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 - "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 t e r on i n pregnancy, apparently i n a n t i c i p a t i o n of the "wives t a l e s " he assumes she w i l l be hearing on the subject ("If your pregnancy i s normally progressing, then bleeding doesn't matter."). In the previous case discussed, B a r t l e t t e l i c i t e d information from the patient about her d a i l y habits before giving advice about them: "Do you l i k e s a l t " Patient: Yes. B.: . . . 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. B.: It ' s the best thing f o r mother and baby." In t h i s case, he also uses the same procedure: "B.: Do you do a l o t of exer-cise? Patient: No. B.: Do a l o t of exercises to get away from the kids; . . . . You're having sex less often due to the bleeding? Patient: No. 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 . " I take i t that he f i r s t e l i c i t s t h i s information from the patient i n answer to these "leading questions," or points out v i s i b l e features of her "condition" (e. g., her build) before giving advice to make i t appear warranted i n terms of her present habits and "condition." On the other hand, when they deal with patients making t h e i r f i r s t v i s i t s , most of the res t of the c l i n i c s t a f f simply issue 205 advice, admonitions, and warnings without t r y i n g to f i r s t demonstrate to the patient t h e i r warranted character i n the patient's circumstances. Presumably, the patient may, i n these cases, f i n d such advice presumptive or even i n s u l t i n g . Sands: "See the d i e t i t i a n . Eat salads, meat, orange j u i c e . Get help by c a l l i n g here." Note that i n e l i c i t i n g information about the patient's frequency of intercourse, he shows greater circumspection than when asking "leading questions" about her other l e s s "intimate" habits, such as her d i e t or exercising routines. The main evidence f o r t h i s observation can be found i n the way he formulates these more "personal" "leading ques-t i o n s " — v i a what Sacks has c a l l e d correction i n v i t a t i o n devices ( C i d ' s ) . 1 4 Instead of asking a straightforward question to e l i c i t information on her rate of intercourse to warrant h i s advice to "cut back a l i t t l e " (e_. g., "How often do you have sex when you're bleeding?"), he i n v i t e s her to correct his assumption that she regulates the frequency according to her medical con-d i t i o n (bleeding). This device serves to get the information from the patient with l e s s r i s k of her t r e a t i n g i t as a moral question about her "normalcy" i n having intercourse. F i n a l l y , his advice on "cutting down a l i t t l e " on sexual intercourse i s j u s t i f i e d by the invocation of an anthropomorphic conception of "nature" that gives "signs" of "trouble" i n the form of bleeding. He seems to be ex p l o i t i n g a lay view of physiological events as being governed by a 206 mystical, unseen force to j u s t i f y his advice, rather than the "medical f a c t s " of her case or h i s own authority as her doctor. In private p r a c t i c e , too, a s i m i l a r prenatal lecture may be routinely delivered once the patient has been diagnosed as pregnant. Here a private o b s t e t r i c i a n r e l a t e s his standard procedure f o r persuading the patient to view her new status from the medical perspective. (The doctor has just t o l d the patient that she has been diagnosed as pregnant.) F i n a l l y , Bonnie asked, "Dr. Sweeney, you're absolutely positive? I mean, i t ' s d e f i n i t e ? " "It's d e f i n i t e , Bonnie." "Oh, that's wonderful. I can't believe i t . I can't wait to t e l l Syd. He won't believe i t ! " "Why?" I asked. She blushed. "Well, he w i l l — I mean, t h i s i s the f i r s t time we t r i e d , and i t just happened." I smiled. "Do you have any questions?" She looked surprised and then shook her head, which i s not unusual, because when I've just t o l d a woman she's pregnant, she's so excited she can't remember her f i r s t name, l e t alone what her questions are. So I have a sort of s p i e l I usually d e l i v e r about pregnancy: I give the lady her vitamins and i r o n and t e l l her to keep her weight gain down to twenty pounds. She i s not eating f o r two, that's an old wives' t a l e . And I explain what she should e a t — t h e proteins and vegetables and things l i k e that. I t e l l her s h e ' l l come back to be examined every four weeks u n t i l the seventh month, then every three weeks, then two weeks and then every week or more often i f she needs i t . I go through a l l t h i s so when she's t o l d at seven months to come back i n three weeks, she won't suddenly exclaim: "Three weeks! What's wrong?" And I t e l l her not to expect to f e e l the baby move f o r four and a h a l f to f i v e and a h a l f months. Otherwise s h e ' l l be convinced the baby's dead because i t hasn't s t i r r e d when she's three months pregnant. I t r y t o anticipate what she's going to worry about. I 207 always say there w i l l be cer t a i n days when she won't f e e l so hot, and there may be some nausea. After a l l , something has to give as t h i s uterus gets bigger, and the bowel and stomach get pushed out of the way. I say her back i s going to ache and her feet sometimes w i l l be swollen; and s h e ' l l have to go to the bathroom more often, including i n the middle of the night. The discomfort w i l l get worse as the uterus gets bigger and pushes on the bladder. I explain that i n the f i r s t part of pregnancy, nature wants her to slow down, so she becomes t i r e d . In the middle t h i r d of pregnancy, everything's f i n e : suddenly the nausea i s gone and she's got her energy back. But toward the end, i t ' s going to happen a l l over again. I t r y at t h i s point not to mention the abnormal things. A l l the women have heard about them anyway. I f I just say, "Edema i s a danger sign," they've a l l got swelling and excess f l u i d . So I don't bring i t up as long as I'm watching each lady so c l o s e l y . Obviously I t e l l her that i f she has any bleeding she should l e t me know. And I always advise her to buy a book about pregnancy—but please not to concentrate on the section about abnormal obstet-r i c s ! I encourage her to go to some classes, whether or not she's thinking of natural c h i l d b i r t h , because s h e ' l l learn a l o t . I also say that pregnancy i s a p h y s i o l o g i c a l process; there's nothing pathological i n being pregnant; you're not s i c k . But there are a l o t of old wive's t a l e s connected with pregnancy, and I t e l l her to c a l l me i f she has any problems. And f i n a l l y I warn her: "Druggists are worthless; husbands don't know much; and mothers and mothers-i n - l a w — f o r g e t i t . " The woman who comes into the h o s p i t a l and has her gallbladder or appendix removed doesn't leave f e e l i n g she's an expert on these operations, but a lady has one baby and s h e ' l l be delighted to t e l l you a l l kinds of things about being pregnant, most of which are i n c o r r e c t . Now, not every doctor runs a pregnancy the same way I do. I may be more l i b e r a l i n some things and not as l i b e r a l i n others. But once I've assumed r e s p o n s i b i l i t y f o r a lady's care, she's i n my b a l l park and has to play by my r u l e s . Bonnie l i s t e n e d to a l l t h i s , nodding, and she didn't seem as f i l l e d with anxieties as I expected. "Bonnie," I said, "you're going to go home and t a l k to Sydney and I know darn well you're going to come up with a bunch of questions. Write them down and bring i n your l i s t next time so you don't forget them. And remember, you can c a l l me i f you want to ask something i n the meantime."16 This doctor seems to draw on his medical knowledge of "normal prenatal troubles" to anticipate her complaints and fears He then t r i e s to "teach" her the medical view of these "troubles" by t r y i n g to "normalize" them as occurring to most pregnant women. Like B a r t l e t t , he u t i l i z e s the f o l k view of "nature" as a governing, i n v i s i b l e force which makes "signs" of i t s " w i l l " which the doctor acts as an authority to i n t e r -pret. He uses t h i s management device i n t h i s case to normalize anticipated "troubles," such as becoming e a s i l y t i r e d — r a t h e r than go into a technical explanation of the medical " f a c t s " causing these "troubles." Also, l i k e B a r t l e t t , he assumes the patient has been and w i l l be exposed to f o l k medicine, which he p e j o r a t i v e l y labels "old wives' t a l e s . " Thus, he t r i e s to persuade her to ignore and disavow these practices and b e l i e f s by encouraging her to do some "homework": reading medical texts and attending c h i l d b i r t h classes where the medical per-spective i s taught. Also, to t h i s end he, himself, emphasizes a p a r t i a l medical view wherein "There i s nothing wrong with pregnancy; you're not s i c k , " while not teaching her the abnormalities that may occur and discouraging her from study-ing t h i s medical aspect of pregnancy and c h i l d b i r t h ("—but please not to concentrate on the section on abnormal obstet-r i c s ! " ) . Without mentioning i t e x p l i c i t l y , he portrays f o l k medicine as viewing c h i l d b i r t h as involving many pathological processes. Thus, he teaches her a p a r t i a l view of the medical perspective which deals with the "normal troubles" and non-pathological processes and avoids discussing "abnormal obstet-r i c s " which may support or reinforce t h i s f o l k pathological 209 conception of pregnancy to which he assumes the patient has already been exposed: "I t r y at t h i s point not to mention the abnormalities. A l l the women have heard about them anyway. . • • The same private obstetrician's experiences bear out t h i s i n t e r p r e t a t i o n of the r e l a t i o n s h i p between attempts to conceal information about medical abnormalities and the doctor's assumption that the f o l k medical view involves a conception of the pregnant woman as subject to many pathologi-c a l processes, and therefore b a s i c a l l y " s i c k . " Now I believe i n being p e r f e c t l y honest with my p a t i e n t s — and a l l the more so as they go into the l a s t few months of t h e i r pregnancies, by which time we have b u i l t a basis of understanding. This doesn't mean that I go into a l l of the t e c h n i c a l d e t a i l s or abnormal p o s s i b i l i t i e s which would serve no purpose except to f r i g h t e n the expectant mother unnecessarily—one of the reasons I so despise ominous Old Wives Tales.17 Sweeney, i n the lecture described above not only uses selected medical " f a c t s " to persuade the patient that pregnancy i s a "normal, physiological process" with just "normal troubles" to be expected; he also e x p l i c i t l y locates s p e c i f i c f o l k sources and castigates them as ignorant or not u s e f u l . At the same time, he implies she should use him as the sole r e l i a b l e , v a l i d source of "information" about pregnancy and c h i l d b i r t h . Next, he t r i e s to teach her the medical view that pregnancy i s an event to be "run" or governed by a s p e c i f i c doctor who has his own p a r t i c u l a r prescriptions and proscriptions which, neverthe-l e s s , patients are to regard as binding, as rules of a game are binding on the p a r t i c i p a n t s . In other words, he i s putting 2 1 0 her on notice that i f she wants to receive his care she must regard him as the ultimate authority on a l l matters re l a t e d to pregnancy and c h i l d b i r t h and, therefore, should treat h i s r u l e s about the prenatal regimen as sanctionable constraints. Thus, the doctor sets himself against not only f o l k sources but other doctors, as well, who may have somewhat d i f f e r e n t approaches to the prenatal regimen. Apparently, he i s t r y i n g to get her to see pregnancy and c h i l d b i r t h as not so much an event over which she has control, but as f a l l i n g i n his sovereign domain; wherein h i s rules are the only ones sanctioned as legitimate. He concludes h i s " s p i e l " by encouraging her to use him as the sole source f o r answers to her questions. Apparently he has a model of the t y p i c a l or "normal patient" as one who find s pregnancy and c h i l d b i r t h problematic, a cause f o r anxiety and inquiry. He anticipates that t h i s w i l l be her reaction and t r i e s to persuade her to draw up a l i s t of questions and wait u n t i l the next v i s i t to have them answered—or, phone i n the meantime, presumably, to prevent her from turning to lay or f o l k sources f o r answers or reassurances. 211 FOOTNOTES 1 . 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 ) , p. 2 5 5 . 2. Roy Turner, "Some Formal Properties of Therapy Talk," i n David Sudnow, ed. Studies i n S o c i a l Interaction (New York: Free Press, 1 9 7 2 ) , p. 2 1 . 3 . Erving Goffman, The Presentation of S e l f i n Everyday L i f e (New York: Doubleday Anchor, 1 9 5 9 ) . 4. 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, 1 9 7 3 ) , pp. 1 0 6 - 1 0 9 . 5. Joan Emerson, "Behavior i n Public Places: Sustaining D e f i n i t i o n s of Re 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. 1970). p. 6. Joan Emerson, "Social Functions of Humor i n a Hospital S e t t i n g " (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, C a l i f o r n i a , 1 9 6 3 ) , p. 4 8 . 7 . Lewis Yablonsky, The Violent Gang (New York: Free Press, 1 9 6 2 ) . 8 . Emerson, "Social Functions of Humor i n a Hospital Setting," p. 8 9 . 9. Roy Turner, "Some Formal Properties of Therapy Talk," i n David Sudnow, ed., Studies i n S o c i a l Interaction (New York: Free Press, 1 9 7 2 ) . 1 0 . Bruce Katz, "Conversational Resources of Two-Party Psychotherapy" (unpublished Master's t h e s i s , University of B r i t i s h Columbia, Vancouver, B.C., 1 9 7 1 ) . 1 1 . Emerson, "Social Functions of Humor i n a Hospital Setting, p. 4 6 . 1 2 . Matthew Speier, How to Observe Face-to-Face Communication: A S o c i o l o g i c a l Introduction ( P a c i f i c Palisades. C a l i f o r n i a : Goodyear Publishing Company, 1 9 7 3 ) , pp. 1 4 8 - 1 4 9 . 212 13. Turner, "Some Formal Properties of Therapy Talk," pp. 17-32. 14. Harvey Sacks, "U.G.L.A. Lectures," unpublished, Los Angeles, C a l i f o r n i a , 1966. 15. Anonymous M.D., Confessions of a Gynecologist (New York: Doubleday and Company, 1972), pp. 10-12. 16. Sweeney, Woman's Doctor: A Year i n the L i f e of an Obstetrician-Gynecologist. pp. 145-147. 17. Ibid., p. 143. 