looking at the si z e of the uterus." Patient: (giggles) "I f e e l l i k e a guinea p i g ! " Resident: "An examination at 37 weeks i s okay." Dr. B.: (quietly, but very annoyed) "Let's not argue i n front of the patient." (He turns away from the resident, and continues the examination.) Evidently, B a r t l e t t i s engaged i n a more time-consuming method of determining pregnancy with which the resident i s not f a m i l i a r . B a r t l e t t t r i e s to teach him the t e c h n i c a l purpose of t h i s approach, which i s more thorough than the c l i n i c ' s ; but the resident p e r s i s t s i n advocating the c l i n i c r u l e of thumb despite the patient's complaint of being used as an object f o r teaching or research. B a r t l e t t then cuts o f f the 143 argument by sanctioning the resident f o r a lack of "team d i s c i p l i n e " i n questioning his treatment of the patient i n front of her. I i n f e r that B a r t l e t t i s more se n s i t i v e to the i d e o l o g i c a l l y prescribed importance of a mutual support of the appearance of a competent performance and not t r e a t i n g the patient, who presumably came f o r help, as a teaching or research object. Also, such consultations or debates i n front of the patient are a source of faux pas because s t a f f concentrate on learning from each other, ignoring the implications of t h e i r t a l k f o r the patient, who may be overhearing. As a r e s u l t , the patient may detect "troubles" with her case or sexual implications which may alarm or i n s u l t her. In the following example, the two residents are concentrating on a discussion of the d i s p o s i t i o n of a case of a patient who has discovered she i s pregnant and desires an abortion. Resident: (to patient) "Take a few breaths i n and out." (He i s t r y i n g to get the patient to relax while attempting to do a pe l v i c examination. A resident comes int o the cubicle and he says to him) "The g i r l i s p e t r i f i e d to be examined. November 9 was her l a s t period. In January we did a vaginal and found the uterus swollen. We did a p o s i t i v e (pregnancy) t e s t ; and that didn't excite her at a l l ; and she's s t i l l pregnant. I met the guy l a s t time (the patient's boy f r i e n d ) . He seemed l i k e a reasonable guy; but he can't seem to get a job. I think he's exploiting her. (to the patient) How do you f e e l about the baby?" Patient: "I want to get r i d of i t . " This practice contrasts with that of B a r t l e t t who, when he encounters a patient who i s "too tense" to be examined, does not mention t h i s to the students i n front of the patient, but waits u n t i l they step outside the cubicle while the patient i s being "put up" to discuss the patient's troubles with them. The resident's remarks about the boy f r i e n d could i n s u l t the patient and make her l e s s cooperative. Moral Control and Experience The c l i n i c s t a f f ' s "technical approach" may stem not only from t h e i r concern to learn from patients, work-load pressures, and an i n t e r e s t i n l i m i t i n g the work day, but also from a lack of experience i n "handling" patients, and l e s s f a m i l i a r i t y than consulting obstetricians ( l i k e B a r t l e t t ) with the professional l i t e r a t u r e on implementing ideals of "patient-centered" medicine. This assertion i s supported by Dr. B a r t l e t t ' s view of the residents' competency, as well as the f a c t that the junior residents usually c a l l f o r the chief resident when patients confront them with " s o c i a l " or "family" matters, such as paternity determination and "sex counseling." Here B a r t l e t t r e l a t e s to me the r e l a t i v e experience and com-petency of the residents. Dr. B.: "B. P., H., and Sands are a l l second-year residents. The t h i r d year resident i s Chief Resident C a r l s . He's more experienced than much of the s t a f f and knows most of the l i t e r a t u r e . The r e s t are weak on experience and are not sure of themselves." The following i s an example of where Carls i s brought i n by a resident to deal with a "family problem," determination of paternity. Unlike Sands, he does not t r y to avoid dealing with such a case, but instead t r i e s to advise the patient on 145 how to deal with her husband and agrees to provide a blood t e s t . Patient: (crying) "My husband i s cheating on me because he suspects the baby i s not h i s . " Dr.: "When did you l a s t have intercourse with him?" Patient: "I fve never cheated." Dr.: "It's too early i n the pregnancy to get a f e t a l blood type. Come back and go to the second f l o o r . Your husband won't h i t you, w i l l he? Don't l e t your husband r i d e you! I suppose you are clean?" Patient: "Yes." Carls i n f e r s that the patient i s requesting information as to the baby's paternity and t r i e s to get information as to her "sex l i f e " i n order to "help" her. However, the patient t r e a t s his question as "none of his business" and having non-medical implications, i . g , . , that the doctor wants to question her f i d e l i t y and not merely gather information as to paternity. In f a c t , his question has relevance only i f she has had i n t e r -course with someone el s e . Consequently, she protests her innocence. His advice to the patient to not l e t her husband "ride her" presumably constitutes a "pep-talk," where he t r i e s to influence her to "straighten out" her husband. His question on whether her husband w i l l h i t her and the subsequent "pep-t a l k " seem based on the doctor's assumption about "normal trouble" i n paternity cases, since the patient only mentioned that her husband was u n f a i t h f u l . On the other hand, his f i n a l question ("I suppose you are clean?") shows he i s not t o t a l l y convinced by her protest of innocence. He seems to be advising 146 the patient, as well, to be sure she i s f a i t h f u l to her husband and not l y i n g about the paternity of the baby. Thus, unlike the other residents, he not only o f f e r s to provide a blood t e s t , but t r i e s to d i r e c t l y intercede i n the "family problem" by giving a "pep-talk" and reminding the patient of her moral r e s p o n s i b i l i t y as a "good" mother-to-be. Further support that a lack of experience and f a m i l i a r -i t y with the professional medical l i t e r a t u r e on "patient-centered care" contribute to the employment of a "technical approach" May be found i n a de s c r i p t i o n of a c l i n i c routine provided by an experienced o b s t e t r i c i a n . In the following depiction, the writer, Dr. William Sweeney, I I I , a forty-nine year old New York teaching consultant, makes i t clea r that he t r i e s to implement the "patient as person" approach i n his practice and espouses i t i n "pep-talks" to his students, as well as subscribes to a "negative" view of c l i n i c s t a f f , as did B a r t l e t t . I think those women who go to I n f e r t i l i t y C l i n i c are i n some ways the most courageous people I know. I always t e l l the medical students that the c l i n i c patient with a gynecological or o b s t e t r i c a l problem i s very s p e c i a l . She probably doesn't have enough money to go to a private doctor, but she's no less s e n s i t i v e about intimate things than anyone e l s e . So she comes to the great h o s p i t a l and she expects a gray-haired kindly old doctor i s going to see her. What happens? F i r s t she's herded into a waiting room f i l l e d with other women and moved around. F i n a l l y , when i t ' s her turn to have her history taken, who comes i n but t h i s bright-eyed, bushy-tailed l i t t l e medical student. Now that's her f i r s t r e a l contact with the hos p i t a l and she's shocked. I mean, she expected a d i s -tinguished f i f t y - y e a r - o l d man and she got what she thinks i s a twelve-year-old boy asking her when she l a s t made love. I don't know how fehe answers any of the questions. 147 E s p e c i a l l y i f t h i s i d i o t s i t s down and says, "Okay, now l e t ' s go to work, when did you l a s t have intercourse?" Or, "When was your l a s t menstrual period?" I think i f I were that woman I'd either get up and leave or I'd slap his l i t t l e face or spank his behind. But i f she can stomach the young doctor's unintentional crude-ness, she's whisked into a small room and t o l d to get undressed. Then she's put i n the most ungodly p o s i t i o n i n the world with her legs spread apart, and i n bounces t h i s same l i t t l e boy, accompanied by a nurse who looks l i k e she's twelve and a h a l f and never had a period i n her l i f e . Together they futz around and then they probably say, "Well, now we're going to have the older doctor examine you." And who walks in? A resident doctor, age t h i r t y , or a young attending, age f o r t y , both with h a i r down around t h e i r shoulders. She s t i l l hasn't got the gray-haired kindly old doctor she was looking f o r . So c l i n i c s are d i f f i c u l t f o r patients, even though tech-n i c a l l y a woman probably gets the best medical care i n the world at the c l i n i c of a good teaching h o s p i t a l . . But s c i e n t i f i c care and knowledge aren't a l l a patient needs. There's an art to medicine that the young c l i n i c doctors are lacking. The in t e r n or resident i s taught what questions to ask, but not how to ask them. He doesn't have to s i t down and say, "Okay, now l e t ' s go to work. . . . " He can t a l k a l i t t l e b i t f i r s t . "How are things? Is i t s t i l l r a ining?" Anything to break the i c e . Or, es p e c i a l l y i n a crowded c l i n i c , "There are some things we have to know i n order to take care of you, but I'm sure we can keep our voices down so everybody doesn't have to hear us." I can remember one resident at I n f e r t i l i t y C l i n i c saying, "Now I want you to have intercourse at 2 p.m. and then come straight i n here by two f o r t y - f i v e . . . ." After the woman l e f t , I said, "What do you mean, you want her to do t h i s and that? Don't you agree i t sounds nicer to say, " I f i t i s possible f o r you to have intercourse at two, could you be here about two f o r t y - f i v e ? " But none of t h i s stops the woman who r e a l l y wants to get pregnant. She'11 w i l l i n g l y go through a l l the te s t s we make before we get around to the p o s t - c o i t a l t e s t , (of the husband's sperm) Once we're ready to do the p o s t - c o i t a l t e s t , these women 148 have to go home and have intercourse that i s not love-making. It's just p l a i n , "Lie down and have intercourse on the twelfth, fourteenth and sixteenth days, dear, because Dr. Sweeney says we have t o . " And a l o t of husbands r e a l l y can't do that. I always t e l l my ladies to go home and use t h e i r feminine wiles. "Don't ever say, 'We have to do such and such f o r Dr. Sweeney.' You can con him." So i t ' s the twelfth, fourteenth and sixteenth and he doesn't know what's happening; he's having intercourse but he's making love. The wife i s just having intercourse because she's thinking about the dates and the reason, but he can be had. There's more to f e r t i l i t y than screwing, l e t ' s face i t . 4 I i n f e r from what Sweeney t e l l s his students that he shares with B a r t l e t t the i d e o l o g i c a l l y prescribed model of the c l i n i c patient as a "poor s i s t e r , " who has certain expectations about medical personnel as well as concerns f o r modesty and a romantic view of sexual intercourse. He contends that students and young doctors do not r e a l l y "pass" as competent doctors with the t y p i c a l " c l i n i c patients." He implies that t h i s alone presents an obstacle to having the patient frankly divulge her "private l i f e . " Youthful doctors compound t h i s d i f f i c u l t y by asking questions i n a "crude" manner. They ask these "crude questions" because they are not experienced enough and trained to attend to patient "needs" beyond that covered by " s c i e n t i f i c care and knowledge." He claims they lack the t r a i n i n g and experience to ask "intimate" questions i n an " a r t f u l " manner, g.. g., by f i r s t establishing a state of t a l k v i a small t a l k , or prefacing the question with assurances that he w i l l be circumspect, and thus take into account the obvious public character of the c l i n i c . His c r i t i c i s m s of the New York c l i n i c r e c a l l s B a r t l e t t ' s depiction of the City c l i n i c 149 (". . . that farm . . . . " ) , where matters of privacy and modesty are "being tramped on a l l the time." Sweeney t r i e s to teach a resident to implement his approach of persuading the patient to be cooperative i n following instructions, which r e f l e c t s his i d e a l model of the patient as being "very s p e c i a l , " deserving of "respect" and "politeness." On the other hand, s t a f f ' s approach i n the New York c l i n i c compares with Sands admonitions to the students at City that, l i k e a baby, patients have to be a u t h o r i t a t i v e l y guided by t e l l i n g them e x p l i c i t l y what to do. Apparently, Sweeney would go beyond being p o l i t e ( i n an e f f o r t to control