213 CHAPTER V LABOR AND DELIVERY: THE ORGANIZATION OF WORK ROUTINES This chapter documents the intransigence of labor and d e l i v e r y as "raw materials" f o r organizational programming, as well as the patient management routines developed to cope with the n a t u r 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 at the beginning of 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 u s e f u l 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 con-trasted with a s t r u c t u r a l survey approach to theory and method which imposes the researcher's organizationally a l i e n view of events i n the h o s p i t a l as r e s u l t i n g from extra-hospital a t t r i -butes and processes of s t a f f and patients (§_. g., s o c i a l c l a s s , s o c i a l psychological attitudes, b e l i e f s , e t c . ) , and thereby often produce demonstrably spurious analysis of such organiza-t i o n a l events as labor and d e l i v e r y . When studying c h i l d b i r t h , s o c i o l o g i s t s generally concentrate on f i n d i n g s t a t i s t i c a l r e l a t i o n s h i p s between 214 "medical" or "phy s i o l o g i c a l " events and "problems" experienced by the patient i n the delivery room, and the patient's and s t a f f ' s " s o c i a l c h a r a c t e r i s t i c s . " T y p i c a l l y , t h i s standard approach has tended to ignore how such "medical" events and "problems" are also organizational products, shaped by the medical s t a f f ' s work routine. For example, one such study, e n t i t l e d "Some So c i a l Psychological Aspects of Delivery Room D i f f i c u l t i e s " by William R. Rosengren, t r i e s to f i n d and explain correlations between measured " s o c i a l c l a s s " of patients, t h e i r measured "adoption" of Parsons' "sick r o l e " i n pregnancy and delivery, and observed "medical d i f f i c u l t i e s " which these patients experience i n the childbearing process. In his study, t h i s researcher set up an "Indices of D i f f i -c u l t i e s , " as well as collected " s o c i a l psychological data" v i a focused interviews on patients' "perception of pregnancy as ' i l l n e s s ' " i n terms of Parsons' "sick r o l e . " Indices of D i f f i c u l t y : Two major indices of d i f f i c u l t or complicated d e l i v e r i e s were used: length of labor time and gross complications. Labor time was determined by means of data which were recorded f o r purposes of the Collaborative Study. S p e c i f i c a l l y , observers noted the time of the onset of contractions on standardized forms, and l a t e r noted the time at which the patient entered the delivery room. The lapse i n time was regarded as a suitable indicator of length of labor time. . . . An operational assumption of t h i s study was that a lengthy labor time was a greater i n d i c a t i o n of d i f f i c u l t y during delivery than was a shorter labor time. Second, indices of gross d i f f i c u l t i e s and complications were drawn from the re g u l a r l y maintained records at the l y i n g - i n Hospital. Notations were f i r s t made of any complications noted while the woman was i n the labor room. These included such observations as unexplained bleeding, 215 any f e t a l positions or movements which seemed to i n t e r f e r e with the course of labor, and so on. Notations were also made of the general condition of the woman i n the labor room (e_. g., premature rupturing of the membranes, any abnormal heart murmurs or p a l p i t a t i o n s ) . Third, abnormal conditions i n the delivery room i t s e l f were noted (e. g., breech p o s i t i o n of the fetus, abnormal f e t a l heart beat, extreme blood pressure changes on the part of the mother, and the l i k e ) . Fourth, a record was kept as to the use of forceps: low, mid or high; and mild, moderate, or heavy pressure needed. F i n a l l y , notations were made of any cord complications as to both the number of loops and t h e i r degree of tightness. The subjects were then divided into two groups: those women who had experienced a "gross abnormality" during labor or delivery; and those who had not — r e g a r d l e s s of the length of labor time. There were 30 women i n the "abnormal" group and 64 i n the "normal" category. Those women whose labor had been interrupted f o r purposes of sectioning were placed i n the "abnormal" group, while those whose section had been anticipated from the outset were assigned to the "normal" group. • • .1 By using the time spent p r i o r to being sent to the delivery room as a "suitable indicator of length of labor time," the researcher overlooks the ethnographic observation that labor, presenting "natural" scheduling and control problems, may be prolonged or shortened by treatment routines i n the delivery room i t s e l f , which i n turn may be related s t a f f ' s concerns f o r work scheduling and producing v i s i b l y competent work, rather than t h e i r ' s or the patient's " s o c i a l psychological character-i s t i c s . " In presenting his findings, t h i s researcher provides a post hoc explanation and makes clear that the research was primarily concerned with helping doctors deal with " p r a c t i c a l " health problems. There was a s t r i k i n g r e l a t i o n s h i p between length of labor time and the extent of the woman's d e f i n i t i o n of pregnancy as an " i l l n e s s . " Those women who expected to act "as i f " they were s i c k during pregnancy were also those whose labor time records bore out that expectation. I t seems clear 216 that as an anticipatory response phenomenon, t h i s i s what might be expected. These women were ac t u a l l y enacting a cer t a i n kind of s o c i a l r o l e during t h e i r pregnancy with which a long and arduous labor i s not inconsistent. . . . Of suggestive importance i s the r e l a t i o n s h i p between length of labor time and the incidence of gross physiologic or morphologic d i f f i c u l t i e s . The longer the labor time the more l i k e l y the appearance of a gross complication of some kind. . . . I f t h i s i s i n f a c t the case, then whatever means—socialpsychologic as well as medical—by which t h i s e f f e c t (of lengthy labor) may be reduced i s of p o t e n t i a l p r a c t i c a l importance.2 Aside from the irremediable methodological d i f f i c u l t i e s inherent i n imposing the researcher's theory and categories on patients' and s t a f f ' s accounts when doing focused interviews and status c l a s s i f i c a t i o n s , the primary problem with such a study l i e s i n i t s i m p l i c i t assumption that mainly abstract " s o c i a l character-i s t i c s " and " b e l i e f s " of patients and doctors influence the "medical" outcomes i n labor and d e l i v e r y . In f a c t , t h i s struc-t u r a l survey approach detaches behavior i n labor and c h i l d b i r t h from the organizational s e t t i n g and work routines i n which they naturally occur i n order to impose the researcher's own theories of the r e l a t i o n s h i p of c e r t a i n abstract, general s o c i a l c l a s s -i f i c a t i o n s and b e l i e f systems and observed "medical" outcomes. An ethnographic approach, on the other hand, reveals, f o r example, how such assumed " d i f f i c u l t i e s " as "length of labor," "bleeding," "rupturing of the membranes," "forceps d e l i v e r y , " and "caesarian section" may be defined and produced to an important extent by the everyday s o c i a l organization of c h i l d -b i r t h i n a h o s p i t a l . "Length of labor," f o r example, may be affected by the doctor's administration and regulation of the drug p i t o c i n , 217 which augments and induces labor contractions. A doctor's decision to use t h i s drug may be based on considerations of work scheduling, rather than "physiological" or "medical" c r i t e r i a . ^ In the following case i n the delivery room, an ob s t e t r i c i a n i s concerned to "speed up" a patient's labor i n order to meet an appointment with another doctor to consult on a Caesarian section. (Outside the delivery room) Ob. to Nurse: "Well, give her a l i t t l e p i t o c i n so the contractions w i l l come more regula r l y and I won't have to wait." (Later i n the delivery room) Ob. to Patient: "These contractions are funny, go a few and disappear." Patient: "That's the way i t was t h i s morning. I t ' s funny." Ob: "That's why we gave you that ( p i t . ) to have them come r e g u l a r l y . (Later i n the labor.) We could have waited a few weeks (to d e l i v e r ) . " Patient: "I was o f f the p i l l s a month so I couldn't be f a r o f f . I think I got pregnant on the f i r s t of J u l y . I got that old f e e l i n g two weeks ago and I had these contractions e a r l i e r s t i l l . I was disconcerted when I was premature (an e a r l i e r baby) but t h i s time I was composed." Ob: "A healthy sign. Since the baby i s premature by dates anyway, I have a consultation a f t e r one before I go home." Patient: "That's ok. As long as you have somebody to take care of i t . Dr. R. t o l d me that you'd be too busy." (The Ob. leaves to get a resident to supervise her delivery.) The doctor's verbalized warrant f o r using p i t o c i n (suggesting i t i s f o r her own welfare) shows how medical routines dictated by demand c h a r a c t e r i s t i c s are translated into responses to patients' "health needs." Next the doctor t r i e s to preface or 218 or "set up" his exit by t r y i n g to get the patient to see that she came to the h o s p i t a l i n f a l s e labor. However, she counters by claiming she i s not to be held accountable f o r bringing the doctor t o the h o s p i t a l on " f a l s e pretenses." Nevertheless, the doctor invokes her estimated due date of the a r r i v a l of the baby to s h i f t grounds on which to claim i t i s the "prematurity" of her coming to the h o s p i t a l which warrants his leaving her, rather than simply saying he has "more pressing" business e l s e -where, which could c a l l his competence into question. A case reported by a "natural c h i l d b i r t h " patient also demonstrates how a doctor may t r y to provide an acceptable warrant f o r using p i t o c i n i n terms of the patient's state of labor, while a c t u a l l y u t i l i z i n g i t to f i t the patient i n t o his work schedule. No sooner was I comfortably s e t t l e d than Dr. Sedley reappeared. "How are you doing?" he asked. I had to confess that nothing much was happening. Whereupon he got out the needle again and injected another dose of that non-synthetic oxytocin preparation. Just then I noticed a large b o t t l e that stood on the table by the w a l l . "You aren't planning to pump a l l of that into my arm?" I asked warily. His only answer was a noncommittal laugh. Almost immediately the contractions picked up with redoubled force; again there was l i t t l e time i n between them. (Later i n the labor) Dr. Sedley was back again. I was beginning to wonder i f he would go away again without giv i n g me another shot i f I said the contractions were tremendous. I brooded over t h i s question f o r some time. Later on, I r e a l i z e d that he was probably gi v i n g me the shots on a schedule, and i t wouldn't have made any d i f f e r -ence what I s a i d . 4 Another management approach involves persuading the p a t i e n t to accept p i t o c i n by glossing i t s often powerful e f f e c t s on labor as (euphemistically) being used t o "speed 2 1 9 things up." Here i s a case of a "natural c h i l d b i r t h " patient who, while t r y i n g to cope with the "normal rhythm" of her contractions, i s persuaded to accept p i t o c i n so the doctor can deal with his work load. The patient t o l d me the doctor used p i t o c i n when she "slowed down" i n her e f f o r t s to push the baby out. Since the doctor had other patients, he wanted to speed my contractions up. However, t h i s caused pain and d i s -rupted the na t u r a l l y intended pace of my contractions. Plus i t caused a p a i n f u l lump i n my arm. I wasn't aware of what they proposed when they asked me i f they could "speed i t up." F i n a l l y , a private o b s t e t r i c i a n r e l a t e s how common the practice i s of inducing and c o n t r o l l i n g labor v i a p i t o c i n f o r the doctor's and the patient's convenience. . . • There are those who c a l l t h i s (induction) meddlesome ob s t e t r i c s , but I believe inductions are p e r f e c t l y j u s t i f i a b l e even f o r nonmedical reasons. Any doctor who t e l l s you he only induces patients on a medical basis i s l y i n g , because he does i t sometimes f o r his convenience and sometimes f o r the woman he's d e l i v e r i n g . I had a lady who l i v e d out on Long Island. She was t e r r i f i e d of Long Island Expressway on a summer night. When she got to term, we induced her rather than have her r i s k getting stuck i n t r a f f i c . 5 One of the " d i f f i c u l t i e s " claimed by Rosengren as r e f l e c t i n g the enactment of the "sick r o l e " by the patient i s i t s e l f a frequently used resource to regulate the "length of labor" i n regard to the pacing of work i n the labor and deli v e r y rooms: "forceps d e l i v e r y . " I r o n i c a l l y , while gathering his focused interviews concerning the "sick r o l e , " Rosengren also did a non-participation observation of a deli v e r y service, the r e s u l t s of which l a t e r appeared i n an 220 a r t i c l e e n t i t l e d "Time and Space i n an O b s t e t r i c a l Hospital." I say i r o n i c a l l y because the r e s u l t s of his more ethnographic study i t s e l f can be used to demonstrate how the organization of work influences the frequency of forceps delivery, a f a c t overlooked i n his s t r u c t u r a l survey study. In f a c t , i n t h i s l a t e r published a r t i c l e , Rosengren describes how forceps and anesthesia were both ro u t i n e l y used to deal with the work scheduling that r e f l e c t s on the s t a f f ' s competence and pro-f e s s i o n a l "status." Tempo: Conceptions of the "Normal" i n the Hospital The number of d e l i v e r i e s taking place i n a given period of time p a r t i c u l a r l y r e l a t e s to the tempo of the service. In the c l i n i c service, the number of b i r t h s i n a twenty-four hour period may range from as few as one or two to as many as f i f t e e n or twenty. This lack of a natural tempo seemed to be handled i n a number of ways i n order to impose a "functional" tempo where a "physiological" tempo did not e x i s t . For example, when d e l i v e r i e s were occurring at a n a t u r a l l y slow pace, the residents showed much anxiety and concern over the one or two women who might have been holding up the tempo of events i n l a b o r — c o n s t a n t l y check-ing and rechecking f o r signs of change. S i m i l a r l y , i n the del i v e r y room i t s e l f , there seemed to be an attempt to impose a tempo—to adhere to a pace of scrubbing, of administering anesthesia, and so f o r t h . There was also an emphasis upon keeping track of the length of time involved i n each d e l i v e r y . In terms of tempo, the unusually pro-longed d e l i v e r y was as up-setting to the team as was an unusually rapid d e l i v e r y — e v e n though both might be equally normal or abnormal from a medical point of view. As one resident put i t , "Our (the residents') average length of delivery i s about 50 minutes, and the Pros (the private doctors) i s about 40 minutes." Thus, the "correct" tempo becomes a matter of status competition and a measure of professional adeptness. The use of forceps i s also a means by which the tempo i s maintained i n the delivery room, and they are so often used that the procedure i s regarded as normal. The student externs showed p a r t i c u l a r reluctance about admitting patients to the service because of the possible 221 f a c t that the patient might be i n "f a l s e labor." This would upset both the rhythm and the tempo. I t may not be unrelated to the f a c t that such a "mistake" on the part of low-status personnel i s much more c r u c i a l than a si m i l a r mistake on the part of higher-status personnel. In addition, the p o t e n t i a l high tempo f o r the o b s t e t r i c i a n i s necessarily l i m i t e d ; he can be i n attendance f o r just one case at a time. When the phys i o l o g i c a l tempo begins to outrun the f u n c t i o n a l tempo, the margin of safety can be p a r t i a l l y maintained by the anesthetist who can hurry cases along or delay them, depending upon the kind and amount of anesthesia he administers. As one anesthetist joyously announced one night when the physiological tempo was very high, "I've got f i v e going (ready f o r delivery but delayed) at once now."6 At C i t y , "length of labor" often was inadvertantly extended by the common use of drugs and anesthesia to "calm" and make a patient "cooperative>" Patients who complained loudly about t h e i r labor pains, the treatment they were receiving, c r i e d , did not cooperate, and appeared "too appre-hensive," were given drugs and anesthesia u n t i l they "calmed down." For example, here i s a case of an I t a l i a n patient who was given a narcotic to "calm" her while a resident f i n i s h e s connecting a f e t a l monitor. I t i s given i n t h i s case i n the early stage of labor when drugs are usually not administered because they might a f f e c t the baby and slow labor. (Patient groans and c r i e s . ) Resident: "Ok, dear, i t won't be long." Patient: "I can't!" Resident: "In a l i t t l e while, I ' l l give you an i n j e c t i o n . I t ' s too ear l y . Patient: t r 'Why?" Resident: "We'll f i n d out about the baby f i r s t . Then we'll take care of the pain." Patient: " I t hurts." 222 Resident: "You have to put up with i t . This i s labor. I f you don Tt have the pain the baby won't come down." Patient: "No more!" Resident: "Ok. I won't touch you any more. Don't touch the instrument." (the f e t a l monitor) Patient: "Ow! Yeow!" Resident: (to nurse) "Get her a heroin." (Turns to students who have been observing) "I don't l i k e to give pain k i l l e r too early. We'll record the f e t a l heart beat. I f she doesn't have good contractions, we'll put a d r i p pan under her." Staff tend to treat any loud "emotional" utterance or expression as a "reaction to labor pains" and therefore warranting anesthesia or drugs, whether the patient requests i t or not. This observation i s supported by the experience reported by a "natural c h i l d b i r t h " patient who found her loud summons to the s t a f f treated by anesthetic i n r e p l y . I was l e f t alone i n the delivery room f o r about 20 minutes while everyone scrubbed. At t h i s time, without my great (labor) coach I l o s t control, couldn't remember what to do and began to moan and toss my arms about. Then a l l of a sudden the urge to push was overwhelming, and I began to y e l l , "Push, Push!" The nurse ran i n and gave me a shot of Demerol. I hadn't r e a l l y wanted i t , nor had I l o s t c o n t r o l — I just wanted them to come before the baby did!7 In another case at City, a patient, described by her doctor as " h y s t e r i c a l , very worried, and l e t s i t a l l out" because she does not have the "right a t t i t u d e " to delivery, becomes "emotional" i n the delivery room and refuses to "cooperate" with s t a f f i n keeping her hands o f f the s t e r i l e sheet which covers her abdomen, and i s given anesthesia. Patient: "Ow! Ow! (grabs the s t e r i l e c l o t h and the nurse p u l l s her hands loose) I can't put my 223 hands down! I want something to hold on t o ! " Nurse: "Just remain calm! I t ' l l be over i n f i v e minutes." Patient: "Oh! Dr. B., can I hold on?" Nurse: (angry) "Don't put your hands on the green sheets!" Patient: "I don't know! I don't know what I ' l l remember! Oh! Dr. B! Don't!" Dr. B.: "It's the contractions you are having!" Anesthetist: (when the patient continues to shout and protest he pushes the mask over her mouth) "Just breathe i n and out!" In addition to using anesthesia to obtain the patient's cooperation with medically prescribed "aesepsis" procedures, a s t a f f may also use i t to "calm" a patient who has been "uncooperative" i n conforming with the "approved" po s i t i o n f o r d e l i v e r y . On the other hand, the patient's behavior may r e f l e c t her view that the prescribed p o s i t i o n and much of the routine preparation f o r delivery are unnecessary and i n t e r f e r e with her attempts to apply "natural c h i l d b i r t h " t r a i n i n g to stay i n "control" while i n labor. After the nurse took me to my labor room, Larry (a medical student) and Dr. Ischal came i n to s t a r t my IV running, and t h i s i s where the trouble began. I was having tremendous back labor, and I had to lay on my back which made i t worse. U n t i l t h i s time, I was i n f u l l control, but I had to tense my arms so they could f i n d a vein. Dr. Ischal spent one and one h a l f hours t r y i n g to s t a r t the IV and I t o t a l l y l o s t c o n t r o l . He kept jabbing me with the needle of xylocaine, and then before i t took e f f e c t , he'd s t a r t the IV, or t r y . F i n a l l y about 3 p.m., he got i t to stay i n , but by t h i s time both arms were bruised a l l over and I was crying. I probably would have l e t Dr. Ischal have i t but Larry managed to keep me f a i r l y calm as Therean (her husband) wasn't allowed i n . I f he had been I might have been able to stay i n c o n t r o l . At three, they examined me and I was s t i l l 5 cm. but 80% effaced. Between 3-3:30 Therean and I were alone and I was just beginning to calm 224 down and get i n control again; he was coaching me i n breathing. About 3:30 I f e l t two very strong contractions and I t o l d Therean that i f I wasn't a f r a i d Dr. Ischal would examine me I'd c a l l because I f e l t l i k e I was i n t r a n s i t i o n almost. Just then Dr. Ischal walked i n p u l l i n g on a glove. He checked me (but not gently at a l l ) and I was 7 cm. Dr. Patchin (her personal physician) had l e f t word to be c a l l e d between 7 and 8 cm. so he came i n a few minutes l a t e r to do a paracervical block and I was i n no p o s i t i o n t o object. I was so t i r e d from a l l they'd done and l a y i n g on my back a l l but a few minutes they l e f t us alone, that any kind of r e l i e f was welcome. Only i t wasn't r e l i e f — I had to lay on my back and i t took 20 minutes or so to do i t a l l . Then a l l i t d i d was numb the cervix which wasn't hurting i n the f i r s t place, I s t i l l had very bad cramps and my back hurt worse. A few minutes l a t e r they brought the f e t a l heart monitor, and that's when I r e a l l y went wi l d . I just sobbed; I was scared to death, and I had to turn over on my back f o r another 20 minutes or so. They put i t i n and i t didn't hurt at a l l but my back was worse so Dr. Patchin gave me some demerol and I began to relax a b i t . As soon as he gave me the shot he checked me; i t was 4:30 and he said I was ready to go. They took me to the delivery room and I wasn't f e e l i n g very cooperative by then, and I was so disgusted with the e f f e c t of the medication, I wasn't i n any rush to turn over on my back so they could strap me i n . I f i n a l l y turned over and they got me a l l f i x e d up, and during t h i s time, Dr. Gibson (a new resident replacing Ischal) took over the f l o o r and he just started giving me gas, which I didn't want since everything else had been no help. I t ' s a good thing f o r him my hands were t i e d or I would have punched him out. But I guess the gas made me more passive, which was good f o r them because by now I was so mad at the way things were going, I was y e l l i n g at them.8 S t a f f at C i t y t y p i c a l l y do not t r e a t a patient's loud "emotional reactions" and r e s u l t i n g "uncooperative behavior" as possibly r e f l e c t i n g On the hospital's treatment routines, as t h i s patient shows may occur. Instead, they usually locate the cause within the patient h e r s e l f i n terms of d i f f e r e n t " c u l t u r a l expectations" which are assumed t o govern how d i f f e r e n t "ethnic" types of patients should behave i n labor or i n terms of the patient's personality or "attitude," a product of her past r e l a t i o n s h i p s . For example, one doctor claimed that Greeks and I t a l i a n s " y e l l a l o t because t h e i r mothers expect them t o " or "to get back at t h e i r husband, who i s usually i n the h a l l outside within hearing distance, f o r not allowing them to have babies f o r a long time or because they want t h e i r husbands to leave them alone (sexually) and they t r y to stay i n the h o s p i t a l as long as possible. "We don't allow Greek and I t a l i a n husbands into the delivery room because i t just makes the patient y e l l louder." Thus, s t a f f t r e a t "bad reactions" to labor as perhaps having a c u l t u r a l l y determined instrumental purpose v i s - a - v i s marital relationships rather than the r e s u l t of s t a f f ' s treatment or the character of the labor contractions themselves. "Dramatic reactions* to labor are assumed to be "unnecessary" and p h y s i o l o g i c a l l y "unwarranted" by the pain a patient may " a c t u a l l y " be experi-encing. S i m i l a r l y , when no "ethnic" t y p i f i c a t i o n can be applied to the "bad patient," her psychological c h a r a c t e r i s t i c s are assumed to produce t h i s "excess" of emotion and "uncoopera-t i o n . " For example, one doctor shows how he r e l i e s on the patient's "cooperativeness" i n the doctor-patient r e l a t i o n s h i p p r i o r to d e l i v e r y , as well as her "psychological background," to account f o r her "poor reaction" to "labor s t r e s s . " (Following a delivery the doctor discusses the patient's "performance" with me.) The background i s important to understand the reaction of t h i s patient. She's not too bright and has an inadequate personality. I can under-stand why her f i r s t husband beat her. Her parents adopted her f i r s t two children because she's not capable of caring f o r them. This husband i s a l l r i g h t . I didn't i n v i t e or encourage him to come into the delivery room, 226 since although I haven't delivered any of her babies before, I could t e l l that her personality would not be good f o r delivery s t r e s s . E s p e c i a l l y since each week she seemed to lack confidence i n the delivery and her doctor (himself) and she was always voicing more doubts and asking a l o t of questions. Thus, both modes of t y p i f i c a t i o n accounting f o r "bad reactions" provide grounds to anticipate i t and provide d i f f e r e n t i a l t r e a t -ment f o r these "types" by excluding t h e i r husbands from attend-ing the delivery, as well as to deflect attention from the h o s p i t a l treatment routines when patients are "bad." Exclud-ing the husband also helps to prevent such "behavior" from v i s i b l y r e f l e c t i n g on the doctor's competence. Not a l l doctors at City treat "bad reactions" and "uncooperativeness" as warranting the exclusion of the husband and the use of anesthesia and other drugs. Dr. B a r t l e t t and several other senior teaching obstetricians generally avoided these p r a c t i c e s . Their approach to labor and c h i l d b i r t h was related to me by Dr. B a r t l e t t a f t e r a "noisy d e l i v e r y " by an " I t a l i a n " patient. An important feature of his remarks i s that i n accounting f o r a patient's reaction he seems les s con-cerned than other doctors to d e f l e c t attention from the hospital's routines. Different n a t i o n a l i t i e s do react d i f f e r e n t l y to labor. I t a l i a n s and Greeks may express themselves a l o t but not necessarily according to the amount of pain experienced. However, that y e l l i n g also varies with the treatment of them by nurses and doctors. In the long run, i t may be better f o r the patients to express emotions rather than clench t h e i r teeth l i k e the Anglo-Saxons, Indians and Chinese. Nurses and doctors see the best patient as one who doesn't cry or be apprehensive because they are Anglo-Saxon and therefore they associate crying with unhappiness and because i t r e f l e c t s on t h e i r competence. There's a l o t of abuse of anesthesia and drugs at City i n that i t may be used i n the amounts and when necessary to keep the patient from being uncooperative or being apprehensive and upset or t a l k i n g back to the doctor ot ta l k i n g d i s r e s p e c t f u l l y . I take i t that B a r t l e t t ' s approach r e f l e c t s a f a m i l i a r -i t y with professional and academic l i t e r a t u r e which generally espouses the use of the findings of s o c i a l science and tech-niques of psychotherapy i n implementing "patient as person" i d e a l s of the medical ideology when coaching labor. In any event, his remarks suggest that the s t a f f ' s use of anesthesia and interpersonal management techniques (to be discussed) to control and quiet patients derives to some extent from t h e i r concern to give a v i s i b l y competent performance. Thus, the patient's"condition" may not be the only warrant f o r using anesthesia. Depending on whether a doctor implements ideals of the medical ideology i n "coaching" labor and c h i l d b i r t h , (as does B a r t l e t t ) i t s use may be influenced by such mundane work concerns as scheduling and making competence v i s i b l e to colleagues. The cases I have been discussing suggest how these work concerns r e s u l t i n the more frequent use of anesthesia and drugs which may prolong labor, a " d i f f i c u l t y " Rosengren assumes r e f l e c t s the patient's b e l i e f s about playing the "sick r o l e " i n labor and c h i l d b i r t h . Returning to the " d i f f i c u l t y " of "forceps d e l i v e r y , " besides scheduling concerns, another organizational contingency that may re s u l t i n i t s frequent use i a whether or not teaching i s one of i t s routine tasks i n a h o s p i t a l . At City, forceps 228 d e l i v e r i e s often were performed not because of "medical requirements," but because the interns on duty had to get experience at doing t h i s operation. One general p r a c t i t i o n e r who delivered a l o t of his babies at C i t y described the rou-t i n e character of t h i s practice and pointed i t out as one kind of d i f f e r e n t i a l treatment accorded " c l i n i c " or " s t a f f " patients as opposed to "private patients." A l l s t a f f patients are delivered with sp i n a l block (a l o c a l anesthetic) and forceps on f i r s t d e l i v e r y (the patient's f i r s t baby), whether i t ' s required or not, so the interns can get p r a c t i c e . However, i f the forceps s l i p , they may r i p the mother further than an epesiotomy. Or they may get the forceps i n and not get them out and r i p the mother with the rough edges. Also, i f they (the forceps) s l i p on the baby's head i t may cause brain damage. One of the "gross d i f f i c u l t i e s , " "caesarian section," used by Rosengren to indicate the e f f e c t of " s o c i a l psychologi-c a l " f a c t o r s , i s i t s e l f susceptible to use by a s t a f f as a means to shorten labor time to schedule a "normal work day." The following remarks by a nurse who had worked at a h o s p i t a l near City suggests how the use of caesarian section may demon-strate the sanctity of work-shifts and d i f f e r e n t i a l treatment of " c l i n i c " or " s t a f f " patients. She related to me that Metropolitan Hospital has a " f i v e o'clock p o l i c y " whereby any patient d e l i v e r i n g a f t e r 5 p.m. i s delivered by caesarian section so the doctors and nurses can have an "eight to f i v e day." Metropolitan i s located i n what the nurse termed an "ethnic ghetto." "Many of the patients there are ' s t a f f or ' c l i n i c ' , unwed, and do not speak English. Even i f the husband i s present, the s t a f f explain that ' i t ' s just the way babies are born now.'" Many of the patients are scared f i f t e e n and sixteen year-olds, unwed, who don't want to keep t h e i r babies, and want the pain over with, so they do what the s t a f f wants. By t h i s nurse's account, i n her hos p i t a l , the doctors t r y to persuade a patient and her husband to accept a "c-section" by "r o u t i n i z i n g " i t as part of the l a t e s t medical approach to c h i l d b i r t h methods. At City i t s e l f , patients t y p i f i e d as l i k e l y to have a "bad reaction to the stress of labor,' i . g.., "lose c o n t r o l " of t h e i r emotions and become "uncooperative," sometimes were given c-sections to avoid having to manage t h e i r behavior to conform to s t a f f ' s image of the "good patient" (organizationally programmable) i n labor and de l i v e r y . ^ For example, one doctor just before a c-section related to me how his patient had a " d i f f i c u l t " f i r s t delivery and appeared "too apprehensive" f o r regular c h i l d b i r t h . This was the main reason, I was t o l d , why a vaginal delivery was not attempted. The doctor described his management technique i n t h i s case as follows. So I had to brainwash her with a general description of the operation and assure her how safe i t i s . I didn't go into d e t a i l because that would scare her since she wouldn't understand even a f t e r having experience with a previous c h i l d b i r t h . When the baby was delivered, i t s heart beat only f o r a few times f o r the f i r s t hour and i t was les s than s i x pounds i n weight. I t was immediately taken to intensive care, i t s prognosis uncertain. Afterwards, the consulting o b s t e t r i c i a n discussed with the doctor how one of the possible reasons f o r 230 a "poor baby" was the chance that i t may have absorbed some of the general anesthesia given the mother f o r the c-section. He implied that even though there had been no sign of trouble p r i o r t o delivery, a vaginal b i r t h would have reduced the r i s k to the baby. In reply, the doctor agreed that " i t would be bad to t a l k the mother into an operation and d e l i v e r t h i s way and lose the baby." I suggest that what i s of s o c i o l o g i c a l i n t e r e s t here i s not "sloppy medicine," but the f a c t that s t a f f have at t h e i r disposal and u t i l i z e various medical procedures with medical ratio n a l e s ( p i t o c i n , anesthesia, forceps, c-section) to control the'length of labor" and manage and avoid organizationally "troublesome patients," so as to expedite t h e i r work schedules and ensure a v i s i b l y competent performance. These s t a f f con-cerns f o r the "shaping up of a day's work" and providing f o r the v i s i b l e competence of that work seem to be taken f o r granted invariant properties of occupational routines i n general. Roy Turner has termed them demand c h a r a c t e r i s t i c s of occupational routines i n his study of the influence of schedul-i n g and