patients' sex l i v e s ) and t r y to a c t i v e l y intercede by encouraging the patient to deceive her spouse by casting a "medical a c t i v i t y " (sexual intercourse to c o l l e c t a sperm sample) i n a romantic guise. Like Sweeney, I found generally that the older doctors d i f f e r e d from the "raw r e c r u i t " students and young residents not so much i n technical s k i l l s and knowledge, but i n s k i l l s i n exercising more control over the patient. For example, when the students dealt with the patient, there were more chances f o r equal conversational exchanges, whereas, older doctors l i k e B a r t l e t t and Carls t i g h t l y managed in t e r a c t i o n so patients were not treated as an equal co-participant i n t a l k . With younger doctors and patients, there was more "give and take," with more opportunities f o r the patient to introduce sexual and moral overtones. I observed an example i n the c l i n i c of how t h i s "give and take" i n conversation r e s u l t s i n disruptive incidents. Also, t h i s incident shows how, as i n the New York I n f e r t i l i t y C l i n i c , younger s t a f f may provoke moral reactions i n patients by t h e i r " a r t l e s s " questions which i n v i t e moral sexual implications. Here a student t r i e s to manage a "reluctant" patient i n the interview and examination. Patient: "I haven't had a period f o r three months. I'm either sick or pregnant." Student: "Either way you should be here." Patient: "My period wasn't regular l a s t year. It ranges from 21 to 36 days. I hate p i l l s . I took them four months l a s t year." Student: "Have you had intercourse r e g u l a r l y ? " Patient: "Yeah. I'm married. Ha! Ha!" Student: "Well . . . I see so many people during the day. It may seem funny, but i t ' s important. You're not taking p i l l s , so you've been t r y i n g to get pregnant i n other words. How's your appetite?" Patient: "Shit. It's gone completely. I f e e l bad i n the morning." Student: "Do your breasts turn darker or swell, or become sore?" Patient: "My breasts have always been sore, but I don't notice any pain i n my breast, so I guess not." Student: " I ' l l have to get a book to see what a l l t h i s means..." Despite B a r t l e t t ' s "pep-talks" on "passing devices," t h i s student did not t r y to a r t f u l l y dodge the patient's implied question about her breasts "always being p a i n f u l , " and thereby t r y to gloss his ignorance. His question, "have you had i n t e r -course regularly?", i n v i t e s moral and sexual implications. T y p i c a l l y , senior doctors pose i t i n a less " r i s k y " manner; "Frankly t e l l the doctor when you've had intercourse" or, 151 "How often do you have sex?" This approach provides l e s s opportunity f o r the patient to treat these "intimate" ques-tions morally i n formulating her responses. It presumes that the patient does have sex routinely as part of being married, as opposed to the student's formulation which i n v i t e s the moral interpretation that the student wants to inquire as to the normalcy of the patient's sex l i f e and, by implication, her marriage. An unmarried patient may detect implications of promiscuity, or "abnormal" sexual appetite. I take i t that her response, "I'm married," i s intended to prevent the student from seeing her as "abnormally" sexed. His techniques of formulating questions provide a target f o r the patient's moral views. I t offers an opening i n which the patient can display her b e l i e f that they (his questions) constitute an unwarranted invasion of privacy and are motivated by suspected prurient i n t e r e s t s ; i . g,., she e x p l i c i t l y disavows the purely technical character of such questions, and suggests that she sees them as dealing with shameful and " d i r t y " matters. She organizes her response so i t f a l l s within the accepted pr o p r i e t i e s ; i . g., she does not say she has sex a l o t , but instead, makes i t c lear that her rate of intercourse f a l l s within the range of morally acceptable behavior. As B a r t l e t t mentions i n h i s lectures, as a r e s u l t of t h i s process, the patient shapes the information given i n the interview. On his part, he apolo-g e t i c a l l y accepts the patient's sanctioning of his question. Normally, older s t a f f would ignore sexual and moral implica-t i o n s , introduced by her as a commonly used management technique to control the inte r a c t i o n by t r y i n g to prevent them from becoming topics f o r a "give and take" conversation. The student reveals his inexperience i n t h i s response by "crudely" displaying the normative outlook on the proprieties of marriage: (he implies) "Sorry I asked; I know marriage has regulations and should be the rock on which society i s based." "You're not taking p i l l s , so you've been t r y i n g to get preg-nant, i n other words?" shows that the student took cognizance of her e a r l i e r remark about having stopped taking p i l l s and takes t h i s as s i g n i f y i n g that she has been del i b e r a t e l y seek-ing to get pregnant. He seems, thereby, to make v i s i b l e the medical view that conception i s "naturally" a matter f o r " r a t i o n a l " planning. Thus, although probably inadvertantly, he i s i n d i r e c t l y advising the patient on t h i s prescribed approach to conception—whereas she treats b i r t h control as a matter of personal taste, to be used or not depending on whether she l i k e s or "hates" i t . As further support f o r my analysis, I would l i k e to r e f e r to Joan Emerson's study of p e l v i c examinations performed i n the gynecological ward of a medical school. She points out that the patient i n the examination i s the most frequent source of e x p l i c i t sexual connotations, which implies one important c r o s s - c u l t u r a l feature of the pe l v i c examination and interview; i . e., patients often treat them as having obvious sexual implications, as opposed to s t a f f who t y p i c a l l y t r y to persuade the patient to treat them as non-sexual events. However, she 153 also implies that experience plays a large part i n determining the frequency with which s t a f f , themselves, introduce sexual overtones into the i n t e r a c t i o n , and thereby f a i l to implement the ideals of the "patient as person" ideology advocated and practiced by the older, more experienced s t a f f . Precariousness i n Gynecological  Examinations Threats to the (non-sexual—J.E.F.) r e a l i t y of a gyne-c o l o g i c a l examination may occur i f the balance of opposing d e f i n i t i o n s (medical versus l a y — J . E . F . ) i s not maintained as described above. Reality i n gynecological examinations i s challenged mainly by patients. Occasionally a medical student, who might be considerably more of a novice than an experienced patient, seemed uncomfortable i n the scene. Experienced s t a f f members were r a r e l y observed to under-mine the r e a l i t y . 5 In the above example at City, I pointed out how the younger s t a f f do not ignore sexual and moral overtones i n t r o -duced by patients as frequently as did the Chief Resident and the teaching o b s t e t r i c i a n . Instead, they often engaged i n conversational exchanges wherein they j o i n the patient i n e x p l i c i t l y acknowledging these implications. S i m i l a r l y , when a "reluctant" patient protests about being examined, thereby introducing sexual implications, they, themselves, may i n t r o -duce sexual and moral overtones i n t h e i r attempts to persuade the patient to cooperate and not t r e a t i t as a matter f o r modesty. In addition, they may t r y to coerce or cajole her to t r y to persuade her to forego her "sensitiveness." Emerson's study provides support f o r these observations at City i n the following example. Here a black nurse i s putting a gown on 154 a married black patient i n preparation f o r the a r r i v a l of the doctor and the pelvic examination. Nurse: "I didn't mean f o r you to be exposed, your shape and a l l . " Patient: "Oh, that's okay. I have such a be a u t i f u l one. /joke/ I had two at once giving me shots, /joke/ When I came to the c l i n i c , I was doing a l l r i g h t u n t i l they got down t o — a n d I said, 'you going to examine me down there/' He said, 'Aren't you married?'" /humor/ Nurse: (laughs) "I'm ashamed of you." /joke/ Patient: "I don't l i k e that sort of thing. He was a young doctor, too."6 The young doctor uses a sanction which i n v i t e s sexual implica-tions and the patient apparently found him i n s u l t i n g . He already knows she i s married and uses her status as grounds f o r claiming she has no r i g h t to protest. In so doing, he implies that marriage requires the patient to allow a male to "take l i b e r t i e s " and v i o l a t e p r o p r i e t i e s of modesty. He implies that, since t h i s i s so, she foregoes the r i g h t to demand that these p r o p r i e t i e s be observed when other males i n a medical s e t t i n g wish to v i o l a t e them. Thus, he i n v i t e s the i n s u l t i n g implication that married patients are no longer e n t i t l e d to have these pro p r i e t i e s honored. The attending nurse had p o l i t e l y and f l a t t e r i n g l y shown concern f o r these p r o p r i e t i e s by draping the patient before the doctor's a r r i v a l . However, she adds her own mild chastisement ("I'm ashamed of you") to the doctor's sanction. I i n f e r t h i s to be an instance of the kind of "team work" that routinely goes on whereby s t a f f 155 support each other's attempts to manage a "reluctant" patient. As I have mentioned, younger s t a f f at City also t r y to manage the sexual overtones introduced by the protests of a "reluctant" patient by coercing and c a j o l i n g her. In the following example, a student treats a patient's gasp as con-s t i t u t i n g such a protest. Student: "What makes you think you are pregnant?" Patient: "A lump i n my stomach. Maybe there's something wrong with me. I t could be cancer; and besides I've been having periods. Or, Heart disease. I have a cousin with a hole i n the heart." Student: (ignoring the remark about heart disease) "Oh, okay. I ' l l bet i t ' s not cancer; so I better take a look down there, (the patient gasps) That's what you sign up f o r when you come here. It's not bad when i t ' s done c a r e f u l l y . Are you game? You've never had an exam before? (the patient shakes her head; and the nurse proceeds to "put her up" on the st i r r u p s ) " I ' l l bet i t i s not cancer . . . ." stands as his e f f o r t to provide a medical warrant or pretext to do the examination since, even when cancer i s not suspected, i t i s routinely per-formed. Next, he shows that he assumes the cr o s s - c u l t u r a l character of the examination by " f i l l i n g i n , " or i n f e r r i n g a protest when she gasps. "That's what you signed up f o r . . . " appears to be an "ecological device" s i m i l a r to that employed i n m i l i t a r y t r a i n i n g camps where the "reluctant" r e c r u i t i s r h e t o r i c a l l y coerced to cooperate on the grounds that, "You're i n the Army now." In other words, the patient must accept t h i s "care" since, whether she knew i t or not, she agreed to i t when she signed the "consent to care" form at the receptionist's 156 desk on a r r i v i n g at the c l i n i c . He implies she has no legitimate grounds to protest or refuse because she, herse l f , already agreed to be examined just by coming to the c l i n i c f o r care. Following t h i s management e f f o r t , he seems to redefine her apparent protest of embarrassment as being merely fear of a p a i n f u l examination at h i s hands. As a r e s u l t , he pre-sumptuously and i n d i r e c t l y protests his competence by speaking i n the abstract ("It's not bad when i t ' s done c a r e f u l l y . " ) In other words, while he does not d i r e c t l y "advertise f o r him-s e l f , " he makes an abstract, general formulation which pre-sumably the patient i s to hear as applying to her case. After t h i s oblique self-defense he t r i e s to cajole her by o f f e r i n g a "sporting challenge" ("Are you game?"). This management technique i s s i m i l a r to the process of "sounding" i n juvenile gangs whereby members t r y to persuade one another to engage i n " a n t i - s o c i a l " a c t i v i t i e s by "daring" each other to show that they are not "chicken."' F i n a l l y , the patient allows h e r s e l f to be "put up" without protest, other than the gasp which he treated as a protest warranting management e f f o r t s . Thus, as i n Emerson's study, t h i s student displays h i s inexperience by quickly endeavoring to deprive her of legitimate grounds to refuse or protest. Instead of invoking her marital status, (as i n that study) he uses an ecological device, t r i e s to redefine her "protest," and then t r i e s to cajole her. In contrast to these methods, older, more experienced doctors at C i t y usually simply t r y to ignore such protests 157 or else t r y to redefine them as merely a concern to know the medical purpose of the examination, which may be more e a s i l y dealt with without acknowledging moral or sexual overtones. Again, Emerson's data may be c i t e d to support my observations at C i t y . Patient: "You're not going to f e e l me, are you, Dr. Raleigh?" Dr.: "I'm going to examine you to f i n d out what's going on." (The patient protests t h i s a l i t t l e and Dr. R. keeps i n s i s t i n g . Mrs. Biggs (the patient) t a l k s a great deal during the examination on the subject of the examination.) Patient: " I f you'd been poked i n as many times as I have, been hurt as many times as I h a v e — i t ' s t e r r i b l e . " Dr.: "Yes, I know." Patient: "Oh, Dr. Raleigh, what are you doing?" Dr.: (exaggerating his southern accent) "Nothin'." Patient: "Well, you are, too." Dr.: "I'm just cleaning out some blood c l o t s . " Miss Nero: (the nurse) "He's just t r y i n g to f i x you up a b i t , Mrs. Biggs." Patient: "Are you through yet. . .?"