v i s i b i l i t y i n organizing the routine conduct of police work. What i s of significance i n t h i s ethnographic approach i s not the "uncovering" of medical practices or police practices which may be disapproved of by the public (§.. g., t r e a t i n g patients with regard to the structure of the work day or to a v i s i b l y competent performance) but the discovery of "the s i t u a t i o n a l and contextual features (demand c h a r a c t e r i s t i c s ) 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 . " x u Such a perspec-t i v e draws attention to the f a c t that what the public, i t s guardians, and s o c i a l s c i e n t i s t s regard as possible indications of "poor performance" by "public servants," or simply as " d i f f i c u l t i e s " the public encounter while obtaining service ("long labors," "forceps d e l i v e r y , " etc.),may i n f a c t indicate the operation of c e r t a i n organizing p r i n c i p l e s (demand charac-t e r i s t i c s ) governing the service's routine. Now I would l i k e to discuss yet another resource s t a f f may draw on to control "length of labor": "guiding" the patient i n the delivery room to push to get the maximum eff e c t of each labor contraction i n expelling the baby. In the s t a f f ' s view t h i s e n t a i l s both i n s t r u c t i o n on how to " c o r r e c t l y " push as well as persuading the patient to exhibit the "right a t t i t u d e " or, as one s t a f f member put i t , "a relaxed and happy mental approach," so she would not become " h y s t e r i c a l " from labor pain and the long arduous "work" of pushing the baby out and quit pushing. While increasing these management e f f o r t s to "pressure" the woman to push when s t a f f was concerned to shorten labor time, a l t e r n a t i v e l y , they instructed her to. stop pushing, although she may have had the urge to do so, when they wished to prolong the labor period and delay the d e l i v e r y of the baby. Routinely, nurses monitor the patient's progress i n labor and only summon the doctor when the patient i s considered advanced enough f o r the delive r y room, usually at complete d i l a t a t i o n (10 cm.) of the cervix. This frees the doctor f o r sleep, l e i s u r e , work at his o f f i c e or i n the ward, and to d e l i v e r other patients. However, when the nurses "miscalcu-l a t e " i n diagnosing the patient's progress, they often have to rush the patient to the d e l i v e r y room and manage her to e f f e c t i v e l y "hold" the baby from being delivered u n t i l the doctor a r r i v e s , the only one permitted by organizational r u l e s to conduct the d e l i v e r y . T y p i c a l l y , when he f i n a l l y a r r i v e s , he continues the instructions on how not to push the baby out i n order to have time to "scrub up" and make an epesiotomy. Nurses evaluate the patient's progress i n labor using cer t a i n assumptions about the c h a r a c t e r i s t i c s of the t y p i c a l or normal patient i n l a b o r . x x The patient i n labor i s assumed to take a c e r t a i n amount of time to reach complete d i l a t a t i o n of the cervix according to whether she's had a baby before (called a "multigravida" or "multip"; 6-12 hours) or not "primigravida" or "primip": 6-18 hours). Also, c e r t a i n noticeable "behavioral and emotional changes" are assumed to occur i n t h i s period of d i l a t a t i o n . Toward the end of t h i s period (8 to 10 cm.) d i l a t a t i o n the patient i s assumed to experience the most discomfort and appear most "agitated" and "emotional." Nurses (and doctors) r e l y not only on scheduled (according to whether she has had a c h i l d before) periodic p e l v i c examinations to detect the amount of d i l a t a t i o n , but also on t h i s t y p i c a l or normal change i n behavioral d i s p l a y . Loud complaining, crying, or screaming i s often treated by nurses as the s i g n a l to do a f i n a l p e l vic examination before summoning the doctor and taking the patient to the delivery room.12 They often account f o r the lack of such displays i n terms of the " e t h n i c i t y " of the patient. The following remark from a nurse demonstrates t h i s t y p i f i c a t i o n process and the degree to which nurses r e l y on "emotional displays" to evaluate labor progress and the assumed amount of pain experienced i n labor, which organizationally warrants the administration of drugs f o r r e l i e f . Unlike Greeks and I t a l i a n s , Chinese and Indians are very s t o i c and hold t h e i r f e e l i n g s i n . Sometimes they have t h e i r babies i n bed and are given too l i t t l e anesthesia and analgesics. Another "type" of patient, who i n the view of s t a f f causes "miscalculations," due to "controlled" behavioral displays, are those who have had t r a i n i n g i n "natural c h i l d b i r t h " tech-niques whereby they supposedly "breathe" and "relax" t h e i r way through labor, rather than " f i g h t i n g " contractions and increas-ing pain. I take i t that s t a f f ' s recognition of labor behavior as c r o s s - c u l t u r a l matter, suggests conversely, that t h e i r organizational standards of "normal behavior" i n labor r e f l e c t s t h e i r own "ethnic" ("Anglo-Saxon") expectations that labor i s p a i n f u l (as opposed to "natural c h i l d b i r t h " teachings) and provokes periodic "emotional" outbursts and complaints. However, an a l t e r n a t i v e explanation f o r t h i s notion of normal labor may be found i n the f a c t that the majority of t h e i r patients were t y p i f i e d by s t a f f as middle-class Anglo-Saxons. So, s t a f f 234 believe they have had more exposure to t h i s "type" of patient. Whatever the explanation f o r t h i s standard, i t i s clear i t was used to organize the monitoring and assessment of labor. This observation i s supported by reports of "natural c h i l d b i r t h " patients' experiences i n other h o s p i t a l s . For example, here a husband recounts his wife's treatment by a nurse who, to some extent, apparently scheduled p e l v i c examinations according to patients' d i s p l a y s . I had to leave at 10:45 to go to work, and as Jane had not yet been examined, the nurse arranged to do so before I l e f t . She was very surprised to f i n d how f a r advanced Jane was i n the f i r s t stage; she was already 3 fingers (cm.) d i l a t e d and they c l e a r l y expected her to be making more noise and writhing around.13 These normal patient expectations can even lead to s t a f f ' s denial of "obvious," observable "va r i a t i o n s " i n the progress of labor v i s - a - v i s the patient's "emotional behavior." In these cases, the s t a f f may act as i f the patient has not progressed as f a r as she a c t u a l l y has and, as a r e s u l t , force her to conform to the ho s p i t a l routine which i s normally followed with labor patients. In t h i s case, f o r example, a "natural c h i l d b i r t h " patient reports how she practiced her breathing techniques to avoid n o t i f y i n g the nurse of her progress, choosing to schedule her own departure to the d e l i v e r y room. When the patient goes through the f i n a l part of the f i r s t stage without "screaming" and d e l i v e r s the baby's head, the nurse denies that she has progressed as f a r as she obviously has and continues t r e a t i n g her as she normally would. This forces the patient to "hold" the baby from being delivered. 235 Then, on a r r i v a l i n the delivery room the nurse treats the patient as i f she's a normal labor patient who by t h i s time has only reached f u l l d i l a t a t i o n , not expulsion of the baby as t h i s patient has; the patient i s required to transfer her-s e l f from the t r o l l e y to the delivery t a b l e . The nurse's denial of progress even r e s u l t s i n her not i n s t r u c t i n g the patient to "hold" the baby u n t i l the doctor arrived, which normally takes place when the s t a f f recognize that the patient i s being taken to the delivery room i n an advanced stage of labor. . . . (the patient has summoned the nurse using a buzzer) The nurse eventually appeared and examined me. I asked her to r i n g my husband too. She then l e f t to telephone the doctor and to fetch the t r o l l e y on which I was to be transported to the delivery room. During her long absence the membranes broke. I knew then that i t would not be long and pressed the b e l l once more. She arrived armed with the t r o l l e y which she maneuvered alongside my bed and casually ordered me to "hop on." As I was at the height of a contraction, I continued to pant. She repeated her order. As the contraction sub-sided, I took the opportunity to crawl from a rather damp bed onto the t r o l l e y . As she pushed me down the corridor, I had another two or three contractions, thus giving b i r t h to the baby's he a d — q u i e t l y ! I t o l d the nurse what had happened, as I f e l t very pleased with myself. She stopped the t r o l l e y i n s t a n t l y and had a "peep," covered me quickly and said "Nonsense, you haven't screamed!" I was amazed at her denial so I continued the conversation no f u r t h e r . We arrived at the delivery room. She pushed the t r o l l e y beside the d e l i v e r y table and once more ordered me to "hop on," and went o f f to scrub up. Bewildered f o r a few moments, I then decided that i t wasn't worth an argument and somehow wriggled onto the delivery table supporting the baby's head with one hand and with the other edging my way onto the t a b l e . I do not think I could do i t again, but I was so f u l l of confidence! The nurse by t h i s time had returned ( a l l scrubbed) i n time 236 to d e l i v e r the t a i l end of Perdita—my gorgeous 6 l b s . 5 oz. baby g i r l . Before even cutting the umbilical cord she rushed o f f to open the front door f o r the doctor, who had been r i n g i n g the door b e l l f o r the past ten minutes. A l l the drama was over, but he was the f i r s t to off e r his congratulations.14 I take i t that t h i s process of t y p i f i c a t i o n , expecta-t i o n , and denial of observed variations with r e s u l t i n g coercion of the patient into conforming to the normal routine also can occur i n other medical s p e c i a l t i e s . For example, here i s a case of a s p i n a l i n j u r y of a returning Vietnam veteran who finds his "progress" denied v i s - a - v i s the Veteran Administration Hospital S t a f f ' s t y p i f i c a t i o n of his case as a "young (new) i n j u r y , " with an expected normal rate of improvement. Two days a f t e r I arrived at Hines (V.A. Hospital), I had my f i r s t physical therapy appointment and I was looking forward to i t because of the progress I had made at Walter Reed (Hospital). That morning, I put my braces on, put my pants on and walked on my crutches down to the physical therapy room. The doctor took one look at me and said, "I thought you were a young (recent) i n j u r y . " I t o l d him that was r i g h t , that I had been wounded just a l i t t l e more than three months e a r l i e r . "Well, i t ' s impossible f o r you to walk," he s a i d . "What do you mean?" I demanded, "You can see I'm walking, can't you?" "Young i n j u r i e s , " he informed me, "never walk so soon." So I walked back to my room, took o f f the leg braces, stood the crutches up i n the corner and went back to physical therapy i n my wheelchair. That seemed to please the doctor very much. I suppose the main thing I object to i s always being categorized as a "patient." There i s a nurse, a patient. Never Pete Rios (the w r i t e r ) . You are i n a wheelchair so you are a "spinal cord i n j u r y " — not a person. You are 30 years old, and you've had more than your share of experiences, but you are treated as i f you were a child.15 237 Here the doctor coerces him to conform to the procedural c r i t e r i a of the normal category "young s p i n a l i n j u r y " (using a wheelchair) by teaching him the organizational view of the normal behavior of his "type of case." Besides a lack of "normal" emotional display, the other type of miscalculation of progress of labor comes i n cases of women who give b i r t h more quickly than i s normally expected f o r the number of children they have had. Again, women who are de l i v e r i n g f o r the f i r s t time (primigravida) are assumed to take longer. However, "natural c h i l d b i r t h " patients often take le s s than the "normal" time, apparently because of the absence of anesthesia and analgesics which may slow contractions and t h e i r supposedly e f f i c a c i o u s breathing-relaxing techniques. Thus, s t a f f ' s assumptions of the normal labor patient seem based on t h e i r b e l i e f s and experiences of the " t y p i c a l patient" as one who experiences a good deal of pain i n labor, requires anesthesia, and must be instructed on how to relax (not "struggle") during early stages of labor and to push i n the prescribed manner i n the second stage of labor i n the delivery room. For example, here i s a case of a "natural c h i l d b i r t h " patient who found that nurses scheduled t h e i r p e l v i c examina-tions according to how long they believed she, a primagravida, would take to de l i v e r , as well as how much "emotion" or "pain" she displayed. Such scheduling permitted them to deal with t h e i r heavy work load by reducing the amount of time they had to spend with each patient. 238 At the hospi t a l , I had strong contractions f o r only about the l a s t hour. They were uncomfortable but not unbearable. From my reading about the Lamaze method I did t r y to r e l a x . I wasn't scared but I do remember f e e l i n g very lonely and wishing someone I knew could be with me. The nurses were very busy and did not think I was progressing as quickly as I was since t h i s was my f i r s t d e l i v e r y and I had not been there very long. I was also being quiet. After checking me, they rushed me to the delivery room. My con-tractio n s were stronger and closer together but I cer-t a i n l y wasn't i n a l o t of pain or about to lose my head, except I was rather frustrated about not being allowed to push. I remember f e e l i n g a l o t of pressure below and the strong urge to push everything out that was i n ! I was never so relieved when they f i n a l l y l e t me push and that wasn't u n t i l I was i n the delivery room and the doctor was at my feet ready to catch the baby.16 When the patient's doctor i s already i n the h o s p i t a l and assumes r e s p o n s i b i l i t y f o r monitoring the patient's labor, the nurses i n these cases use notions of the progress of "normal labor" to warrant reducing the number of times he must be "disturbed" while he i s elsewhere i n the hospital sleeping or t r e a t i n g other patients. For example, i n t h i s case the "natural c h i l d b i r t h patient" i s a nurse by occupation and uses her knowledge of ho s p i t a l p o l i c y concerning those treatments which require the presence or approval of her doctor to undermine the nurse's attempt to teach her the organiza-t i o n a l view of the "normal labor" progress which would l e g i t i -mately warrant "disturbing" the doctor. "Wake up the doctor," I said b r i g h t l y . "I think I'm ready to d e l i v e r ! " Thr nurses were sweet. "Oh, no, dear, he was just here and you were only 8 cm. d i l a t e d , we r e a l l y can't disturb him f o r another check so soon." " A l l r i g h t , " I said, remembering the doctor had to approve my medica-t i o n , "I'd l i k e to be sedated." So the doctor came and was equally doubtful, but I was f e e l i n g more and more l i k e pushing and could hardly stop. We rushed to the delivery room. When we got there, the panting f o r pushing was perfect and I had two pushes. At that point the doctor said, "Please stop pushing u n t i l I get my gloves on. I want some part i n t h i s . " F i n a l l y , one push and Jessica's head came out. Two hard pushes f o r the shoulders.17 Here the doctor t r i e s to persuade the patient not to push by reminding her of his entitlements as a doctor to take part i n the expulsion of the baby ("I want some part i n t h i s . " ) In other words, she i s not to regard the delivery simply i n terms of expelling of the baby. Instead, i t i s c a l l e d to her attention that she should d e l i v e r him i n the medically prescribed manner by observing aesepsis (". . . u n t i l I get my gloves on.") and the entitlements of the medical s t a f f surrounding her, i n t h i s case those of the category "doctor." Again, t h i s shows how the interpersonal