** Here we see an instance of the commonly used techniques of "teaching" the patient the "medical purpose" f o r her discomfort and the objectionable treatment being administered. ("I'm going to examine you to see what's going on." "Just cleaning out some blood c l o t s . " "Just t r y i n g to f i x you up a b i t . " ) In so doing, s t a f f seldom provide a t e c h n i c a l l y complete or accurate picture of what they are doing or why they are 153 t r e a t i n g her. Usually, t h i s "teaching" involves some vague, general, euphemistic description which, presumably, the patient would understand. They t r y to avoid using technical terms and graphic d e t a i l s which they assume would further alarm or anger the patient. In any event, t h i s method's es s e n t i a l purpose i s not to keep the patient informed so she can give "informed consent" to the treatment as i t i s administered, but rather to persuade her to accept the "medical f a c t " that i t i s i n some way "required," yet does not involve "serious trouble" i n her case. Besides protesting the examination i t s e l f , patients at Ci t y may introduce sexual overtones i n expressing disapproval of the attendance of more than one "doctor" when several stu-dents t r y to "practice" on a patient without the supervision of B a r t l e t t or a resident, who usually do not want to be present u n t i l the pelvic examination. The students are often at a loss f o r words to respond to such a protest of embarrass-ment, allowing the patient's sanction to stand while proceeding to do the interview and physical examination. When they do manage to make some reply, they often introduce sexual over-tones or implications of pain s i m i l a r to t h e i r attempts to manage a "reluctant" patient as discussed above. In any event, regardless of students' management e f f o r t s , or lack of them, i n subsequent i n t e r a c t i o n i n the interview and physical exam-in a t i o n , patients often make i t clear that they regard them as peers without the conversational r i g h t s and p r i v i l e g e s usually granted a doctor v i s - a - v i s a patient; e. g., i n the t i g h t l y structured interview a patient may f e e l free to ques-t i o n students, i n turn, on topics on which she i s being queried. Also, as a r e s u l t , she may treat t h e i r questions and subsequent examination as a "game" wherein the students are not to be taken seriously since they are peers "playing at medicine." While usually allowing them to do the interview and physical examination, the patient may, i n some cases, per-s i s t e n t l y refuse to allow them to perform the p e l v i c examina-t i o n , i n s i s t i n g on the services of a " r e a l " doctor. The following i s an example at C i t y of how students may be dumb-founded when a patient protests the large number (four) by pointing out how i t provokes embarrassment i n her. (Four students come into the cubicle) Patient: "Are you a l l students?" Student: "Yes." Patient: "Don't you know i t makes a patient nervous to have a l l these people around her?" (Students do not reply.) "Oh, you are probably used to h o s p i t a l surroundings!" Student: "How are you f e e l i n g ? " Patient: "Okay, I guess." (The student asks about past diseases i n the family and then about her past drug use.) Student: "Do you use drugs?" Patient: "I smoke hash; but I don't use any needles." Student: "Do you use L.S.D.?" Patient: "I haven't used i t l a t e l y . Do you turn on, Doctor?" (The student does not reply.) 160 Patient: "I don't expect you to say." (He takes her blood pressure.) "Is my blood pressure normal?" Student: "Yes." Once the patient has ascertained t h e i r lack of credentials, she scolds them fo r v i o l a t i n g her privacy. In the process, she categorizes them as mere "people," implying she sees them as lacking credentials or s p e c i a l expertise, distinguishing them from lay peers. When the students are unable to reply, she apparently takes t h e i r silence f o r incomprehension of her concerns and chastises them by accusing them of being so accustomed to events i n the hospital having a s t r i c t l y technical or medical si g n i f i c a n c e ( i . e.., using a "technical" approach) that they inconsiderately ignore how these same events may appear d i f f e r e n t l y to the lay patient, making them "nervous." However, again the students are unable to muster a reply to persuade the patient to accept t h e i r large number. In the subsequent interview, she proceeds to show that she regards them as peers by acting as i f she has equal conversational righ t s with them to ask and answer questions. Her r e c i p r o c a l question about his use of L.S.D., f o r example, i s presumptuous i n the sense that she has the r i g h t to ask questions of the "doctors" on the same matters on which she i s being interviewed, regardless of t h e i r moral or sexual implications. Ordinarily, patients i n t h e i r i n t e r a c t i o n with " r e a l " doctors observe the p r o p r i e t i e s governing who can ask what sort of questions and l e g i t i m a t e l y expect an answer; i.e.., such r i g h t s are regarded as not symmetrical or equal. In f a c t , one way of making an 161 i n s u l t i s f o r the patient to ignore these proprieties and ask r e c i p r o c a l questions of the doctor, p a r t i c u l a r l y of a moral or Q sexual nature. When the student does not reply to her ques-t i o n on L.S.D., she then implies that she was "out of place" as a patient i n acting as i f there were r e c i p r o c a l or symmetri-ca l r i g h t s to ask "personal" or "medical" questions by e x p l i c -i t l y acknowledging that she did not expect them to treat her "moral" question as requiring an answer. By apologetically acknowledging that she has violated these proprieties she shows she i s cognizant of them. Another p e l v i c examination observed at City i l l u s t r a t e s how students may employ "crude" humor to reply to a patient's protest at t h e i r large number and thereby themselves introduce overtones of pain and embarrassment. In t h i s case the patient's r e f u s a l to be " i n t e r n a l l y " examined by them apparently i s honored by them. However, the patient proceeds to treat the interview and physical examination as a "game" where the stu-dents are treated as peers merely "playing at doctoring." She displays the c r o s s - c u l t u r a l character of the interview, also, by t r e a t i n g t h e i r clumsily formulated "medical" and "personal" questions as having moral and sexual connotations, or as just i r r e l e v a n t . I want to present t h i s i n i t i a l o b s t e t r i c a l v i s i t i n i t s entirety because i t i l l u s t r a t e s many of the features of the younger s t a f f ' s "technical approach" to patient care and management which I discussed e a r l i e r . (Three students enter the cubicle.) Student: "Hi." "Hi. Oh! Why do you need so many of you?" Patient: Student: Patient: Student: Patient: Student: Patient: Student: Patient: Student: Patient: Student: Patient: Student: "To hold you down i f you get rough! Ha! Ha! Have you had heart trouble?" "Ha! Ha! I haven't eaten f o r two months and I get severe hunger pangs. I don't eat now because I have no money." "Do you have high blood pressure?" "No, whatever that i s . I get headaches a l l the time." "How long have you had these?" "Why do they always ask that?" ( i r r i t a t e d ) "I get nightmares i f that means anything. My doctor says I had kidney trouble, then says I don't. I don't know. I have had my eye muscles loosened, but that was when I was twelve. I t doesn't matter." (She asks each student i n turn i f he i s a doctor and each says 'No, I'm a student.•) "Not one of you i s a doctor and I'm not going to l e t you examine me." "Is there a c l e f t palate i n the family or congenital diseases?" "Ha! Ha! You mean they look funny? Ha! Ha! No." "Anything else i n t e r e s t i n g i n the family?" "Ha! Ha!" "Why do you laugh?" "My s i s t e r had bad nerves and there i s alcoholism i n the family. But don't worry about i t . I t hasn't touched me. I'm certa i n I'm pregnant. You know when they asked me when I started having periods? I never counted the days of the period, but i t ' s i r r e g u l a r by three days, I think. "Do you think there i s anything abnormal about your flow?" 163 Patient: Student: Patient: Student: Patient: Student: Patient: Student: Patient: Student: Patient: Student: Patient: Student: Patient: "No, I never gave i t much thought." (to a fellow student) "I wish I had a desk to write on." "Ha! Ha! Why don't you use my stomach? go three months, can you have a tubular pregnancy?" I f you (ignores her question) "How's your appetite?" "I'm hungry, but i t ' s my f a u l t , ask about my pains?" Why don't you " I ' l l ask the questions, you answer. I am the, quote, doctor on everything." (He f e e l s her breasts and asks i f they are tender, but receives no answer. Then he f e e l s her stomach.) "Are there any other pains?" "Does i t matter i f I had an i n f e c t i o n l a s t month?" "Trichomonus started again today. I have these sharp pains." (She p u l l s up her legs and winces, but the student continues asking questions anyway.) "They come o f f and on a l l at once." "Have you f e l t the baby?" (Holds her thumbs up and f i n a l l y answers) "I can't f e e l i t , but there i s one." "It's too early. Can I check your chest?" (with a stethoscope) "Ha! Ha! Ha!" ( i r r i t a t e d ) "Do you want us to send f o r the other doctor (Bar t l e t t ) ? You objected to us." "Oh, i t ' s a l l r i g h t as long as the doctor sees me eventually. I'm not going to l e t you examine me (va g i n a l l y ) . " (The student begins doing the physical examination.) "What kind of doctor are you going to be? I don't see how you can examine people." "Why?" "I'd be too embarrassed. You're very patient. Y o u ' l l be a very patient doctor. When you touch my stomach I usually get quite v i o l e n t . " 164 Student: Patient: Student: Patient: Student: Patient: Student: Patient: "You wouldn't do that, would you?" (He examines her feet.) "You're f e e l i n g the bone." "You're a f r a i d that I don't know what I am doing?" "No, i t hurts." "I get very violent when patients don't cooperate." "I've got pel v i c pain. You can note that i n your records. You never socked me before? My doctor i s i n the Northside of the City, but I don't have the money to make the t r i p there, so I come to the c l i n i c . The woman at the desk (the receptionist) doesn't l i k e me jumping from the doctor to the c l i n i c , I t o l d her that I might have a miscarriage i f I go to the Northside and she l e t me be examined here. ( s a r c a s t i c a l l y ) I love to be examined. I've been i n the hos p i t a l e a r l i e r . I only had one donut to eat today." "You l i v e on MacDonald hamburgers?" "I was being s a r c a s t i c . I'm not r e a l l y having trouble with the ki d , just these pains. I t must be constipation, because i t f e e l s s o l i d i n back." (The nurse comes into the cubicle and begins putting her up i n the s t i r r u p s preparatory to the pel v i c examination.) "Don't put me up on s t i r r u p s ! Ha! Ha! I f e e l embarrassed! I'm not a good judge of doctors. You think I imagine everything." Student: Patient: Dr. B.: "I didn't say that!" "Most doctors think I'm imagining." (B a r t l e t t enters the cubicle and uses a f i r m tone of voice with the patient.) "Just answer my questions. F i r s t , when I point out further pains. (Touches her back and abdomen.) You're determined to keep the baby? (She's unwed.) (No answer.) You're not sure of your dates (of conception)? (No answer, and he begins doing the pe l v i c examination.) Let your knees re l a x . " Patient: "Oh! But I can't t e l l you, because you didn't ask." Dr. B.: "What?" Patient: "It's been r e a l l y itchy and sore down there. I can't stand t h i s ! Ow! You're not going to s t i c k that s i l v e r thing i n me?" (The speculum, an instrument shaped l i k e a double shoe horn to expand to diameter of the vaginal canal, so i t may be examined.) "Am I a l l r i g h t ? " Dr. B.: "We're going to check the things you t e l l us about." Patient: "This darn shoe horn! Can you see the baby?" Dr. B.: "No." Patient: "Are you going to s t i c k . . . . I f I was carrying i t low, could you t e l l ? " Dr. B.: "Yes." Patient: "Does i t matter that I have a small uterus? That's what