management techniques employed by a s t a f f member may serve to prolong "length of labor," just as does use of anesthesia and other means of "physical" intervention. At City, I observed s i m i l a r attempts to persuade the patient to stop pushing on the grounds of allowing time f o r aesepsis or other medically prescribed preparatory a c t i v i t i e s , such as performing an epesiotomy. In f a c t , these warrants often were dramatically presented to f r i g h t e n the patient into cooperation. For example, i n ^he following case the patient has begun expelling the baby when the doctor a r r i v e s . The nurses have already had her get on the delivery table and instructed her to "hold" the baby from being delivered. Dr. "Don't push! Just pant!" Patient: "But I can't help i t ! " 240 Dr.: "Don't push, whatever you do! We want to be ready and not have the baby i n bed! You're going to be washed. It's going to be cold. L i f t your bottom up dear." Nurse: "You've just been baptized. Ha! Ha!" Dr.: "Don't push! Don't push! Just pant! Just pant! Thata g i r l ! You're going to f e e l a needle prick now." (He i n j e c t s the l o c a l anesthesia f o r the epesiotomy; but the baby s t a r t s to come out before he can begin cutting.) Although the patient i s already i n the delivery room and on the delivery table, the doctor t r i e s to dramatically equate the absence of his preparatory a c t i v i t i e s with "having the baby i n bed," which i f i t were true, presumably a lay patient would f i n d i t unaesthetic or dangerous and therefore adequate grounds to "hold" the baby. Another common management technique, which was demon-strated to some extent i n the l a s t case, i s "pressing" the patient with repeated instructions to "pant" or "breathe" instead of pushing and i n s i s t i n g the patient can do i t , not accepting any protests of being unable to r e s i s t the urge to push. A "natural c h i l d b i r t h " patient r e l a t e s an example of t h i s method and implies that "natural c h i l d b i r t h " t r a i n i n g would already give the patient the s k i l l s to breathe, pant, and not push which would enable her to avoid being "pressed" and cajoled to learn to use t h i s technique during labor i t s e l f . We (she and her husband) could hear a lady y e l l i n g and crying from down the h a l l . Two nurses were t e l l i n g her to breathe deeply, to keep from pushing before the doctor a r r i v e d . The lady kept saying she couldn't and the nurse kept i n s i s t i n g she could. I was glad not to be i n the same s i t u a t i o n . I knew I was able to do something to help myself.19 241 Indeed, from my examination of natural c h i l d b i r t h reports and observations at City, I suggest that the "trained" patient usually received d i f f e r e n t i a l treatment i n terms of being managed to "hold" the baby. They le s s often were t y p i f i e d as having " l o s t composure" or protesting incapacity to not push. Thus, "untrained" patients, the majority, were more frequently treated with t h i s technique of "pressing" and c a j o l i n g . I f the doctor takes too long to a r r i v e , these i n t e r -personal management techniques or the patient's own past t r a i n -ing may be inadequate to s u f f i c i e n t l y prolong labor. Fre-quently at t h i s time, nurses and the anesthetist t r y to i n t e r -cede "p h y s i c a l l y " by administering a l o c a l anesthesia, or an add i t i o n a l dose of i t , to slow down contractions even fu r t h e r . In the following case a "natural c h i l d b i r t h " patient r e l a t e s how her progress i n labor was miscalculated by nurses using "normal labor" standards i n order to avoid c a l l i n g the doctor "needlessly." As a r e s u l t , she has to be rushed to the delivery room. There she follows t h e i r i n structions to "hold" the baby and gains them ten minutes. However, apparently they have to administer several doses of l o c a l anesthesia (epidural) i n order to avoid having to d e l i v e r the baby themselves. Contractions were two minutes apart and lasted 75 to 90 seconds. I used accelerated panting at t h i s time. The nurse gave a r e c t a l exam and said I was 2 cm. I was scared. I f e l t i f contractions got any stronger I wouldn't be able to control them. I asked to see my doctor. The nurse didn't want to c a l l him u n t i l I was at l e a s t 3 cm. Well, I got t h i s sharp pain around the bladder so I decided since I was only 2 cm. I'd better head f o r the bathroom before t r a n s i t i o n . I had one hard contraction on the way, two i n the bathroom, and two on the way back 242 to bed. They were 90 seconds long and 2 minutes apart. My water hadn't broken yet. Then a l i t t l e old nurse came i n and said, "Stop that breathing or y o u ' l l hyperventilate!" Boy, I wasn't going to stop f o r anybody. I asked her to get my doctor but she wanted to check me f i r s t . This was about 7 minutes a f t e r the l a s t check. Just then OGGGG, the big push came and a l l the nurses ran i n . I remember saying "What's the matter with me, I'm only 2 cm. and these contractions are OUT OF SIGHT!" They rushed me to delivery while I was t r y i n g to wave good-bye to Ron (the husband). I was so happy because i t was so easy. The doctor hadn't arrived so I was t o l d to l i e on my s i d e — knees together and to pant and hold the baby. I did my best f o r 10 minutes but his head was coming out and the nurses were panicky. I t o l d them to do what they f e l t was best. Well, I got an epidural again. That stopped contractions u n t i l the doctor a r r i v e d . I delivered Gregg with two easy pushes while watching him being born. Dr. Gallivan was very nice. He had delivered many natural b i r t h s i n Europe but f e l t that medication was best at the end of the second stage. The nurses thought I did b e a u t i f u l l y . I f only they could have diagnosed my d i l a -t i o n c o r r e c t l y and i f the doctor had been there I could have delivered Gregg i n two pushes with no epidural at a l l ! Looking back . . . I w i l l always believe what I f e e l and not what I'm told.20 This "natural c h i l d b i r t h " patient locates the cause f o r her " f a i l u r e " to d e l i v e r quickly and without anesthesia i n the "inc o r r e c t " diagnosis of her labor which lead the nurses to delay "bothering" her doctor. This experience r e s u l t s i n her resolve to ignore nurses' diagnoses i n future d e l i v e r i e s (". . . always believe what I f e e l . . . " ) . Again, t h i s demon-strates how these patients from t h e i r past experiences i n h o s p i t a l context or from exposure to "natural c h i l d b i r t h " lectures and l i t e r a t u r e may begin t r e a t i n g t h e i r progress i n labor and i t s warrantability as grounds to summon t h e i r doctor as a c r o s s - c u l t u r a l issue. This approach may r e s u l t i n e x p l i c -i t l y c o n f l i c t i n g with s t a f f on t h i s issue or developing devices to undermine t h e i r control, e.. g., by asking f o r treatments 243 that require the approval of t h e i r doctor. F i n a l l y , a private o b s t e t r i c i a n r e l a t e s his concern to maintain a "normal work day" with the consequence that, as he puts i t , the patient "should not expect the doctor to be i n constant attendance from the onset of labor." Also, he describes the function of the nurses to monitor labor by orienting to "normal labor" c h a r a c t e r i s t i c s (after a l l , they "have seen a l o t of women i n labor") to permit him t h i s freedom to manage the rest of his work load and/or his "personal l i f e . " However, here he condemns the practice which I found common at City and i n the "natural c h i l d b i r t h " reports of "holding" the baby back on grounds of the possible adverse effects t h i s practice may have on the baby i n the " b i r t h canal." F i n a l l y , he shows how the s t a f f may collaborate with the doctor to ensure that he w i l l give a v i s i b l y competent performance f o r the waiting r e l a t i v e and patient i f t h i s monitoring and "holding" process f a i l s to provide f o r his timely a r r i v a l f o r the d e l i v e r y . I t ' s not unusual f o r women to fear t h e i r doctor w i l l miss the d e l i v e r y . Of course, no patient should expect the doctor to be i n constant attendance from the onset of labor. He may be i n the operating room, or with other patients, or sleeping. And the nurse who has seen a l o t of women i n labor doesn't want to wake a doctor at two o'clock i n the morning f o r a patient who's not going to d e l i v e r u n t i l three the next afternoon. But occasionally they make mistakes. I've had a resident or nurse phone me and say, "Your patient, Mrs. So-and-so, just came i n and she looks l i k e she's got about four hours to go." So I r o l l over and go back to sleep, or continue seeing patients, and suddenly I ' l l get a f r a n t i c c a l l : "Your patient's ready f o r d e l i v e r y . " I ' l l say, "I'm on my way, but i f I'm l a t e , don't you hold the baby back." 244 This i s actually done i n some places. The lady's about to d e l i v e r and the doctor's not there, so that baby i s l i t e r a l l y held b a c k—or the nurses w i l l cross the lady's legs. The baby i s i n there t r y i n g to be born. I t may take two or three breaths i n the vagina, where there i s n ' t any oxygen, and may suff e r brain damage. I t ' s inexcusable to delay d e l i v e r y . There's always somebody at the h o s p i t a l who can take over. We don't miss many d e l i v e r i e s , but anybody who's i n obstetrics misses an occasional one. I've never faked i t , but there are some doctors who do. When the patient i s ready f o r delivery and her doctor i s n ' t there, she's given some anesthesia that puts her out and she i s delivered by a d i f f e r e n t o b s t e t r i c i a n . Then her own doctor comes roaring i n with his white coat on, takes some blood—there's always plenty of blood around, with the placenta and episiotomy—and he smears i t over him and acts as i f he's just f i n i s h e d the d e l i v e r y . He walks out to greet the father and says, "It's a boy." I've seen i t done.21 Medical students and young doctors also use t h i s device of a l t e r i n g t h e i r appearance to convey to colleagues and superiors t h e i r recently gained experience and competence. After an operation or de l i v e r y , f o r example, they often wore t h e i r blood stained s u r g i c a l gowns to the hospital c a f e t e r i a , whereas older, more experienced doctors changed into t h e i r business s u i t s or white h o s p i t a l pants and jacket immediately a f t e r a d e l i v e r y . Another way that interpersonal management techniques serve as a resource to control "length of labor" i s i n t h e i r use to "pressure" the patient to follow medically prescribed methods of pushing with each and every contraction or "pain." For example, the following case observed i n the delivery room at City shows how s t a f f may increase t h i s "pressure" i n order to t r y to shorten labor time so that they meet the demands of t h e i r work schedule. 245 Nurse to Intern: "We'll have to teach her how to push." (The patient groans a l o t . ) "Go to the bathroom! Get r i g h t down and push!" (Patient screams and complains about the pain.) Dr. to Patient: (as he taps her on the chin with his f i s t ) "No noise now! No noise now? Just push!" (The anesthetist puts the mask over her mouth when she t r i e s to y e l l again.) Nurse: "Breathe and push to get maximum diaphragm pressure." Dr. "Are you ready to push?" (patient y e l l s and complains about the pain.) Nurse to Dr. "She's not r e a l l y pushing." Dr. to Nurse: "I can't see the baby." (He i s doing a pe l v i c examination.) Nurse: "She's not pushing." (The doctor and the rest of the "delivery team" leave the delivery room f o r a coffee break.) (After ten minutes two nurses return. One stands at the end of the delivery table and, l i k e a cheer leader, y e l l s at the patient.) Nurse: "Hold you breath and push! Hold your breath and push! Much better! Push! Push! Very good!" (She addresses the other nurses) "This i s her second baby, so labor (the push stage) shouldn't l a s t more than one-half hour and often only ten to t h i r t e e n minutes. I do believe she's started to d e l i v e r . Push! Push! One more. That was very good! Ok. Now r e s t . " (Nurse l i s t e n s f o r the f e t a l heart beat and quietly t e l l s the other nurse o f f to the side of the table) " I t ' s not r e a l l y strong. It' s t i g h t " (the b i r t h canal), (patient loudly groans again) "No noise! A long, long push." (the doctor reenters the delivery room.) Dr.: " I f she's not pushing, put her i n bed." Nurse: "She's pushing, but the baby i s not getting lower" (says t h i s q u i e t l y ) . Dr. "I am needed over at Metropolitan Hospital . . . " Nurse: "I wouldn't do that." Dr.: "How often i s the pain?" (contraction) Nurse:, "Every three minutes." (Patient loudly groans.) 246 Dr.: (roars at the patient) "Keep your mouth closed and push a l i t t l e harder!" (The nurse smiles and seems amused at t h i s sudden i n t e r e s t on the part of the doctor to "pressure" the patient to push even harder.) (He addresses the nurse) "Yeah, i t shouldn't be too long. That's my g i r l ! I t won't be long now! It won't be long now!" (Patient continues to y e l l and exclaim at the pain.) "Ow! Yeow!" Anesthetist to Dr.: "Do you want any anesthesia?" Dr.: "Not just yet." (The nurse puts her hand over the patient's mouth when she screams.) "Ok! Ok!" Anesthetist: "You did very w e l l ! " (The baby c r i e s when i t i s expelled.) (In a hurry to leave, the doctor pats i t s bottom perf u n c t o r i l y , cuts the umbilical cord, and hands the baby to the nurse.) "It's a l l yours." Nurse to Dr.: "They l e f t her alone f o r a few minutes and then she pushed. I guess she was scared." The doctor refuses to give any more anesthesia, although the patient complains loudly about pain, presumably because i t may prolong labor and he i s i n a hurry to leave. The doctor also t r i e s to step up the patient's e f f o r t s by roaring i n s t r u c -tions at her. He seems concerned to meet his work commitment at Metropolitan and w i l l put the patient back i n the labor room i f d e l i v e r y does not seem imminent. S t a f f had taken the lack of progress early i n the pushing stage as an opportunity to take a coffee break, leaving the patient alone i n the delivery room. At the conclusion, the nurse suggests that t h i s may have inadvertantly served to reduce labor time because the patient may have found t h e i r vigorous "teaching" f r i g h t e n i n g . Thus, the scheduling of t h i s "pressure," as well as deliberate attempts to i n t e n s i f y i t may a f f e c t the "length of labor" besides any supposed expectations (according to Rosengren) a 247 patient may bring to the h o s p i t a l with regard to playing the "sick r o l e " i n labor. Generally, with regard to management techniques, I found two somewhat d i f f e r e n t approaches. The senior consult-ing obstetricians who also taught at the h o s p i t a l , as well as some of the younger, more highly trained nurses, followed a d i f f e r e n t approach to "teaching" patients to push than did the r e s t of the doctors, most of whom were general p r a c t i t i o n e r s and some s t a f f residents. The above example of "pressuring" the patient i n order to shorten labor time was t y p i c a l of the approach used by most of the doctors. In the following remarks to me, Dr. B a r t l e t t contrasts his approach with that one. The delivery room i s too a n t i s e p t i c . There's no T.V., flowers, or radio. Nothing to d i s t r a c t the patient. The average patient i s not prepared or trained f o r de l i v e r y , so they get confused, disoriented and d i s -organized when she's being shouted at by s i x d i f f e r e n t people, giving d i f f e r e n t i n s t r u c t i o n s . Masks scare them (for anesthesia). They d i s t r u s t i t . I t disorganizes and confuses them. When I d e l i v e r , I make everyone shut up and I do a l l the t a l k i n g so the patient has someone to focus on. Also, i t ' s sometimes better i f everyone leaves the room rather than pressuring the patient to d e l i v e r . Some nurses are nicer than others. The older ones, esp e c i a l l y , are callous and order the patient to push the baby out. They are the cheer leader type. They think they are important and they are d e l i v e r i n g the baby and don't l i k e to leave the d e l i v e r y room. Some of the younger, more educated ones are more quiet and come and go rather f r e e l y since they know i t ' s the woman who's d e l i v e r i n g the baby. Most of the nurses are not trained i n aiding contractions. There's just a poor organization i n the d e l i v e r y room. A l o t of student nurses, a l o t of people running i n and out and around the t a b l e . Everyone t r i e s to get i n some words to the patient. I have never been able to understand why the d e l i v e r y room i s organized t h i s way with t o t a l chaos. An in t e r n described to me t h i s approach i n s i m i l a r terms. 248 Dr. B a r t l e t t and some of the others believe the mother has the baby and does most of the work. But here most of the doctors follow a d i f f e r e n t technique f o r the labor. Some w i l l leave the room occasionally, but most w i l l stay and keep encouraging the mother to d e l i v e r . I might add that most doctors usually leave only to meet the demands of t h e i r work schedule or f o r l e i s u r e , (§.. g., a coffee break) rather than as a deliberate technique to speed up delivery by l e t t i n g up on the "pressure" put on the patient to d e l i v e r . Thus, the "length of labor" that a patient experi-ences may depend on her doctor's approach to patient management and work schedule as much as any conceptions she might have about acting "as i f s i c k " i n labor, as Rosengren assumes. Thus f a r I have attempted to show how the organization of s t a f f ' s occupational routine, e s p e c i a l l y t h e i r management techniques, can strongly influence the events i n labor Rosengren c a l l s " d i f f i c u l t i e s . " I have engaged i n t h i s discussion to demonstrate that an adequate analysis of such "medical" or "p h y s i o l o g i c a l " events requires an ethnographic approach whereby the routine organizational procedures that constitute them are examined, as opposed to a s t r u c t u r a l survey approach which ignores t h e i r c o n s t i t u t i v e properties. Now I would l i k e to turn to a more det a i l e d d e s c r i p t i o n of management methods used by s t a f f i n the d e l i v e r y room. As I have just described above, I found two rather d i f f e r e n t management approaches i n the d e l i v e r y area. The approach used by B a r t l e t t and some other teaching obstetricians s t a r t s with the same assumption about the t y p i c a l or normal patient i n labor as did the more prevalent approach: she lacks the t r a i n i n g and proper "frame of mind" to be self-guiding i n e f f e c t i v e l y pushing. Most of the s t a f f , including the private general p r a c t i t i o n e r s , p e r s i s t e n t l y "pressured" the patient to d e l i v e r from her a r r i v a l i n the d e l i v e r y room u n t i l the baby was expelled. As B a r t l e t t indicated, they often used such methods as c a j o l i n g , name-calling, scaring, sanctioning, and i s s u i n g authoritative commands to d e l i v e r . On the other hand, B a r t l e t t and others usually refrained from what he c a l l s " c a l l ous" and "authoritative treatment" and allowed the patient more time to push unassisted. I take i t that t h i s approach follows from B a r t l e t t ' s and other teaching and consulting o b s t e t r i c i a n s ' f a m i l i a r i t y with the professional l i t e r a t u r e advocating the implementation of i d e o l o g i c a l "patient as person" ideals and psychotherapeutic p r i n c i p l e s i n labor "coaching." Indeed, they did seem more concerned to observe the patient's lay s e n s i t i v i t i e s by not shouting at the patient and t r y i n g to be l e s s "authoritative" and "callous." This approach seemed based on the i d e o l o g i c a l i d e a l model of the patient as an active participant (". . . she's having the baby."). On the other hand, most of the doctors tended to t r e a t the patient as a passive c h i l d requiring strong authori-t a t i v e guidance and constant, rigorous "pressure" ("cheer leading") to d e l i v e r expeditiously and s a f e l y . This approach probably r e f l e c t s p r a c t i c a l work concerns v i s - a - v i s scheduling and v i s i b l e competence to a greater extent than does that of 250 the o b s t e t r i c i a n s . I t i s more "job located" or "setting s p e c i f i c " than based on any professional medical or academic i d e o l o g i c a l p o s i t i o n . Coerced Cooperation To describe the "pressure" techniques of the more prevalent approach I would l i k e to provide several examples of each of the methods mentioned above: commanding, ca j o l i n g , name-calling, sanctioning, and frightening or scaring the patient. Commanding simply entailed one or more of the s t a f f a u t h o r i t a t i v e l y and loudly ordering the patient to d e l i v e r the baby with her next pushing e f f o r t s . Dr.: "Ok, Dorothy. Let's have t h i s baby!" (To Nurse) "Ok. l i f t her up." Nurse: "That's the one (push) that did i t , eh?" Dr.: "No. Maybe next time." Patient: "But I can't breathe!" Dr.: "That's ok. I got i t . " (The baby i s f i n a l l y pushed out.) Nurse: "Push!" Patient: "I'm pushing!" Nurse: "Push! Push that baby r i g h t out! Much longer!" Patient: "I can't do i t again." Cajoling i s another commonly used method when the patient i s viewed as being "negligent" i n helping to push the baby out. Nurse: "Come on, you! Push! Push i t out!" 251 Dr. ( s a r c a s t i c a l l y ) : "You can be a help by pushing a b i t ! " Nurse: "She's not r e a l l y pushing." Dr.: "I can't see the baby. Are you ready to push yet?" Name-calling may be resorted to when the patient does not respond " s u f f i c i e n t l y " to the s t a f f ' s commands to push. Dr.: "Bear down, please. Push! Push that baby out! You're a lazy thing!" Also, the patient may be slapped, severely reproved or sanctioned f o r "lagging" i n her e f f o r t s to push as s t a f f i n s t r u c t , although t h i s may be due to the effects of drugs the s t a f f have given. Dr. ( s a r c a s t i c a l l y ) to Nurse: "She gets a nice relaxation from the epidural." Nurse: "Keep i t up! There's s t i l l a contraction!" (slaps the patient) "You're f a s t asleep! I t ' s (the baby) going to come t h i s time. Nurse (to a "lagging" patient): "Don't you dare stop pushing or else y o u ' l l get spanked." A "natural c h i l d b i r t h " patient reports how she was reproved f o r apparently "losing c o n t r o l " and refusing to cooperate i n pushing as instructed. She attr i b u t e s her "uncooperative" behavior to her disapproval of t h i s hospital's routine of excluding her husband from the delivery room, who most "trained" patients are taught to depend on f o r e f f e c t i v e labor coaching rather than s t a f f , who usually aren't trained or concerned to do so, e s p e c i a l l y i n the early stages of labor. This was also the case at C i t y . 252 . . . things moved quickly—and nearly l e f t me behind. I was expecting to l i e i n the labor ward next to the de l i v e r y room f o r a couple of hours, breathing away. The nurse said: "Let me know when you f e e l the baby i s pushing down i n the back passage," and the next thing I knew, he was. So up I got and walked into the delivery room and clambered onto the t a b l e . I asked f o r my f i r s t shot of pethidine at t h i s stage—about 3 :00 p.m.—as the pains i n my back—were getting a b i t excruciating, though not unbearable. With the second shot, about 15 minutes l a t e r , which I didn't ask f o r , I went o f f into a kind of drunken stupor, which I regret. However, I was able to arouse myself when necessary and interrupted the nurses' conversation with a peremptory: "Here comes another one" or "Hold my foot please," or "Can someone hold my head up?" I f James (her husband) had been there, he could have done these things f o r me, and would also have encouraged me to be more awake, I think. As i t was, the drug seemed to release rather h o s t i l e f e e l i n g s towards the doctor and nurse f o r not allowing him to be there, and I even took a perverse delight i n not pushing when they were t e l l i n g me to . I had negative rather than p o s i t i v e f e e l i n g s , which probably slowed the labor down. I c e r t a i n l y wasn't at a l l i n h i b i t e d emotionally i n the d e l i v e r y room and c a l l e d variously on God, James (several times), and the baby—to get a move on. " I t ' s no use you t e l l i n g the baby to get a move on," the nurse reproved me. I t ' s you who should be getting a move on—come on, push!" "I am pushing," I roared, so loudly they must have heard me at home.22 F i n a l l y , an apparently common method used to get the patient's cooperation with s t a f f ' s i n structions was that of scaring or fr i g h t e n i n g the patient with the p o s s i b i l i t y of a lengthy, exhausting labor or "complications" which threaten the baby's welfare. For example, a "natural c h i l d b i r t h " patient reports how she was repeatedly reminded every time she didn't push with a contraction that she was lengthening her labor. She reports that her lack of cooperation, however, was due to the drug (a pain k i l l e r ) which was "forced" on her. By t h i s time the Demerol had taken ef f e c t and I was dopey. I f e l t i n e f f e c t i v e i n my pushing and the nurse said I was doing i t wrong and that i t should be " l i k e a bowel movement." 253 I stayed on my bed quite a while before they had me move to the d e l i v e r y t a b l e . I remember having a very, very dry mouth and f i n d i n g i t d i f f i c u l t to understand what they were saying to me. Following directions was p a r t i c u l a r l y hard, e s p e c i a l l y t r y i n g to push l i k e they wanted me t o . I also found i t d i f f i c u l t to push through the contractions and would stop and pant. The nurse kept t e l l i n g me that every contraction that I didn't work with would make i t that much longer.23 S i m i l a r l y , a doctor graphically reminds a "natural c h i l d b i r t h patient of the p o s s i b i l i t y of having to do a forceps delivery ( r i s k i n g damage to the baby) a f t e r she had been given a l o c a l anesthesia unless she pushes e f f e c t i v e l y and a great deal. Again, a f t e r persuading the "natural c h i l d b i r t h " patient to accept a l o c a l anesthesia on the grounds of her baby's welfare, she i s s t i l l held accountable f o r a rigorous and e f f e c t i v e push-ing e f f o r t . . . . I just wanted to sleep. B i l l (her husband) said every time I would push he could see the baby move down and then come back up when I stopped pushing. The nurses were very supportive and commented on how relaxed I was when not pushing. I was laughing inside, thinking, "Oh heck l a d i e s , i f you were as t i r e d as I, you'd be very relaxed too!" I f I could have spared the energy, I would have t o l d them. The doctor said that i t would be better f o r the baby i f I had a saddleblock, since her head had pushed against my rectum f o r so long. So at 2:50 I had one and at 2:56 Kimberly was born, without instruments or nurses' pushing (on her abdomen). The doctor had said, "Remember, the more you push, the less I ' l l have to p u l l . " With those words, I pushed with more energy than I'd used i n nine hours of labor.24 F i n a l l y , a patient at City i s informed i n graphic, t e c h n i c a l d e t a i l of her baby's "condition" i n her uterus, r e f e r r i n g to i t s "low heart beat" and "pressure on i t s head," to appeal to her assumed concern f o r the baby's welfare. (The patient i s draped and given a l o c a l anesthesia.) 254 Nurse: "Can you f e e l any more contractions?" Patient: "Yes." Dr.: "How long has the block ( l o c a l anesthesia) been i n ? " Nurse: "20 minutes." Dr.: (to patient) "If you could l i s t e n to the f e t a l heart beat, you would f i n d i t ' s low a f t e r you've ruptured your membranes because there's pressure on the baby's head. So, with the next couple of contractions please push to bring i t s head down! Push as hard as you want. The anesthesia has taken hold." E a r l i e r I described how most of the s t a f f are concerned to use anesthesia and interpersonal management techniques to quiet "noisy" and "complaining" patients. Generally, I found that they used the same management methods to teach her to be a "good patient" while experiencing the "stress" of labor so as to "pressure" her to be a "good pusher": commands, sanctioning (verbal and physical), c a j o l i n g , chastising, and invoking the welfare of the unborn baby. Most frequently, when a patient i s perceived as having " l o s t c o n t r o l , " she i s commanded to stop making what the s t a f f p e j o r a t i v e l y c a l l "noise" or "to get control of h e r s e l f . " Dr.: "Now i t ' s (the contraction) coming. Push hard! Again! Again! Again!" Patient: "Help me! (starts crying) Please help me! I'm too t i r e d ! I don't think I can push any more!" Dr. and Nurses (loudly): (when she s t a r t s to cry)"Sh! Sh! Sh!" Patient: (groans loudly) "Help! Help!" Nurse: "No noise! A long, long push! That's the way! Push! Push! That's the way, r i g h t down!" 255 Dr.: "Don't push yet, Mrs. , please! Y o u ' l l f e e l a l i t t l e p r i c k . " ( l o c a l anesthesia f o r the episiotomy) Patient: "Ow! Ow! Dr. Please help me!" Dr.: "Do you want to push now? Give a push!" Patient: "Give me some . . . Ow! Ow!" Dr.: " A l l r i g h t ! Come on! Let's have i t a l l under co n t r o l ! " Patient: "Ow! Ow!" Dr.: "Now, Mrs. . Come on!" Patient: " I t f e e l s l i k e i t ' s r i p p i n g ! " Dr.: "It's not! Put your bottom on the table! Give one bi g push and put your bottom on the tabl e ! Come on! Come on! Mrs. push! Push t h i s baby out!" I f a patient p e r s i s t s i n making "noise," then s t a f f may p h y s i c a l l y sanction or t r y to s t i f l e her. Dr. (as he taps her on the chin with his f i s t ) : "No noise now! Just push! No noise now! Just push!" Patient: (screams) "Help!" Nurse: (puts her hand over her mouth) Dr.: "Ok! Ok!" Anesthetist: "You did very w e l l ! " Another commonly used device involves c a j o l i n g the patient to "control" h e r s e l f by pleading with her to do so. Patient: "Yeow! Ow! Ow!" Dr.: "Lois! Give a poor Jewish boy a chance!" Patient: "Yeow!" Dr.: "How about a Catholic boy?" 256 Here the doctor and patient are members of the same ethnic category, "Jewish." He uses t h i s as a resource to plead f o r her cooperation on the grounds of ethnic l o y a l t y . When the patient p e r s i s t s , out of exasperation, he s h i f t s ethnic cate-gory (Catholic) to make a facetious plea. In another case, the doctor's plea i s based on the patient's presumed desire to please her personal physician, who i s on vacation. Apparently, the doctor sees that categori-c a l r e l a t i o n s h i p (personal physician-patient) as having more moral force than the current, temporary r e l a t i o n s h i p i n terms of persuading the patient to control her expressions of pain and other complaints. Patient: "Ow! Oh, my legs f e e l so funny! Yeow!" Intern: "That's the p e r i d u r a l . " (a l o c a l anesthesia) Dr.: " I f you can r e a l l y , r e a l l y bear with me a while, Dr. Conrad (her personal physician) w i l l be happy." Another technique involves chastising a "bad patient" and teaching or convincing them that there i s no acceptable warrant i n t h e i r physical condition f o r t h e i r "noise." Also, s t a f f may promise that the labor w i l l be over soon i n order to placate the patient. (Doctor puts his hand on her abdomen to f e e l f o r the next contraction. The patient apparently complains about a labor pain and he treats i t as a reaction to his hand and therefore grounds to claim i t i s unwarranted.) Patient: "Oh! Oh!" Dr.: "What do you mean Oh! That's my hand!" 257 Patient: "Ow! Ugh!" Nurse: "Contractions gone now, Mrs. ." Patient: (screams) "Yeow!" Dr.: "You're ok! I t ' l l be over soon!" Patient: " I t hurts too much!" Dr.: "Just breathe, normally, slowly." Patient: "It hurts too much on the top!" Anesthetist: "Just breathe and push hard! Keep pushing!" Dr.: "Now i t ' s (the baby) coming! Keep pushing!" Patient: "Oh! Oh!" Nurse: "It's a l l going to be over with i n a very short time." In a case where a patient continues "complaining," even a f t e r the de l i v e r y , while the placenta i s being expelled the doctor t r i e s to convince her that she should "control" herself by normalizing the sensations she i s experiencing; implying, thereby, they do not constitute adequate warrant f o r a "loud emotional diaplay." Also, i n t h i s case the doctor t e l l s the patient that she i s " a l l through," though she has yet to be instructed to push out the placenta (the t h i r d stage of l a b o r ) . Patient: "The pressure i s building i n my rectum!" Dr.: "It's contractions." Patient: "Please, where i s the other doctor?" (the anesthetist) Dr.: "You're a l l through now! Push!" Patient: "I can't any more!" Dr.: "That's the a f t e r b i r t h and you're a l l through!" 