the other doctor t o l d me." Dr. B.: "No." (to the students) "It's blue." Patient: "Why i s i t blue? That hurts! What does i t mean?" Dr. B.: "Infected." (She p u l l s her arms up and gasps.) "Let your muscle go or i t ' l l hurt more." Patient: "I'm very big? Big enough f o r a baby?" Dr. B.: "Yes. What size baby do you want?" Patient: "Just normal s i z e . " (Bartlett t e l l s the students i n medical jargon the symptoms of her infection.) "What are you saying?" Dr. B.: "We're t a l k i n g doctor t a l k . It's nothing bad. You're normal." (She gasps and moans.) (A student begins p r a c t i c i n g a r e c t a l examination.) Patient: "Hey! I'm constipated, you know. Does he have to do t h i s , too?" Dr. B.: "Yes. We check each other out." Patient: (to the other students who are observing) "No way you're going to examine me too!" (As the the student probes her rectum with his fingers) "You're not going to examine my rectum' Can you f e e l how big I am? I think I'm having a bowel movement! Push the l i g h t back, i t ' s too hot!" (A large lamp i s positioned close to the g e n i t a l area routinely.) (After the student begins the r e c t a l examination, B a r t l e t t leaves the cubicle. When the examination i s completed, she s i t s up.) "I can go now." Student: "No. The doctor (Bartl e t t ) might want to see you." (Bartlett returns.) Dr. B.: "You have the normal pains of c h i l d b i r t h and stretching." Patient: "How along am I?" Dr. B.: "Three or four months." Patient: "No, I'm not. I can't be." Dr. B.: "Why can't you be?" Patient: "My doctor says three months." Dr. B.: "It doesn't matter." Patient: " I t matters to me." Dr. B.: "Your pregnancy i s normal, but at t h i s point you get big f a s t . I ' l l give you a p r e s c r i p t i o n f o r iron- p i l l s . " Patient: "iVe taken them before." Dr. B.: "How long did you take them?" Patient: "One month, l i k e they s a i d . " Dr. B.: "Why did you quit?" Patient: "I just d i d . " Dr. B.: "Why?" Patient: "I didn't want to take them anymore." I n i t i a l l y , the student does not treat her challenge to t h e i r 167 numbers seriously, introducing overtones of sex and pain i n his humorous reply ("To hold you down i f you get trough."). "Have you had heart trouble?", l i k e most questions i n the interview, presumably t h i s i s intended to be heard by the patient as meaning not that she, personally, i s competent to diagnose t h i s , but that she i s to " f i l l i n " the intended meaning that she has been professionally diagnosed as having heart trouble i n the past. This i s the sort of conversational competence on the part of the patient which s t a f f routinely assume and use as a resource to ask questions and have them heard as part of a medical interview. 1^ On t h e i r part, patients t y p i c a l l y do display t h i s competence by not asking f o r c l a r i f i c a t i o n , but just providing a recordable answer to "medical" questions. I take i t that she laughs at t h i s question about heart trouble because she sees i t as ir r e l e v a n t f o r her since she i s only twenty years o l d . Despite t h i s lack of substantive response, the student does not repeat h i s question to get a clear p o s i t i v e or negative answer but, instead records on the medical h i s t o r y form that she has not had t h i s trouble. Thus, he treats her laughter as a recordable answer. This lack of probing f o r a d e f i n i t i v e answer may be accounted f o r by the f a c t that the student i s t r y i n g to f i l l out the medical h i s t o r y form as completely as possible i n the a l l o t t e d time ( f i f t e e n minutes) before B a r t l e t t T s a r r i v a l to supervise the p e l v i c examination. S i m i l a r l y , she complains about her eating habits and poor economic circumstance, but students ignore t h i s problem. Again, 168 t h i s may be accounted for, as B a r t l e t t described, i n terms of time pressure and the inexperienced students using those "darn forms" to structure t h e i r i n t e r a c t i o n with a patient. Another feature which may contribute to t h i s treatment i s the f a c t that the patient i s acting "smart" and laughing at his questions. Likewise, when the patient responds to the question on high blood pressure by saying "No, whatever that i s . " , the student nevertheless treats t h i s as a recordable answer and writes "No" on the form. When the student t r i e s to h i s t o r i c i z e the topi c of her headaches ("How long have you had these?"), she becomes i r r i t a t e d . She takes i t as representative of the kind of questions which she has been asked at medical interviews, i . e., dealing with her "medical" past ("Why do they always ask that?"). She implies that such " h i s t o r i c a l " questions are i r r e l e v a n t and bore her. Her remarks on past nightmares, kidney trouble, and eye problems seem intended as sarcasm (". . . i f that means anything."), deriding the medical pre-occupation with the past as being t r i v i a l and i r r e l e v a n t to her present health. After "putting up" with these early " i r r e l e v a n t " questions ("It doesn't matter."), she becomes i r r i t a t e d and interrupts the interview to check on the credentials of the students as doctors. She then makes i t clear that she w i l l only accept an M.D. bearer as e n t i t l e d to perform the p e l v i c examination. She seems angered by the f a c t that they are not doctors, and appears to resent the threatened sexual access 169 by them, her peers. On t h e i r part, they do not t r y to argue with her on t h i s point and appear intimidated by her r e f u s a l . Next, she treats the question about congenital disease as a joke, e x p l i c i t l y introducing the moral implications of the question. At the same time, she shows she competently heard the intent of the question by c l e a r l y answering, "No." The students ignore t h i s "wise crack." Following t h i s sequence, he clumsily formulates a vague, general question about the family's medical history ("Anything else i n t e r e s t i n g i n the family?"), which i n v i t e s the introduction of moral and sexual implications by the patient, who laughs. Because of the question's sexual and moral connotations, the interviewer could be asking f o r any family scandal which the patient can r e c a l l . However, the student, himself, appears unaware of these implica-t i o n s and sanctions her response as being problematic and inappropriate, as i f she i s "crazy" or a "screwball." Never-theless, the patient's next utterances show she has competently heard the meaning of " i n t e r e s t i n g " i n the intended way by pro-viding the "medical f a c t s . " On the other hand, here she i s presumptuous i n i n s t r u c t i n g him as to the relevance of these " f a c t s " to her current health. Again, she implies that i n t e r -view questions are i r r e l e v a n t and t r i v i a l because they deal with the past. In response to the question about her menstrual flow, she shows her boredom and i r r i t a t i o n , while implying that her "No, I never gave i t much thought" r e f l e c t s her own assess-ment, rather than a past professional diagnosis. Nevertheless, the student treats t h i s , too, as a recordable answer. His 170 "studentish" complaint about a lack of desk provides an opening f o r the patient to i n t e r j e c t a sexual overtone ("Why don't you use my stomach?"). Also, her ("Why don't you ask about my pains?") shows her impatience with his methodical series of questions based on the interview protocal. However, he i s quick to "put her i n her place" by sanctioning her f o r pre-sumptuously v i o l a t i n g p roprieties governing the conversational r i g h t s between a doctor and patient. He reminds her of the lack of symmetry or r e c i p r o c a l i t y on who can l e g i t i m a t e l y ask questions and expect to have them answered. He asserts that he, the "doctor," selects the topics f o r questioning and the patient should be passive i n t h i s a c t i v i t y . ( " I ' l l ask the questions, you answer. I am the, quote, doctor on everything.") He protests his prerogatives as a "doctor," while e a r l i e r admitting he was a student. Apparently, i n s t r u c t i n g a patient i n t h i s manner as to the prescribed conversational p r o p r i e t i e s may be p a r t i c u l a r l y important f o r s t a f f i n the c l i n i c , since they must control what topics are discussed i n order to cover a l l the subjects i n the interview protocal i n the limited time a v a i l a b l e . Thus, l i m i t i n g a patient's r i g h t s to ask questions may be an important resource i n competently performing the interview and expediting the heavy workload, although i t may r e s u l t i n a "technical approach" to patient care. However, the patient p e r s i s t s i n t r y i n g to wrest control from him over what "problems" w i l l be discussed by d i r e c t l y suggesting her present trouble as a topic and making a sar c a s t i c preface to 171 the topic which challenges him to consider i t ("Why don't you ask about my pains?" "Does i t matter i f I had an i n f e c t i o n l a s t month?"). Later i n the i n t e r a c t i o n she even t r i e s to get t h e i r attention to her present complaint by the device of phrasing i t as a matter f o r t h e i r records, apparently because she observes that they seem more concerned with asking a variety of questions to get a "complete record" than simply f i n d i n g out what troubles her currently and t r e a t i n g i t ("I've got p e l v i c pain. You can note that i n your records."). How-ever, the student s t i l l does not pursue the topics she suggests and continues to follow the protocal. F i n a l l y , a f t e r having her complaints consistently ignored, she accuses them of t r e a t -ing her as a crazy or hypochondriacal person ("You think I imagine everything."); and the student, i n defense, o f f e r s a weak, equivocal denial ("I didn't say t h a t . " ) . E a r l i e r i n t h i s chapter, I observed that when younger s t a f f treated patients, there seemed to be more "give and take" or conversational exchanges, providing more opportunities f o r the patient to introduce moral and sexual connotations. This examination i l l u s t r a t e s one common way these exchanges may be precipi t a t e d ; the s t a f f member asks the patient's permission to perform the d i f f e r e n t parts of the examination, thereby providing a conversational s l o t or opportunity f o r the patient to refuse and voice her objections. T y p i c a l l y , more experi-enced doctors seem to exercise more control over the i n t e r a c t i o n by not asking the patient's permission. In t h i s case, such a "give and take" sequence begins with the student asking per-mission to examine the patient's chest with a stethoscope and concludes with her repeating her r e f u s a l to allow them to do the pel v i c examination. As i n the interview questions, he phrases his request i n a manner that i n v i t e s sexual implica-ti o n s , which the patient expresses i n her laughter ("Can I check your chest?"). Like the interview, she i s quick to grasp and express the double entendre significance of his questions, to the student's annoyance and chagrin. In reply, he an g r i l y sanctions her mirth by g r u f f l y asking i f she wants the "other doctor." However, t h i s provides an opening where she can again express her view that they are not categorizable as "doctors" (despite t h e i r "face-saving" reference to B a r t l e t t as the "other doctor") and to repeat her r e f u s a l . Another such conversational exchange occurs i n t h i s case as the r e s u l t of the student's paying attention to her protesting remark ("I don't see how you can examine people."). The student "takes the b a i t " and asks "Why?", which provides a s l o t to protest the sexual connotations of the breast examination ("I'd be very embarrassed.") Ordinarily, when such protests occur and more experienced doctors are i n attendance, they (the senior doctors) merely ignore i t , thereby not providing the patient an opportunity to o f f e r further "objectionable" remarks. Pr i o r to his a r r i v a l i n the cubicle, one of the stu-dents t e l l s B a r t l e t t that the patient has been "acting smart" during the interview and has been uncooperative i n gi v i n g 173 information. So, when he i n i t i a t e s i n t e r a c t i o n with the patient, he immediately "puts her on notice" as to who i s to control the int e r a c t i o n ("Just answer my questions."). In her study of gynecological examinations, Emerson describes another tech-nique whereby s t a f f may t r y to l i m i t the patient's conversa-t i o n a l in-put i n order, i n t h i s case, to prevent her from introducing sexual overtones. From conversations with doctors, the writer was able to form a picture of how the sexual connotations of examining patients were managed by the medical profession. Within a predominantly technical view of the female patient's physique, many doctors r e t a i n an awareness of the patient as a p o t e n t i a l sex object. I f a gynecologist sees a woman whose vagina has been stretched by bearing numerous children, f o r instance, he may think to himself or comment p l a y f u l l y to other doctors: "Maybe we should repair t h i s so she can have some fun." Doctors f i n d that i t i s awkward to t a l k about sexual matters with some women; with these women they t r y to conclude the scene as quickly as possible, perhaps, even cutting short the taking of a medical h i s t o r y . A doctor may consciously turn the edge of embarrassment which most women f e e l i n connection with a p e l v i c examination to serve his own convenience, as one doctor reported: " I f I have a very t a l k a t i v e patient, I have the nurse put her up f o r a p.e. f i r s t , before I t a l k to her. Then while she's on the table I ask her questions and you f i n d the women aren't quite so loquacious i n that s i t u a t i o n . i l Besides describing how the interview and examination are through and through sexual events f o r a l l participants, requiring commensurate management techniques, here Emerson points out how a medical s t a f f may t r y to reduce d i r e c t l y (not merely to i n s t r u c t and coerce her verbally) the patient's a b i l i t y to hold conversational exchanges and ask questions, rendering her a more passive, con t r o l l a b l e , and perhaps organizationally " i d e a l " p a r t i c i p a n t . Despite his e f f o r t to remind her of the patient's proper conversational r o l e ("Just answer my questions."), she, never-theless, while he begins the pe l v i c examination t r i e s to "get the f l o o r " to introduce her complaint by a device si m i l a r to the child ' s technique to compensate f o r his assymetrical con-12 versational r i g h t s . Like a patient, a c h i l d ' s utterances and questions may be ignored by adults, p a r t i c u l a r l y when they are engaged i n some project or other conversation. Patients, l i k e children, use an i n t e r a c t i o n a l device, "You know what?", as well as greetings or summons, to i n i t i a t e conversations, and thereby introduce complaints or sexual over-tones. In t h i s case, the patient t r i e s to use an exclamation ("Oh!"), l i k e the c h i l d uses a greeting ("Hi!" or "Hello!") to get the attention of the doctor. However, she does not wait to see i f the inquiry, "What?" i s forthcoming, but instead immediately adds, "But I can't t e l l you, because you didn't ask." Evidently, she wants to ensure that the doctor w i l l indeed ask "What?" by adding t h i s teasing r e f u s a l to say any-thing unless e x p l i c i t l y requested to do so. This remark i s an i n d i r e c t reference to his e a r l i e r command, "Just answer my questions." used, i r o n i c a l l y , to t r y to further arouse h i s c u r i o s i t y and provoke an inquiry. The e f f i c a c y of t h i s device i s demonstrated by the fac t that the "What?" i s forthcoming, enabling her to introduce her complaint about " i t c h i n e s s " "down there" and about the examination i t s e l f . ("It's been r e a l l y itchy and sore down there. I can't stand t h i s ! " ) In other words, the patient has had her remarks and questions ignored throughout the preceding i n t e r a c t i o n and has been repeatedly t o l d that only the "doctor" i s to ask questions. Now the pelvic examination i s imminent and she wants to be sure that her i m p l i c i t request to the doctor to be c a r e f u l i n the examination, since she's "itchy" and "sore," w i l l be heard. Thus, a patient, l i k e a c h i l d , may have to overcome r e s t r i c t e d r i g h t s to speak and be heard, i.e.., to i n i t i a t e a conversation on a p a r t i c u l a r topic; consequently, she may u t i l i z e the same i n t e r a c t i o n a l devices to "get the f l o o r . " T y p i c a l l y , B a r t l e t t , unlike the "technically oriented" residents, t r i e s to r e f r a i n from d e l i v e r i n g lectures or pep-t a l k s i n front of the patient. When he does do so, he uses te c h n i c a l jargon which presumably reduces the chances of the patient learning the d e t a i l s of her problems, becoming alarmed and demanding to be included i n the discussion. Nevertheless, sometimes the patient w i l l discern that her "troubles" are being discussed and demand to be informed of her own condition; i . e_., i n s i s t on being treated as a relevant "hearer" and con-v e r s a t i o n a l i s t . This occurs i n t h i s case when the patient says, "What are you saying?" The doctor's response i n t h i s case i l l u s t r a t e s a commonly used "exclusion device" to conceal or reduce the amount of information available to the patient, as well as exclude her as a relevant participant i n the teaching session; deny that t h e i r t a l k i s relevant to her concerns f o r her health by claiming i t i s only meaningful to those present with technical expertise ("We're t a l k i n g doctor t a l k . " ) . 176 Although they have been discussing the symptoms of her i n f e c -t i o n , he then further endeavors to evade her question by answering i t s presumed intent: a concern with serious i l l n e s s or "abnormal" physical condition ("It's nothing bad. You're normal."). Thus, perhaps the patient w i l l be " s a t i s f i e d " with t h i s vague, general assurance and not become alarmed, or interrupt t h e i r discussion with further questions. On other occasions, B a r t l e t t would use the "exclusion device" of a n t i c i p a t i n g the patient's inquiry by p o l i t e l y asking her per-mission beforehand i f they can discuss her case i n "technical terms," as i f she had conversational r i g h t s as an equal p a r t i -cipant . (While a student performs a p e l v i c examination.) Dr. B.: " I f he hurts, you kick and h o l l e r . " (He begins to describe her p e l v i s i n technical terms and interrupts his teaching to ask the patient.) "Okay i f I t e l l him i n technical terms?" Patient: "Yes." (He continues to describe i t to the student.) Presumably, such a show of propriety r e f l e c t s his concern f o r "the patient as person," but also i t serves to inform the patient that while she i s i n a p o s i t i o n to overhear, she i s not to be a relevant party to t h e i r discussion, and therefore should not interrupt or "butt i n . " In other words, he i s t r y i n g to prevent what occurred i n the above case, where the patient interrupted and had to be reassured. This case also i l l u s t r a t e s how a patient may treat the termination of the pelvic examination as a negotiable matter 177 when only students are i n attendance, r e f l e c t i n g her view of them as peers. This patient has challenged the students' authority throughout the examination p r i o r to the doctor's a r r i v a l and does so again a f t e r he leaves temporarily by pre-sumptuously announcing, "I can go now." She seems to be challenging t h e i r prerogative to terminate the examination, t r e a t i n g her own judgment as to the termination point as equivalent to t h e i r s . In countering her challenge, the stu-dent does not assert his own authority, but implies that B a r t l e t t may not view the examination as terminated ("No, the doctor might want to see you."). This seems strategic on his part because throughout the examination she has treated them as peers playing at being doctors, whereas B a r t l e t t seemed to be able to make her "behave" more as a "respectful, coopera-t i v e " patient. Normally, B a r t l e t t does not announce or warn the patient that the students w i l l be taking turns examining her. Generally, he does the examination then while she i s propped up on the s t i r r u p s , has one or more of the students do a "practice exam-i n a t i o n " on her while he t r i e s to engage her i n conversation. He only provides a warrant or entitlement f o r t h e i r repeat examinations i f the patient protests, as i n t h i s case, which i s usually a f t e r the student i s already inside of her vagina and she i s i n no p o s i t i o n to refuse, just protest. This case i l l u s t r a t e s a commonly used management method whereby the doctor t r i e s to r o u t i n i z e the repeat examination and, at the same time, imply an equality of competence between he and the students ("Does he have to do t h i s , too? Yes, we check each other out."). Presumably, t h i s method serves to reduce the v i s i b i l i t y that t h i s i s a teaching session by invoking the service model, whereby they are merely t r y i n g to competently service her problems. F i n a l l y , not announcing the repeat examination or asking the patient's permission apparently serves as an attempt to prevent the patient from having an opportunity to refuse or protest, which would also allow her to introduce sexual or moral overtones into the i n t e r a c t i o n . Like Sands' patient, who desired a paternity t e s t , t h i s patient, too, manages her response to his inquiry as to why she stopped taking i r o n p i l l s , apparently to avoid a reprimand ("Why d i d you quit? I just d i d . " ) . B a r t l e t t , how-ever, presses the matter, presumably because he wants her to see i t as an important, accountable part of the prenatal regimen. F i n a l l y , she gives her motive f o r not taking them; "I didn't want to take them anymore." This response suggests why she managed her i n i t i a l answer, since i t does not provide legitimate grounds f o r her "transgression" and r e f l e c t s a "casual a t t i t u d e " toward the drug regimen as a matter of her personal l i k e s and d i s l i k e s . In conclusion, i t may be generally inferred that i n the s t a f f ' s attempts to c o l l e c t information, medical or "personal," patients frequently manage t h e i r responses (although they may be treated by s t a f f as recordable) because they assume that s t a f f are concerned 179 to persuade and coerce them to follow prenatal regimens and w i l l t r e a t t h e i r responses as sanctionable. On t h e i r part, s t a f f , while recording managed responses, often "probe" them, as B a r t l e t t did i n t h i s case, apparently from a concern to make the patient account f o r any "transgression" and, thereby, have her see the importance of the regimens. Talk as a Management Practice I found i n my observations that engaging the patient i n small t a l k was a commonly used, though " r i s k y " management practice to " d i s t r a c t " or prevent the patient from attending to the sexual and p a i n f u l implications and aspects of the pe l v i c examination. One medical student described t h i s tech-nique to me as follows: Medicine i s the art of deception. Doctors spend h a l f t h e i r time p r a c t i c i n g (medicine) and the other h a l f covering t h e i r tracks. We t a l k to the patient to make our job easier. I t keeps t h e i r attention away from the examination. When students and residents do small t a l k f o r t h i s purpose, t y p i c a l l y they deal with topics which are warranted by the patient's "condition," her pregnancy, and status as a " c l i n i c patient." On the other hand, older, more experienced doctors tended to deal with topics not rel a t e d to the patient's pregnancy or "personal" problems. Apparently, they f e l t that such topics were too " r i s k y " when dealing with unwed mothers, p a r t i c u l a r l y because d e t a i l s of her "stigmatized" state may emerge which may r e s u l t i n the patient becoming more embarrassed and tense during the examination. One experienced o b s t e t r i c a l consultant related to me the importance of t h i s circumspection i n s e l e c t i o n of topic when t r y i n g to get " c l i n i c " patients to engage i n small t a l k . We t a l k about anything other than the problems which brought them here to d i s t r a c t and relax them while we probe. Each doctor talks about d i f f e r e n t topics otherwise. B a r t l e t t T s i n t e r a c t i o n with a patient during a p e l v i c examina-t i o n provides an example of t h i s circumspect s e l e c t i o n of topics by the more experienced doctors. (The patient talks about her new car.) Dr. B.: "What does your father drive? Look at the red dot on the c e i l i n g . " (Before she can answer, he p u l l s down the top of her gown and begins examining her breasts. The patient then sighs several times.) "What kind of stone i s on your finger?" Patient: "Garnet." Dr. B.: "That's my father's name. Your parents give i t to you?" Patient: "Yes." Dr. B.: "They s p o i l you." (Replaces the gown over her breasts.) At the beginning of the breast examination, B a r t l e t t t r i e s to s t a r t a conversation on a topic introduced by the patient, which i s unrelated to her pregnancy or unwed status; auto-mobiles. However, the patient appears preoccupied by the breast examination and begins to sigh, apparently from embarrassment. So, he t r i e s again to est a b l i s h a "state of t a l k " by using as a topic an object i n the scene, her r i n g . Again, there appears l i t t l e l i k e l i h o o d t h i s would r e s u l t i n 181 her "condition" or moral status a r i s i n g as a topic" i n the ensuing conversation. Besides the circumspect s e l e c t i o n of t o p i c , another feature of the small t a l k conducted by the more experienced doctors i s that they u t i l i z e topics which emerge from the on-going i n t e r a c t i o n and immediate setting; e_. g., t a l k i s i n i t