258 Patient: "Oh, i t ' s such hard work. It's coming again!" No more! No! A l o t of pressure against my rectum!" Dr.: "You're going to have them a f t e r contractions, every-body does. You're ok! You're hard to convince!" With "natural c h i l d b i r t h " patients, I have found i n examining t h e i r reports that s t a f f chastised t h e i r complaints or "noise," using as a management resource the patient's own r e f u s a l to accept the anesthesia, which the doctor usually t r i e s to convince them to accept. These cases also i l l u s t r a t e how some s t a f f i n some hospitals (not City) regard the use of anesthesia as a c r o s s - c u l t u r a l issue wherein they t r y to per-suade the "natural c h i l d b i r t h " patient to accept the anesthesia which they assume the "normal labor" patient "needs" and should have to prevent "emotional displays" and "non-cooperation." Thus, when the patient "complains" about labor pain or p a i n f u l treatment, these doctors are quick to point out i t i s i n f a c t the patient's r e s p o n s i b i l i t y , since she refused anesthesia. They seem to use the f a c t of the expression of pain as an "object lesson" on the a d v i s a b i l i t y of using anesthesia, as well as chastising her to control her complaints. The doctor gave me a l o c a l anesthetic p r i o r to s t i t c h i n g me up. In spite of i t , I s t i l l f e l t a number of the s t i t c h e s , and I t o l d him so. " I f you'd had a s p i n a l you wouldn't nave t h i s problem," he informed me. "But then the baby wouldn't have c r i e d on the way out," I protested. "That wouldn't have made any difference i n her crying," he s a i d . So I t r i e d a d i f f e r e n t approach. "Then I couldn't l i e on my stomach right away." He had to agree with that one, although he obviously thought i t was a minor consideration. Although we didn't discuss i t , there i s another reason I am glad I didn't have a s p i n a l — s e v e r a l of my friends have had very severe headaches i n the days following delivery, head-aches caused by the f l u i d injected into the spine. I had no anesthetic and f e l t fine.26 259 I wasn't allowed to nurse Brian on the delivery table, but we watched the nurse take care of him while I was being stit c h e d (for the episiotomy). I t seemed l i k e that took forever. My legs were trembling with fatigue and were most comfortable i n the s t i r r u p s . I kept saying "ouch" to Dr. G. about his needlework u n t i l he gave me some more novacain, and he teasingly made some remark to Carl about how i f we knock the ladies out, we don't have to l i s t e n to a l l t h i s complaining!27 F i n a l l y , the patient may be taught that she must accept or "put up" with the pain because i t i s i n some unspecified way e f f i c a c i o u s i n the progress of labor. Here, apparently s t a f f i s drawing on the assumed concern the patient has f o r the wel-fare of the baby to persuade her to be s i l e n t and accept the labor pains. Patient: " I t hurts! Ow! leow!" Resident: "You have to put up with i t . This i s labor. I f you don't have pain, the baby won't come down." To support my descriptions of the more commonly used management techniques to control emotional expressions, I would l i k e to c i t e the report of a husband of a "natural c h i l d b i r t h " patient. He suggests how women may be at l e a s t p a r t l y moti-vated to become "prepared patients," v i a natural c h i l d b i r t h t r a i n i n g , so as to gain "control" over t h e i r emotional expressions i n labor and thereby avoid provoking a ho s p i t a l s t a f f to use the sort of strong interpersonal management tech-niques I have described. . . . As i t turned out, we became quite enthused with the method, and we followed through with i t e n t i r e l y i n the b i r t h process. Upon r e f l e c t i o n afterward, we discovered one equally important, perhaps more important, reason f o r 2 6 0 which we would do i t over again and commend the method to others. That means i n t h i s method there i s a b u i l t - i n human f a c t o r . The wife i s i n control of her emotions, and— because husband and wife work to g e t h e r — t h e couple f i n d that they are treated as participants i n the b i r t h of t h e i r c h i l d . In every case our questions were answered. In every case, a f t e r the doctor's examination, he summoned me back to the labor room and t o l d me about her condition and what to expect. The nurse was very h e l p f u l . She kept us informed of progress, answered questions, and frequently gave words of encouragement. This was a f a r cry from what went on i n nearby labor rooms. There we heard shrieks from women who were "knocked out," and the response of ho s p i t a l personnel to them consisted of remarks such as, "Oh, hush! You're not so bad off."28 E a r l i e r , I discussed how B a r t l e t t and other senior obstetricians followed a d i f f e r e n t approach than most s t a f f members to dealing with "bad patient" reactions to labor. Rather than using anesthesia or the management techniques described above, they tended to permit patients to make these di s p l a y s . In following t h e i r approach, however, often they f e l t i t necessary to correct other members of the "delivery team" who t r y to "quiet" patients and even counter them by p o s i t i v e l y encouraging the patient to "express her emotions." For example, crying i n labor i s a frequently sanctioned behavior i n the delivery rooms. In the following cases, B a r t l e t t and another o b s t e t r i c i a n encourage patients to cry-to compensate f o r the sanctioning e f f o r t s of nurses and interns. In some cases, the "chastised" subordinates revise t h e i r t r e a t -ment, as a r e s u l t , and also encourage the patient to cry. Nurse: "Are you s t i l l crying? You're going to be a l l cr i e d out! Did you cry l i k e that with your f i r s t baby?" Dr.: "Good thing to have a cry! Want a kleenex?" Nurse: "You cry." 261 (Patient s t a r t s crying) Intern: "Do you f e e l ok?" Patient: "Yes, just having a l i t t l e cry." Intern: ( s a r c a s t i c a l l y ) "A l i t t l e comic r e l i e f then." B a r t l e t t : "Have a good cry! Give her a kleenex." Regardless of approach, when the delivery i s completed, the s t a f f usually praise the patient's performance, even though they may have found i t sanctionable. Apparently, t h i s i s done so as to "save face" f o r the patient and encourage her to take a p o s i t i v e outlook on her delivery experience. I found that s t a f f are morally concerned to have the patient e n t h u s i a s t i c a l l y accept and welcome the baby as hers. Thus, they t r y to persuade her to have a po s i t i v e outlook on her delivery behavior to get her i n the prescribed frame of mind to receive the baby. Besides simply praising her f o r being a "good patient" i n deliv e r y , even when they found she was not, the s t a f f are quick to correct any negative assessment proffered by the patient. Patient: "I was shouting so much, wasn't I?" Dr.: "No. Hear those other g i r l s shouting? That's what I c a l l shouting!" Here the doctor t r i e s to persuade her to view her performance p o s i t i v e l y by o f f e r i n g c r i t e r i a f o r "shouting" which he claims exclude the patient's performance from being so categorizable. This patient has been screaming and crying, too, but the doctor corrects or redefines the category she uses to characterize her performance. In the process, he establishes a contrast conception of "shouting" g i r l s which he claims warrants redefining 262 her behavior from the negative description she o f f e r s . This same "face saving" technique of establishing contrast concep-tions i n order to redefine the patients' behavior or condition was also observed i n the c l i n i c where s t a f f t r y to redeem the moral character of unwed Home g i r l s by f l a t t e r i n g l y contrasting them with other "less clean" g i r l s who come to the c l i n i c . In the management of pushing, B a r t l e t t and several senior obstetricians generally avoided these strong "pressure" methods described above. Instead, they r e l i e d more o i l repeated reports to the patient of how much progress she was making with her pushing e f f o r t s (even when she was not) and approving and p r a i s i n g remarks on how well she was performing her pushing job (again, even when they thought she was pushing " i n e f f e c t i v e l y " ) , The r e s t of the doctors also used these techniques, but i n t e r -spersed between the stronger "pressure" methods. These p r a i s i n g remarks were even used i n the labor rooms, apparently to guide the patient to have the prescribed optimistic outlook on her usually long, arduous task. "Natural c h i l d b i r t h " reports pro-vide some supporting data f o r the observations at C i t y . 11:45 a.m. After twelve hours of labor, my doctor's associate came i n to subject me to another grinding, twisting examination. "You are doing just b e a u t i f u l l y , " he sa i d . "How f a r am I d i l a t e d ? " "3 cm." "3 cm.," I s a i d . "My God, no progress at a l l — I was 3 cm. three damned hours ago!" He gave me some cheery t a l k about the head having worked i t s e l f i n the proper p o s i t i o n against the cervix; he said that labor would become more e f f e c t i v e very soon and that I would have to be taken up to the delivery room presently.2 9 263 Here the doctor t r i e s to revise the patient's c r i t e r i a of progress as simply being the amount of d i l a t a t i o n of the cervix. He t r i e s to point out the "engaged" p o s i t i o n of the baby's head as a s i g n i f i c a n t sign of progress to compensate f o r the obvious slowness of her labor and promises more s i g n i f i c a n t progress w i l l occur very soon. In another example, the doctor sanctions the patient as having no grounds f o r being, d i s -appointed at no progress because she should just be s a t i s f i e d with her "easy time" i n labor. Apparently, he i s concerned with teaching her the proper outlook on labor progress: One of constant cheerful optimism. The contractions were now intense, coming every minute and f i f t e e n seconds and were mostly f e l t i n the lower back. I was very sure that I was i n the t r a n s i t i o n phase and started the pant-and-blow breathing. I was u t t e r l y crushed when the examining resident said that I was s t i l l 6 cm. d i l a t e d and nowhere near t r a n s i t i o n . (I wish I had r e a l i z e d that two doctors can give e n t i r e l y d i f f e r e n t evaluations of one's progress. As my doctor explained l a t e r : "One man's 6 cm. i s another man's 8 cm.") At any rate, t h i s resident i n s i s t e d that I l i e f l a t on my back and proceeded to give me a lecture on being g r a t e f u l f o r having such an easy time. I suppose he had a point, but I didn't f e e l l i k e hearing i t just then!30 Another technique involved a t t r i b u t i n g the lack of progress to the yet unknown or non-existent non-pathological at t r i b u t e s of the baby i t s e l f , including i t s "character" or gender. Here, a "natural c h i l d b i r t h " patient shows how t h i s was used, i n conjunction with promises of increased s i g n i f i c a n t progress i n the near future. At 3 p.m. suddenly the contractions stopped. I slept seven minutes. I was having d i f f i c u l t y with sleeping through u n t i l peaks, but Gary (her husband) timed c a r e f u l l y and warned me. Awake at 4 p.m. Contractions have increased i n strength but not length nor have the i n t e r n -als (examinations) decreased. Dr. Grolber checked me at 4:45, said only 2 cm. s t i l l but as soon as I went to 3 things would speed up. He said there weren't any problems, merely a slow baby.31 I found t h i s to be a common practice i n the c l i n i c with patients who were "overdue" to d e l i v e r and concerned about some pathological cause. Resident: "How are things today?" Patient: "Ok." Resident: " S t a l l i n g a b i t , eh? You've gained 40 pounds? Is your baby active?" Patient: "yes." Resident: "You're sure of your dates (of conception)?" Patient: "Yes." Resident: "Where do you f e e l the baby kick? Up here?" Patient: "I don't know." Resident: "The baby gets l o s t . Ha! Ha! I ' l l check f o r i t . Everything i s f i n e . You're not over very much, just a couple of days. You may go into labor at any time, i f I don't see you next Friday to see how you are. I f i t ' s a g i r l , they're slow and they l i k e to make you wait." Here the resident attributes the "slowness" to the behavior of the fetus, as i f i t possessed adult sex-appropriate t r a i t s . However, i f an "overdue" patient returns several times, t h i s device may be ca l l e d into question because i t becomes a source °f faux pas i f the resident forgets or makes a mistake as to which sex he had used to "explain" the delay on the previous v i s i t of a p a r t i c u l a r patient. For example, t h i s occurred 265 with a patient who apparently had been t o l d that her delay was due to the gender-appropriate behavior of the fet u s . Resident: "You're not over very much. Two days. Less than f i v e percent d e l i v e r on the estimated date. You don't want to deviate. You ce r t a i n l y look ready. I t must be a boy . . . " Patient: (cuts h i s utterance short) "You said i t ' s a g i r l l a s t time. I t ' s slower, so i t ' s a g i r l . " Resident: "Hard head l i k e a boy. Head way down here. Lots of beds upstairs so any time you want to come i n we'll be happy to have you." The resident t r i e s to "repair" h is faux pas a f t e r the patient corrects him by implying that he was only t r y i n g to guess the baby's sex by i t s apparent physical attributes ("hard head") rather than t r y i n g to "explain" the delay i n d e l i v e r y . Note that i n addition to the sex of the fetus, he t r i e s to normal-ize her delay by po s i t i n g a statement of p r o b a b i l i t y whereby being "overdue" can be characterized as "normal," i f only on s t a t i s t i c a l grounds. In the del i v e r y room at City, the patient was diagnosed as making good progress i n her pushing, and praised f o r her performance even when neither was the case. Nurse: "Ok, dear. Push!" Patient: "I don't want to push." Nurse: "By one or two contractions you probably can." Dr.: "Ok. I t won't be long. You're doing f i n e ! " Nurse: "Push! Hang on! Good g i r l ! " Patient: "I'm getting t i r e d . " 266 Nurse: " I ' l l bet." Dr.: "You've been very good!" Besides general verbal assurances, s t a f f t r y to provide more concrete evidence that the pushing i s e f f e c t i v e by promis-ing or describing the movement of parts of the baby, usually the head. This usually occurred i n the l a t e r stages of pushing when the baby was i n the vagina. However, a natural c h i l d b i r t h patient reports a device whereby s t a f f t r i e d to give an observ-able i n d i c a t i o n of the movement of baby early i n the f i r s t phase, p r i o r to pushing. A very nice nurse, Mrs. C , prepped me, cranked up the bed, t o l d me she had been impressed with two of our other students who had been there a week ago. Best of a l l , she said i t was okay f o r Dan to come i n , since I was the only one i n the labor section. The intern who checked me said I was 4 cm. d i l a t i o n — v e r y encouraging news—nearly h a l f d i l a t e d and I f e l t great. Mrs. C. came i n p e r i o d i c a l l y to check on the baby's heartbeat. Each time she put an X on my tummy, which was very encouraging because each time i t moved down.32 Also a report i l l u s t r a t e s how a patient may be promised r e s u l t s very soon i n terms of observable movement, when i n fac t she has a good deal more time to go u n t i l d e l i v e r y . At about 1:40 the nurse t o l d me that i n just a few more pushes we would be able to see the baby's head. I was overjoyed with thoughts of a 2:00 d e l i v e r y . But the nurse went away and didn't even come back to check f o r a ha l f hour or so. By about 2:20 the head was s t a r t i n g to appear