i a t e d on topics which the patient, herself, i n t r o -duces (automobiles) or from physical objects they can both observe i n the setting, p a r t i c u l a r l y those which the patient brought with her (the r i n g ) . In f a c t , these are some of the same methods whereby strangers at a c o c k t a i l party, f o r example, t y p i c a l l y select as topics to i n i t i a t e and sustain small t a l k from the i n t e r a c t i o n and setting of the encounter i t s e l f . In t h i s regard, Roy Turner has found that one of the formal routine features of everyday encounters i s the methodical way i n which members enter into a state of t a l k , i . e_., ways of attending to parts of the i n t e r a c t i o n as a basis f o r further i n t e r a c t i o n . For example, i f members do not know each other routinely, they have to get a " t i c k e t " to enter into or begin a conversation. One frequently used method to get t h i s e n t i t l e -ment i s to b u i l d the i n t e r a c t i o n on something one of the i n t e r -13 actants brought with him. ' The s t a f f i n the waiting room also employed t h i s method i n i n i t i a t i n g conversation with a c l i n i c patient who drops i n f o r a v i s i t a f t e r she has delivered her baby. When the former patient comes into the area, the head nurse or s o c i a l worker t y p i c a l l y w i l l speak f i r s t , saying, "Oh, you brought your baby!" or "What a nice baby!" T y p i c a l l y , 182 a discussion of the baby ensues, thereby establishing a "state of t a l k " with the patient a f t e r her long absence from the c l i n i c . The p r i n c i p a l point I wish to make i s that a topic introduced i n p r i o r i n t e r a c t i o n or some object i n the setting usually "emerges" which permits the more experienced doctors and the waiting room s t a f f to membership the patient i n some way alt e r n a t i v e to " c l i n i c patient." They can be seen to invoke t h i s category i n alte r n a t i v e to membershipping her as "patient"—where one consequence of the l a t t e r might be that i t would be appropriate to introduce or suggest "problems" which brought the patient to the c l i n i c . On the other hand, the les s experienced students and residents simply use as a basis f o r making conversation the warrantable f a c t that the woman has come to them as a " c l i n i c p atient," Therefore, they draw on the s o c i a l worker's i n t e r -view sheet i n the patient's medical f i l e l i s t i n g her moral, emotional, and economic "problems" f o r warrantable " f a c t s " concerning her " c l i n i c " status as topics f o r "small t a l k " about which the patient presumably i s knowledgeable and able to talk; i . e., the " f a c t s " i n the f i l e are assumed to provide topics which would embrace the c l i n i c patient as c l i n i c patient and some f o r which the category member would have a value. As a r e s u l t , t y p i c a l l y these s t a f f members engage i n non-emergent small t a l k where the questions they ask the patient r e f l e c t a background knowledge of her "problems" based on having read the summation of her interview with the s o c i a l worker 183 beforehand. Consequently, where one stranger may normally t r y to i n i t i a t e small t a l k with another stranger by asking, "What does your husband do f o r a l i v i n g ? " , the s t a f f member often naively transforms such an "emergent" question to "When did your husband l a s t work?", thereby betraying his background knowledge and appearing presumptive to the patient. Occasion-a l l y , t h i s foreknowledge i s so obvious i t provokes a confronta-t i o n wherein the patient asks the doctor f o r the source of his questions, implying " i t i s none of your business," rather than engage i n an interchange of small t a l k which would develop the patient's "problem" as a t o p i c . For example, i n the following case t h i s faux pas provoked the patient to treat the resident d e r i s i v e l y , which, i n turn, resulted i n the resident attempt-ing to "put the patient i n her place." (The resident begins the p e l v i c examination.) Resident: "You're i n psychiatry?" Patient: "How do you know?" Resident: "It's on your chart." Patient: "Ha! Ha!" Resident: ( i r r i t a t e d ) "What did you do—go and j o i n group therapy? I'm glad you f i n a l l y made your mind up about that!" Patient: "My boy f r i e n d goes, too, do you know?" Resident: (accusingly) "You've got trichomonous, dear. I f i t ' s trichomonous, we'll be able to clear i t up early." (He leaves the cubicle to examine the smear under a microscope.) When the resident sanctions her f o r deriding him, she teasingly asks i f he knows about her boy friend's therapy. However, he ignores t h i s and counters by t r e a t i n g her having a vaginal i n f e c t i o n as i f i t were her moral r e s p o n s i b i l i t y . Thus, rather than successfully engaging the patient i n small t a l k , his clumsy attempt at generating t a l k produces a "confronta-t i o n " wherein the patient disputed his r i g h t to know about her a f f a i r s i n the f i r s t place. In other words, instead of getting the patient to t a l k about h e r s e l f — a frequently used approach—she treated him as one not pr i v i l e g e d to be f a m i l i a r with her a f f a i r s . I take i t that he received t h i s reaction not only because he appeared presumptive by i n i t i a t i n g t a l k with her, a stranger, as i f he had background knowledge of her a f f a i r s , but he did so on a topic which would be "r i s k y " i n most encounters between strangers; her mental health ("You're i n psychiatry?"). I would now l i k e to examine another case which not only i l l u s t r a t e s the " r i s k y " and non-emergent character of the le s s experienced s t a f f s ' attempts to make "small t a l k , " but shows they often use these exchanges as an opportunity to do some "teaching." Resident: (as he begins the p e l v i c examination) "How long have you been married?" Patient: "I don't know." Resident: "Oh, come on. Everybody can remember that." Patient: "Six months, I guess. Ow!" Resident: "Relax. When did your husband l a s t work?" Patient: (in a loud, strained voice) "In June. Yeow!" Resident: "Relax, relax. Two welfare checks . . . can you get along a l l r i g h t on that, then?" Patient: (hushed tone) "Yes. Ow!" Resident: "Did you work before marriage?" Patient: (quiet voice) "No. I was s i c k . " Resident: "What?" Patient: "I had Mono." Resident: (after completing the examination) "Everything's a l l r i g h t . Clean insi d e and out. Okay from our point of view. Mono i s hard to get over, but nothing to worry about. Come back i n three months to check and we'll see you sooner i f there's hemorraging. But you're not pregnant." Patient: "I've been t r y i n g . " Despite the f a c t he already knows her husband has been out of work and she has not worked, he asks her about these " f a c t s " i n a series of d i d a c t i c questions apparently to bring them to her attention so she w i l l draw the conclusion f o r h e r s e l f that as a welfare r e c i p i e n t she should not be, or t r y to get, pregnant. However, instead of d i s t r a c t i n g the patient to relax her, he apparently keeps her tense since she complains a great deal. I take i t that t h i s i s due to the f a c t that while she i s t a l k i n g during the examination, i t i s on a topic r e l a t e d to her " c l i n i c " status, and t h i s proves embarrassing. Thus, while these s t a f f members may not provoke a confronta-t i o n i n every case, where a "state of t a l k " i s established, i t often f a i l s to d i s t r a c t the patient because of t h e i r use of " r i s k y , " non-emergent topics and attempts to " i n s t r u c t " her. To conclude my discussion of small t a l k , I would l i k e to examine another case i l l u s t r a t i n g quite e x p l i c i t l y these s t a f f members' use of i n s t r u c t i o n t a l k as a mode of "small t a l k , " presumably to d i s t r a c t the patient during the breast and p e l v i c examinations. Here a medical student draws on the patient's status as an unwed mother f o r a topic to do t h i s "small t a l k . " In the process, he engages i n some i n s t r u c t i o n which e x p l i c i t l y r a ises d e t a i l s of her moral character and circumstances. Student: (as he begins the breast examination) "Have you decided about the baby?" Patient: "No." Student: " I t gets harder as you go on. You should see someone who i s reasonable. I t ' s hard to when you're down yourself. B i t of a worrier?" Patient: "No." Student: "Oh, come o f f i t ! You look l i k e the concerned type. You l i v e at the Home (for unwed mothers-to-be)?" Patient: "Yes." Student: "Home g i r l s are clean and nice. Not l i k e other g i r l s who come i n here from you don't know where and have bugs and a l l kinds of diseases. When I st a r t to f e e l sorry f o r myself I go t a l k to them. We don't l i k e them." Patient: "I l i k e i t there." Student: (after f e e l i n g her abdomen) "You're r i g h t — about f i v e months. I ' l l get the nurse to set you up." (He leaves to get the nurse and remains i n the cubicle while she i s "put up".) The student has read the s o c i a l worker's sheet on t h i s patient and draws his topics from i t . He already knows from i t that she i s undecided about giving the baby up f o r adoption, as well as the s o c i a l worker's judgment that t h i s i s due to the patient's "emotional state." Also, he knows from the f i l e that she i s staying at the Home. He t r i e s to impress on her the need f o r an early decision about the d i s p o s i t i o n of the baby on the grounds that i t i s f o r her own good, since " I t gets harder as you go on." Actually, the s o c i a l worker i s concerned to have an early decision because i t i s easier to get a baby adopted i f i t i s newborn. Also, both she and the s t a f f regard parenthood as a r a t i o n a l l y planned event, even before conception. Thus, i f she remains i n d e c i s i v e , presum-ably she may not make the prescribed plans f o r i t s economic and s o c i a l "well being." He then makes a presumptive "diagnosis" of her "indecision" as being symptomatic of her emotional state. Apparently, he asserts t h i s to persuade her to see an adoption counselor. He presses t h i s psychological characterization by t r y i n g to get her to admit that she i n fac t has t h i s personality t r a i t ("Bit of a worrier?"). When she denies t h i s he sanctions her, implying that she i s being evasive or managing her response ("Oh, come o f f i t ! " ) . Next, he provides a contrast conception between the g i r l s from the Home and "other g i r l s " whereby Home g i r l s are to be morally (and medically) redeemed from t h e i r unwed status v i a an invidious comparison with "other g i r l s " who are "worse o f f . " This i l l u s t r a t e s a frequently used management technique whereby a general, abstract contrast conception i s provided which allows the hearer to membership h e r s e l f i n the morally redeem-ing category ("Home g i r l s " ) . Then he t r i e s to teach her how to use t h i s categorization "therapeutically" by f i n d i n g an 188 incumbent of the "morally i n f e r i o r " category and discussing with her her problems. Again, he does not e x p l i c i t l y f l a t t e r her or d i r e c t her to use t h i s procedure. Instead, he r e l i e s on her hearing the pronoun " I " and "myself" as r e f e r r i n g to her s e l f when he t e l l s her, "When I s t a r t to f e e l sorry f o r myself I go t a l k to them." He concludes t h i s attempt at therapy through moral redemption by allowing her to hear, or i n f e r , that by comparison to "them" (the "other g i r l s " ) she has the organization's ("We. . .") approval. Generally, his attempt at "therapy" seems based on his i n i t i a l assumption that her "indecision" i s , as the s o c i a l worker describes, symptomatic of unobservable psychological processes. Thus, instead of engaging i n small t a l k which deals with topics that "emerge" from the i n t e r a c t i o n and deals with topics unrelated to the patient and moral status, the l e s s experi-enced s t a f f members r e l y on the s o c i a l worker's sheet f o r topics and t r y to " i n s t r u c t " the patient with regard to them. In t h i s case, the student apparently t r i e s to "follow up" the s o c i a l worker's e f f o r t s to persuade the patient to make an early decision on the d i s p o s i t i o n of the baby. As i n the waiting room, patients who voice an intention to have an unmedicated ex-hospital de l i v e r y i n the cubicle area often receive from s t a f f members strong moral arguments. In dealing with these patients, the residents and students seem to favor the management technique used i n the waiting room; the shock t a c t i c of r e l a t i n g anecdotes wherein such "natural c h i l d b i r t h " r e s u l t s i n h o r r i b l e consequences to the welfare of the baby and mother. Also, the following case i l l u s t r a t e s the f a c t that they treat even i n q u i r i e s from patients about ex-hospital delivery methods as warranting the same strong arguments as does a declaration of intent to have an ex-h o s p i t a l d e l i v e r y . In these cases, they seem intent on show-ing the patient that i t i s not a viable a l t e r n a t i v e to an i n -h o s p i t a l d e l i v e r y . Apparently, they see giving her informa-t i o n on "home d e l i v e r y " as serving only to "encourage" i t , rather than providing the patient the basis f o r making an informed evaluation of various s t y l e s of c h i l d b i r t h . Patient: "How do you give b i r t h at home?" Resident: "I'd advise against that." Patient: "But I know two g i r l s who have done i t . " Resident: "There's no point i n doing a dumb thing since the difference between a l i v e b i r t h and one that i s n ' t i s b i g . What i f the baby i s born with a cord around i t s neck? Or i s not breath-ing? Or i f you s t a r t to bleed? What can you do? You don't have the equipment or oxygen." Patient: "But nothing should go wrong i f i t ' s normal. Besides I can always do something at home i f something goes wrong. Anyway, I ' l l decide about that when the time comes. Can I have a natural c h i l d b i r t h i n the hospital? No sedatives, etc.?" Resident: "Yes. We carry l o t s of patients who have so-called natural c h i l d b i r t h . In the h o s p i t a l you can have the baby anyway you want." Patient: "I'm going to do i t that way i f I do i t " ( i n the h o s p i t a l — J . E . F . ) . The resident does not answer the patient's i n i t i a l question about b i r t h at home, but, instead, simply condemns i t as not 190 a matter f o r consideration. In her reply she implies he should not condemn i t out of hand i n l i g h t of the fac t that women can do i t success f u l l y . Apparently i r r i t a t e d at her arguing the point, he s t i l l does not answer her i n i t i a l question and continues to simply condemn i t as an a l t e r n a t i v e . He then t r i e s to impress on her the value of l i f e , and that an ex-hos p i t a l delivery i s "dumb" i n the sense of being "irrespon-s i b l e " i n terms of t h i s value. Next, he t r i e s to dissuade her by u t i l i z i n g his medical knowledge of the possible "troubles" that can occur i n d e l i v e r y . He implies that f o r her case these "troubles" are a strong p o s s i b i l i t y i f she follows through with her presumed intent to have an ex-hospital d e l i v e r y . As with the arguments used i n the waiting area, he, too, implies that only the h o s p i t a l s t a f f have the expertise and resources to prevent these common "troubles" from becoming threats to l i f e . Again, t h i s i l l u s t r a t e s how c l i n i c s t a f f do not tre a t the s t y l e of c h i l d b i r t h as a matter f o r the patient's choice, and, simply t e l l her the actual p r o b a b i l i -t i e s of these "troubles" occurring i n her case and the actual r e l a t i v e safety of an in - h o s p i t a l d e l i v e r y i n her case. In other words, he cannot just advise that she go out and take her chances, while admitting that the hospital does not always succeed i n preventing these troubles from becoming f a t a l . Instead, he t r i e s to shock her with a di d a c t i c r e c i t a t i o n of the assertedly common "troubles" of delivery i n order to show her that c h i l d b i r t h i s generally problematic, and es p e c i a l l y 191 i f undertaken outside the h o s p i t a l . Presumably, the doctor invokes t h i s view of c h i l d b i r t h as a matter of l i f e and death to "scare" her into cooperating with his recommendation f o r an i n - h o s p i t a l d e l i v e r y . He does so, apparently, r e l y i n g on the assumption that every woman shares with the medical s t a f f the high value placed on l i f e . Nevertheless, the patient seems to t r y to debate him point f o r point. F i r s t , she asserts the empirical p r o b a b i l i t i e s of an ex-hospital del i v e r y being successful (while the doctor does not). By focusing on the actual p r o b a b i l i t i e s involved, she t r i e s to show him that t h i s option i s a viable one ("But nothing should go wrong i f i t ' s normal.") i . g,., a c h i l d b i r t h i s usually not a l i f e and death matter. Secondly, she disputes his claim that the ho s p i t a l has a monopoly on competence i n dealing successfully with these common "troubles" (". . . I can always do something . . . .") Thirdly, she implies that she sees him as t r y i n g to foreclose t h i s as an option f o r her consideration. Accord-ingly, she asserts that despite his arguments, she s t i l l sees i t as a matter f o r her decision, and implies that she wants to keep her "options open." ("Anyway I'11 decide about that when the time comes.") F i n a l l y , her question about the p o s s i b i l i t i e s of non-medicated c h i l d b i r t h i n - h o s p i t a l suggests that her i n i t i a l question about ex-hospital d e l i v e r y was probably just that, an inquiry, and not a statement of intent to have an ex-hospital d e l i v e r y . In other words, apparently the patient takes t h i s examination as an occasion to explore 192 with the doctor d i f f e r e n t s t y l e s of delivery, rather than to simply get his advice on how to pursue one s t y l e of d e l i v e r y . On the other hand, the resident's reaction to her i n i t i a l question treats the topic " s t y l e of d e l i v e r y " as not a matter f o r inquiry. Instead, he seems to regard the question on how to do a s t y l e of delivery morally, as i n d i c a t i n g the intent or committment to use that method, and speaks to the correct-ness of t h i s presumed commitment. Thus, as with s t a f f ' s treatment of questions from a patient on what they are doing to her i n the examination or whether anything negative has been diagnosed, he speaks to the presumed intent, not the l i t e r a l , substantive content, of her question. Generally, s t a f f seemed more concerned with "cooling out" or "reassuring" the patient who asks questions, as well as t r y i n g to exercise moral control over her, than with simply informing or teaching her the t e c h n i c a l " f a c t s " which such questions seem l i t e r a l l y to require. S i m i l a r l y , i n answering her question on the a v a i l a b i l i t y of non-medicated c h i l d b i r t h i n the h o s p i t a l , he does not simply answer the question but adds a "sales p i t c h " to t r y to persuade her to use the h o s p i t a l as the s i t e f o r her delivery ("Yes. We carry l o t s of patients who have so-c a l l e d natural c h i l d b i r t h . In the h o s p i t a l you can have the baby any way you want.") However, the patient implies that i t i s s t i l l her decision to make. She w i l l keep her options open and i s not completely swayed by t h i s s e l l i n g of the h o s p i t a l as a s i t e f o r "natural," or non-medicated, c h i l d b i r t h ("I'm 193 going to do i t that way i f I do i t i n the hospital.") Through-out t h i s sequence, her general stance of "independence" or "open-mindedness" serves to highlight the management techniques employed to morally control and l i m i t the s t y l e s of delivery the patient w i l l consider. In contrast to the s t a f f ' s frequent use of "shock" techniques, the teaching consultant, B a r t l e t t , and the Chief Resident, Carls, primarily used presumptive guidance and "sales promotions" when t r y i n g to teach the patient the necessity of an i n - h o s p i t a l d e l i v e r y . Again, t h i s difference i n management approach probably r e f l e c t s t h e i r d i f f e r e n t approach to "hand-l i n g " patients generally as "persons" rather than as "technical objects." For example, here i s a case where the unwed patient's s o c i a l work interview sheet mentioned that she "plans to have baby at home with midwife and get Welfare assistance f o r c h i l d support." At the conclusion of the i n i t i a l examination, B a r t l e t t t r i e s to persuade her to d e l i v e r i n the hospital instead. Dr. B.: "There aren't any s a t i s f a c t o r y midwives i n t h i s province, but the Hospital i s well attuned to natural c h i l d b i r t h . This i s one of the biggest centers of natural c h i l d b i r t h . They won't force anesthesia on you." Patient: "I'm not a f r a i d of i t being forced on me. I t ' s just that the hospital i s such a negative place. People rushing i n and out, poking about, and uttering i r r e l e v a n c i e s . " Dr. B.: "I know what you mean. You can balance that o f f against getting good care. F i r s t , you have to work some to t r y to establish rapport with one of the interns or nurses—both have to work at i t . Second, come to the h o s p i t a l as l a t e as 194 possible. Third, request natural c h i l d b i r t h as soon as you get there. You're going out to an island where there i s no h o s p i t a l so see a doctor every week f o r the l a s t s i x weeks and keep tabs on your weight. Come back i n two weeks, i f you can. Otherwise, good luck. When your contractions come down to f i v e minutes apart, or you break your waters, come i n . (B. says to the students a f t e r she has l e f t : They're human beings. You can't t r y to t a l k them out of i t . Instead, agree with them i n order to gain rapport. After a l l , she was r i g h t anyway.)" I take i t that his l a s t remark to the students (". • . she was r i g h t anyway. . .") r e f l e c t s his model of the c l i n i c patient as a "poor s i s t e r " (as opposed to s t a f f ' s view of her as a "baby"), and his c r i t i c i s m s of the e f f e c t s on the patient of the s t a f f ' s routine "technical approach." However, while t h i s concern f o r the "patient as person" influences his choice of management techniques, i t apparently does not override the moral duty to nevertheless "guide" the patient to abandon her plans f o r an ex-hospital d e l i v e r y . Thus, he does t r y to "talk her out of i t , " but not i n the same way the other s t a f f members do. Unlike them, he does not t r y to e x p l i c i t l y and strongly argue against the use of a midwife on the moral grounds that i t endangers l i f e . Instead, he uses the technique of implying that while he may f i n d her choice of a midwife to be a "correct" a l t e r n a t i v e , i n her case, i n t h i s province, he recom-mends against i t because, he claims, there just are not any midwives of which he approves. In other words, he offers a show of agreement with her basic choice of method of d e l i v e r y i n order to have her hear his objection to i t as based on the a v a i l a b i l i t y of resources to carry i t out i n her p a r t i c u l a r case, rather than seeming to reject i t on p r i n c i p l e f o r any case, which may appear more " a r b i t r a r y . " In f a c t , he presents t h i s technique to the students as the prescribed method to deal with such patients (". . . agree with them i n order to gain rapport."). However, as I have described, neither they nor the residents routinely employ such an approach, favoring, instead, to more d i r e c t l y t r y to "talk her out of i t . " After a l l , t h e i r model of the patient i s that of a "baby" who requires authoritative guidance. Thus, here again B a r t l e t t t r i e s to anticipate the "technical approach" which the students w i l l encounter when working with c l i n i c s t a f f , and t r i e s to persuade them not to follow i t by providing both a counter recipe ("agree to get rapport") and an i d e a l model of the patient which j u s t i f i e s i t s adoption ("They're human beings."). Returning to his i n i t i a l remarks to the patient, I contend he not only provides a show of agreement, but t r i e s to persuade the patient to treat the hospital as an adequate substitute f o r midwife care by presumptively asserting an equivalence class between the two methods of delivery, based on the c r i t e r i a that the e s s e n t i a l service sought from the midwife can also be obtained from the hospital; an unmedicated or "natural" c h i l d b i r t h . Then, he proceeds to " s e l l " the h o s p i t a l as a s i t e f o r t h i s presumably sought-for "natural c h i l d b i r t h . " ("This i s one of the biggest centers of natural c h i l d b i r t h . They won't force anesthesia on you."). However, 196 i n her reply the patient shows that t h i s equivalence i s indeed presumptively asserted by implying that his c r i t e r i a of s i m i l a r -i t y i s not important to her. She implies that she did not turn from the hos p i t a l to a midwife because anesthesia was "forced on her" i n the past as B a r t l e t t assumes. ("I'm not a f r a i d of i t being forced on me. I t ' s just that the hospital i s such a negative place.") In other words, she claims that she sought the services of a midwife because of a point of d i s s i m i l a r i t y between that and the ho s p i t a l which he glossed over i n his attempt to " s e l l " the hos p i t a l as being equivalent to a " s a t i s -f a c t o r y " midwife; the treatment she would receive as a patient i n any ho s p i t a l , regardless of whether they are "centers of natural c h i l d b i r t h " or any other s t y l e of de l i v e r y . In response, B a r t l e t t again t r i e s to provide a show of agreement ("I know what you mean.") so as to preface or "set up" his counter remarks as appearing to be based on his concern f o r her p a r t i c u -l a r circumstances and "well being," rather than disagreement with her c r i t i c i s m s of hos p i t a l care. In other words, his counter remark, "You can balance that o f f against getting good care," does not suggest he argues with her complaints. Instead, he implies that an important point of d i s s i m i l a r i t y between the midwife and the hospita l , "good care," overrides these " d i s -advantages." Apparently, he i s s t i l l taking care to imply, too, that he may agree with the use of a midwife, at lea s t " i n p r i n c i p l e . " In any event, his e f f o r t to make an invidious comparison, a l b e i t mild, shows he has heard from the patient's 197 remarks that "natural c h i l d b i r t h " i s i n f a c t not the e s s e n t i a l service she i s seeking from a midwife, because he s h i f t s the grounds on which to persuade the patient: "good care." How-ever, here again he i s being presumptive i n assuming that the es s e n t i a l purpose of using a midwife i s receiving "good care." Also, he i s drawing on the same resource as the c l i n i c and waiting room s t a f f who use more bla t a n t l y moral arguments: the assumption that any woman shares with the medical s t a f f a strong concern f o r the value of the s u r v i v a l and "well-being" of the baby and mother. Having made a "sales p i t c h " f o r the hospital as a place where she would receive "good care," he proceeds to presumptively advise her on how to receive medically supervised prenatal care ("You're going out to an islan d where there i s no h o s p i t a l , so see a doctor every week f o r the l a s t s i x weeks and keep tabs on your weight."), as well as on how to receive "natural c h i l d b i r t h " i n the h o s p i t a l (presuming she i s going to use one), and on how to minimize the aversive treatment i n the hospital about which she complains. In the process, he implies that the poor t r e a t -ment she has received may, to some extent, be her own f a u l t , too ("First, you have to work some to t r y to est a b l i s h rapport with one of the interns or nurses—both have to work at i t . " ) . Thus, he seems to be t r y i n g to subtly defend hospital treatment by presumptively locating the cause of her "negative" treatment i n her own behavior; i . e., she may have in v i t e d or "asked f o r i t . " On the other hand, his advice to "come to the h o s p i t a l as l a t e as possible" implies that he agrees with her that 198 h o s p i t a l treatment i s inherently "poor." He implies that, therefore, a l l she can r e a l l y do i s t r y to reduce the ef f e c t s of t h i s treatment by reducing the amount of time spent there, presuming she i s going. This presumptiveness seems p a r t i c u -l a r l y evident when he advises her on when to go to the ho s p i t a l a f t e r the onset of labor. In conclusion, evidently B a r t l e t t ' s (and Carl's) i d e o l o g i c a l ideals regarding the patient as a "person" r e s u l t i n v a r i a t i o n from the s t a f f ' s everyday, work-located practice of using "shocking" anecdotes and l i s t s of possible "troubles" i n presenting moral arguments against ex-hospital d e l i v e r y . While l i k e the rest of the s t a f f , he appeals to "good care" and t r i e s to " s e l l " the ho s p i t a l as a s i t e f o r "natural c h i l d b i r t h , " he does so a f t e r f i r s t t r y i n g to esta b l i s h a show of agreement with the patient's choice of ex-hospital delivery s t y l e . Also, he t i e s h o s p i t a l i z a t i o n to "natural c h i l d b i r t h " as a way of establishing an equivalence class with ex-hospital s t y l e s of delivery, rather than merely praise, as does the rest of the s t a f f , the extent to which the hospital provides f o r a "natural c h i l d b i r t h . " F i n a l l y , he employs "presumptiveness" more than do the rest of the s t a f f i n order to t r y to subtly "guide" or "push" the patient toward choosing an in - h o s p i t a l d e l i v e r y , rather than simply and d i r e c t l y t r y i n g to "talk her out of i t " by moral arguments. In the c l i n i c , B a r t l e t t (less so the other s t a f f members) usually delivered a general d i d a c t i c t a l k to the patient on her i n i t i a l v i s i t dealing with the medical perspec-t i v e on pregnancy and the prenatal regimen. For example, i n the following case, the patient has been examined and returns to the curtained area of the c u b i c l e . While she i s gone, B a r t l e t t lectures the students on the importance of giving the patient advice. When she returns, he proceeds to give her a short lecture on the prenatal regimen she should follow. Dr. B.: "A patient comes to us f o r help; and you can't just f i l l out forms and l e t them go. You have to t e l l them about t h e i r health and give 'em some advice. (The patient returns and he asks her a "leading" question.) Do you know anything about pregnancy and c h i l d b i r t h ? " Patient: "I learned something from my cousin." Dr. B.: "Pregnancy i s normal and natural and should be no problem i f she follows rules and gets some exercise. (He seems to address t h i s to both the students and the patient.) (He asks the patient another "leading" question.) Do you l i k e s a l t ? " Patient: "Yes." Dr. B.: "Report immediately any severe headaches or pains. Avoid s a l t ! I t i s very poisonous to the baby and the mother l a t e r on. Do you l i k e l i v e r ? " Patient: "No." Dr. B.: " I t ' s the best thing f o r mother and baby. Eat l o t s of meat. At least twice a day. Cut out starches, anything with s a l t i n i t ; p i c k l e s , peanuts. Do you l i k e German sausage?" Patient: "No." Dr. B.: "You're over-weight. The sort of g i r l you are, y o u " l l put on weight i f she doesn't watch i t . Your next v i s i t w i l l be to check the growth of the baby and your health. They won't include an i n t e r n a l exam. You won't see the same doctor each time; but t h e y ' l l do the same thing." His i n i t i a l question concerning her knowledge about c h i l d b i r t h , 200 I assume, i s not intended l i t e r a l l y to be a serious p o l l i n g of her present state of knowledge before giving her advice. My i n t e r p r e t a t i o n i s borne out by the fact that he seems to ignore her vague reply and does not probe i t to ascertain how much she learned from her cousins. He could have simply began giving a lecture to her as soon as she returned; but t h i s appears to be a more circumspect and persuasive technique u t i l i z i n g a prefatory conversational device which i s used i n everyday discourse by salesmen and lecturers to get the audience's attention and provide a warrant ( i n t h e i r assumed deficiency i n knowledge about a t o p i c ) f o r the subsequent l e c t u r e . While speaking d i r e c t l y to the patient a f t e r she returns, B a r t l e t t also seems to intend his t a l k to her to be heard by the students as a lecture to them. He makes t h i s e x p l i c i t i n his admonition about the patient's weight, where he r e f e r s to her i n both the second person and t h i r d person pronoun ("The sort of g i r l you are, y o u ' l l put on weight i f she doesn't watch i t . " ) . He uses t h i s device of switching the person of the pronouns apparently i n order to t r y to use the patient's case as a teaching object without seeming to impro-pr i e t o u s l y ignore the patient, who nevertheless came f o r "help." Sands and the other teaching residents usually simply ignored the patient and spoke of her i n the t h i r d person i n her presence, t r e a t i n g her e x p l i c i t l y as a teaching object. B a r t l e t t seems to convey some implied threat of some 201 vague "problems" i f the patient i s not prepared to be obedient and conform to whatever rules he s p e c i f i e s (". . . pregnancy should be no problem i f she follows rules and gets some exer-c i s e . " ) . He prefaces his s p e c i f i c advice about exercise and d i e t with t h i s general admonition apparently so that she w i l l see his advice and rules as intended f o r "her own good" and, therefore, to be obeyed. In describing dietary prohibitions, he dramatically states the e f f e c t s of eating s a l t as being "very poisonous to the baby and to the mother." Later he re f e r s to l i v e r as the "best thing f o r mother and baby." With both of these foods, he makes an e x p l i c i t reference, therefore, to the welfare of the mother and baby as the warrant f o r her observing his advice. As i n the attempts by waiting room s t a f f to manage patients who intend to have a non-medical c h i l d b i r t h or avoid medical prenatal care, he makes e x p l i c i t and i m p l i c i t threats of "trouble" f o r the baby i f the patient does not follow rules and does not "cut out" s a l t from her d i e t . Like those s t a f f members, he does not treat the following of the prenatal regimen as a matter of choice f o r the patient; he treats i t as s e l f -evident that any sane, reasonable woman values her baby's health and, therefore, heeds such threats. Apparently, he, too, f e e l s responsible to society f o r the welfare of the unborn c h i l d and the health of the mother and attempts to manage her by making e x p l i c i t and vague threats of d i r e consequence. Thus, i t i s assumed that the patient does not have the r i g h t to r i s k prenatal "complications." B a r t l e t t also uses the device of t i e i n g an admonition to watch her weight to the patient's p a r t i c u l a r b u i l d ("The sort of g i r l you are, y o u ' l l put on weight."). In other words, apparently he intends to make the routinely delivered warning of "watch your weight" more persuasive by claiming i t i s warranted by her p a r t i c u l a r "sort" or type of b u i l d . In con-cluding the interview, he mentions that she w i l l not be given another p e l v i c examination. Apparently he does t h i s on the assumption that the p e l v i c examination i s one of the reasons that patients avoid using the c l i n i c . Thus, he t r i e s to encourage her return by promising that t h i s aversive experience w i l l not be repeated. In the following case, B a r t l e t t d e l i v e r s a prenatal lecture to a patient who has experienced bleeding as a r e s u l t of an operation i n the pubic area. Here the patient has dressed and returned to the cubicle a f t e r the pelvic examination. Dr. B.: "Keep your health good. Keep your weight down since you are a l i t t l e b i t of a thing. Eat proper meals: orange j u i c e , salad, meat, raw f r u i t . " Patient: "I gained weight f a s t over Christmas." Dr. B.: "Lots of f l u i d s : s i x glasses a day, and no i r o n u n t i l your nausea s e t t l e s . Do you do a l o t of exercise?" Patient: "no." Dr. B.: "Do a l o t of exercises to get away from the kids; and i t may even be good f o r you; tennis, swimming, badminton, archery. I f you do them, i t can be better with the ch i l d r e n you have i f you spend some time away. I f bleeding or cramps occur, come to the c l i n i c ; and don't believe any wives t a l e s about bleeding." Patient: "I don't l i s t e n to them." 203 Dr. B.: " I f your pregnancy i s normally progressing, then bleeding doesn't matter. You're having sex less often due to the bleeding?" Patient: "no." Dr. B.: " I f you do bleed, then nature may be t e l l i n g you to cut back a l i t t l e . Bring i n a urine sample; and we'll see you i n a month." As i n the l a s t case discussed, he t i e s an admonition to watch her weight to her s p e c i f i c physical b u i l d . Apparently, whether a patient i s large or small, he can j u s t i f y his instructions on the grounds of her b u i l d . The patient's remark about gain-ing weight over the Christmas holidays shows she has been "well-programmed" i n the medical ideology and sees weight gain as a sanctionable matter to be "confessed" to the doctor. Next, he t r i e s to " s e l l " her on an exercise regimen by claiming i t w i l l provide a chance to get away from her children, which he apparently assumes the t y p i c a l mother seeks to do. The " r e a l " or medical rationale he downplays with the word "even" ("be good f o r you"). Further, he even claims that the exercising w i l l be good f o r the children she has by allowing her to be absent from them f o r a period of time. Thus, while de-emphasizing the medical rationale (which he apparently assumes would not be as persuasive), he emphasizes the s t r i c t l y l a y or non-medical benefits of the regimen which are assumed to be sought by the "normal" or t y p i c a l housewife with c h i l d r e n . B a r t l e t t t r i e s to anticipate "complications" (bleeding) and "normal troubles" of pregnancy (cramps) the patient might experience. In so doing, he t r i e s to impress on her the 204 importance of using a medical source f o r "help" and advice, rather than lay or f o l k medicine which he denigrates as "wives t a l e s . " In reply, the patient implies that she has been exposed to t h i s sort of lay advice before and displays the medically prescribed approach to these sources of advice ("I don't l i s t e n to them."). He then t r i e s to "normalize" bleeding l a