when I pushed.33 At C i t y , s t a f f would continually and cl o s e l y examine the " b i r t h canal" during the l a t e r phases of labor i n order to be able to report the f i r s t v i s i b l e evidence of the baby, although the baby may be s t i l l quite high i n the "canal." In f a c t , with 267 each push, they may claim to be able to report more "progress" i n terms of more of the baby's head becoming v i s i b l e . Patient: "I can hear you, s t i l l , so keep t e l l i n g me what to do!" Nurse: "I'm going to put t h i s on your tummy. I t ' s heavy but i t ' s necessary to l i s t e n to the baby." (patient groans) Dr.: "That's a g i r l . " Patient: "Please don't stop t e l l i n g me! In the middle of i t (contraction) keep t e l l i n g me what to do so I can concentrate on i t ! " Dr.: "Hold on to the hand holds. I t ' l l help you to push. We can see a l i t t l e h a i r down here. Hang on and push hard and hold on to the bars! That's i t ! Good! Tremendous! Great! There's a g i r l ! Patient: "Oh, doctor!" Dr.: "Ok! I t won't be long! Good! Each time you push l i k e that, I see more h a i r ! " F i n a l l y , when the baby i s down f a r enough, they hold the mother-to-be up to look i n the mirror on the wall at the foot of the d e l i v e r y table, so that she w i l l see the movement that they are reporting as soon as i t i s possib l e . Dr. to the husband: "The baby i s i n the easiest p o s i t i o n — face to the back of mother. Come and see the scalp i n the mirror." Nurse: (holding the patient's head up) "That's good! the baby came down wonderfully that time." Dr.: "She sure d i d ! " Nurse: "You can see the baby when born, eh? Ok, push down. Help your baby!" Here they also membership the baby as the patient's to appeal to her assumed concern f o r i t s welfare. ("Help your baby!") 268 When the baby has been delivered the s t a f f t y p i c a l l y praise the patient f o r a good job of pushing even though she may have been sanctioned as a "lazy" or "poor" pusher. Presumably, t h i s e f f o r t to "save the patient's face" serves to keep her i n a po s i t i v e frame of mind when she i s presented with the baby. Patient: "I have been doing a l l the breathing exercises i n prenatal cl a s s , but a l l those pains came." Dr.: "You did a good job. You pushed f o r two hours." Patient: "When you give me that good ©emerol (pain k i l l e r ) time moves quick." Dr.: " F i r s t c l a s s ! You get a gold s t a r ! " Sometimes younger s t a f f members, student nurses, doctors, and interns vary from t h i s p r a c t i c e . Apparently due to t h e i r inexperience, they w i l l give an "honest", i . e_., often negative or "lukewarm," assessment of the patient's performance, which more experienced s t a f f treat as faux pas warranting immediate r e v i s i o n to restore the strongly p o s i t i v e judgment they have been giving throughout labor. For example, here an intern o f f e r s only a neutral or "lukewarm" judgment of a patient's performance which i s quickly corrected by the doctor. Patient: "How did I do?" Intern: "Ok . . . " Dr.: (cuts his utterance short) "Ok! You did your job!" During the course of labor, s t a f f accompany t h e i r continual praises and diagnoses of progress with e f f o r t s to 269 c o n t r o l or conceal connotations, implications and evidence of a lack of progress or "complications" which presumably would undermine the p o s i t i v e , optimistic "frame of mind" s t a f f i s t r y i n g to persuade the patient to adopt so she w i l l not stop pushing. For example, when s t a f f discuss the patient's lack of progress and i t s physiological causes, they do so usually i n a quiet manner o f f to the side of the delivery table or out i n the hallway of the delivery f l o o r . In the following instances, s t a f f quietly discuss the patient's problems, but when she asks about her progress the doctor gives her general encouragement. Dr.: "Good! Keep pushing!" Patient: "Am I f a s t enough?" Dr.: "Good strong f e t a l heartbeat and everything i s f i n e . " Dr. to Patient: "That's good! Tremendous! Great! (quietly to nurse) Tight p e l v i s . She's had trouble before, (to patient) There's a g i r l ! (to nurse) She has big spines and r e l a t i v e l y narrow arch." Nurse ( q u i e t l y ) : "She's not very b i g . " Dr. ( q u i e t l y ) : "A l o t of i t i s pinning against the spine. Each time i t keeps s l i d i n g back. Maybe t h i s time i t w i l l stay down." Just as i n the concluding assessment of the patient's perform-ance, young s t a f f provide a source of faux pas by t h e i r s t r a i g h t -forward announcements of t h e i r assessments of a lack of progress. For example, i n the following case at C i t y , a patient hears the student's assessment t o l d at a f a i r l y audible l e v e l to the 270 doctor. Alarmed, she demands to know her progress. The doctor t r i e s to "repair" t h i s fame pas by t r e a t i n g her inquiry as a matter f o r humor. Dr.: "Could someone t e l l me when a contraction i s coming?" Student nurse (puts hand on the patient's stomach): "Despite a l l that pushing, the baby has not come down f a r . " Patient: "How long i s i t going to take to d e l i v e r ? " Dr.: "Another s i x hours." Patient: "You wouldn't l e t me go that long?" Dr.: "Not unless I was mad at you f o r gaining weight." The doctor seems concerned that the patient not take her lack of progress too se r i o u s l y . He avoids giving her a s p e c i f i c answer, which would be negative, by t r e a t i n g her question f a c e t i o u s l y and d e l i b e r a t e l y exaggerating his assessment. However, the patient does take his assessment seriously and implies that i t r e f l e c t s on his competence i f the labor becomes even more lengthy. The doctor's reply seems intended to mildly sanction the patient f o r presuming to accuse him of negligence: he humorously claims that such a negligence would be deserved by her past transgression against his dietary i n s t r u c t i o n s . S t a f f normally t r i e s to exercise s i m i l a r control over connotations or implications which a r i s e i n the i n t e r a c t i o n i n the delivery room related to possible "complications" of the patient or baby. However, here also the younger s t a f f tend to make faux pas which older s t a f f t r y to "repair." For example, i n the following case the doctor t r i e s to prevent a 271 student's reference to blood loss from becoming a topic i n the in t e r a c t i o n with the patient. Dr. to the Nurse: "It's nice not having to do an episiotomy." Nurse: "Yes. The l a s t one had blood a l l over the place." Patient (alarmed): "What?" Dr.: "Just Dr. t a l k . " Here the doctor invokes the fac t that the s t a f f discuss many "technical" topics i n the presence of the lay patient which she would be unable, and therefore not e n t i t l e d , to pa r t i c i p a t e i n , i . e., "doctor t a l k " from which the inexpert patient may be warrantably excluded. By casting the student's faux pas i n t h i s guise, the doctor t r i e s to persuade the patient that the remark does not apply to her case: i t i s just "technical t a l k " about which she need not be concerned. In f a c t , t h i s example shows how a patient may be warrantably excluded as a conversa-t i o n a l participant, which i n t h i s case permits the doctor to treat her alarmed inquiry as not requiring a rep l y . In another case reported by a "natural c h i l d b i r t h " patient, a nurse t r i e s to "repair" or revise the frank assessment of progress and complications made by a young resident by o f f e r i n g a general reassurance that her labor was nevertheless " a l l r i g h t . " . . . What a disappointment! Although I was i n r e a l labor, I was only two centimeters d i l a t e d . The f i r s t resident to examine me nearly undermined my confidence by assuring me that "at your age (nearly 30) the f i r s t labor i s always very slow." Then he turned to the nurse and asked, "Is she bleeding too much?" and l e f t the room. The nurse patiently and firmly reassured me that everything was just as i t should be.34 Besides the faux pas produced by younger s t a f f members, doctors and senior nurses also t r y to control the connotations of slow progress and "complications" i n labor or the newborn c h i l d which are introduced by the patient. This occurs when patients mention or query s t a f f on what s t a f f consider "old wives t a l e s . " Also, patients who are by profession nurses or midwives may proffer t h e i r observations related to "abnormal o b s t e t r i c s " based on t h e i r occupational knowledge or experience. In the following case a lay patient mentions what s t a f f l a t e r charac-t e r i z e to me as an "old wives t a l e " concerning the higher incidence of abnormally large heads among babies of German extraction. Patient: "My husband i s German and we l i v e on the Black River and we see a l l these German babies with large heads. They're special types or d i f f e r e n t . " Dr.: "They're big, tough kids." Patient: "But my husband doesn't have a big head." (Dr. doesn't reply.) In order to d i s p e l the patient's apparent fears of her baby having a "German b i r t h defect," the doctor seems to use the method of d e l i b e r a t e l y "mishearing" what the patient obviously intends by "large heads" and "special types" or " d i f f e r e n t " as r e f e r r i n g to the common-sense shared t y p i f i c a t i o n of the physical c h a r a c t e r i s t i c s of Germans, as being "big and tough." Thus he t r i e s to normalize or redefine her observations of an apparent defect as i n fact just a non-pathological ethnic t r a i t . However, the patient's next remark about her husband's appear-ance shows she finds that the doctor has "misheard" her. She t r i e s to "correct" his interpretation by implying that her observations did not involve a l l or most Germans, as the doctor claims. The doctor ignores her rebutting remark, apparently i n an attempt to prevent t h i s p o t e n t i a l l y frightening topic from further being discussed. S t a f f tend to assume that patients who are nurses or midwives are already trained i n the medical perspective on the proper "frame of mind" and behavior i n labor. As a r e s u l t , most s t a f f , except B a r t l e t t and several obstetricians, may simply sanction them f o r mentioning "compli-cations," as i f they "should know better." Apparently, most s t a f f at City expect "exemplary behavior" from such patients i n labor. For example, i n the following case, an o b s t e t r i c a l nurse i s sanctioned f o r mentioning her past experience with excessive bleeding i n the delivery room. Patient: "I saw the movie on home delivery i n England. It scared me. One thing I used to dread i n the delivery room i s bleeding. People used to say there i s no blood i n the delivery room. I've seen sheets of blood." Dr.: "What kind of t a l k i s that?" A private o b s t e t r i c i a n supports these observations i n his description of the "pressures to act l i k e the exemplary mother-to-be" which.his wife experienced when she assumed the r o l e of patient to d e l i v e r her baby. This suggests that s t a f f assume that a patient does not necessarily have to be formally s o c i a l i z e d i n the medical perspective to warrant expecting and enforcing "higher standards" of b e h a v i o r — j u s t be related to one who has been so trained. This doctor d e l i b e r a t e l y avoids 274 going i n t o the delivery room to witness his wife's d e l i v e r y to prevent t h i s "pressure" from being even greater. Also, he suggests that even he would have d i f f i c u l t y sustaining the viewpoint prescribed by the medical perspective were he to act as an observing husband. (Here he i s discussing these issues with a couple i n the labor room.) "Did you d e l i v e r your own children, Dr. Sweeney?" Sydney (the patient's husband) changed the subject quickly. "No," I said. "I've known obstetricians who have, but I wouldn't want to. Because I'm no longer a doctor then. I'm too emotionally involved to think the way I should. I don't take care of anybody i n my family." "I guess you watched your children being born, though," Sydney s a i d . "I was i n the labor room but I didn't go into the delivery room." Bonnie (the patient) and Sydney looked surprised. "It's d i f f e r e n t when Sydney comes i n with you, because he's not a doctor. Having a husband there who i s a doctor puts an awful l o t of pressure on the guy who's doing the d e l i v e r y . And i t wouldn't be f a i r to my wife, ei t h e r . There was enough pressure on her already because she was Dr. Sweeney's wife i n labor. She would r e a l l y have had to act l i k e the exemplary mother-to-be i f I were present."35 In the following case, s t a f f show how they may e x p l i c i t -l y invoke her occupational status as a way of reminding her that the medical perspective should apply to her own delivery as well, and that they expect her to govern her own behavior accordingly. Dr.: (as he enters the delivery room) "I understand you're a midwife. You've been through a l l t h i s from the other end." Patient: "It's d i f f e r e n t t h i s way." Intern (chastising): "That's what they a l l say." 2 7 5 Patient: " I t ' s embarrassing!" Intern: "It's a l l the same thing." Note that the patient's reply ("It's d i f f e r e n t . . .") suggests she has heard his opening remarks as implying that because the patient i s a midwife, she should experience her own delivery i n the same way as she viewed others' d e l i v e r i e s as a p r a c t i -t i o n e r . Thus, she i s quick to correct t h i s expectation that she w i l l behave as a "colleague," implying she can not view i t from the prescribed medical perspective. The i n t e r n then chastises her f o r disavowing that these expectations s t i l l apply to her as a patient. By so doing he suggests that they w i l l hold the patient accountable f o r her behavior v i s - a - y i s the i d e a l patient i n the medical perspective, regardless of any disclaimers on her part. When she protests that she finds being the patient embarrassing, she seems to be claiming that the lay perspective on labor and d e l i v e r y i s governing her behavior and experience, e s p e c i a l l y with regard to conventions of modesty which govern the public exposure of one's g e n i t a l s . However, i n reply, the intern returns to the theme introduced by the doctor at the outset ("It's a l l the same thing."), to persuade her not to attend the obvious sexual overtones of her p o s i t i o n . Like the doctor, he proposes that the patient should regard a continuity between her occupational perspective and her patient experience, whereby normal lay relevances are to be suspended and treated as sanctionable i f introduced into the deli very room. 276 As i n the c l i n i c setting, s t a f f are concerned to pre-vent sexual overtones from a r i s i n g and to manage them i f they are introduced by the patient or younger s t a f f member. To t h i s end they employ draping, euphemistic terminology, and other techniques used i n the c l i n i c . Also, as i n the c l i n i c , one of the most common management methods involved ignoring sexual implications introduced by the patient. For example, i n the following case the patient points out the sexual over-tones of a doctor's question, a f t e r f i r s t showing that she has heard i t as a "medical question" by answering i t i n a competent manner, i . e., as i t was apparently intended by the speaker. Dr.: "How are your legs?" Patient: "My legs are ok, yes. But I would l i k e to have them closer together. But I guess you can't do that! Ha! Ha!" (The doctor does not reply to t h i s remark.) Similar to the case of the midwife, t h i s patient i s pointing out how the medically prescribed p o s i t i o n f o r delivery (and pelvic examination) af f e c t s her legs i n a moral as well as medical manner. This reveals that from the lay view, many doctor's questions both here and i n the c l i n i c s e tting can be heard as double entendres. She seems to be mildly protesting how s t a f f are f o r c i n g her to v i o l a t e "leg d i s c i p l i n e " wherein women i n our culture are s o c i a l i z e d to observe structures of modesty by keeping t h e i r legs together i n public to conceal the g e n i t a l area. However, by next t r e a t i n g t h i s protest as intended i n a joking manner ("But I guess you can't do that. Ha! Ha!") she shows she r e a l i z e s she has spoken "out of place" as a 277 patient and that she has been s o c i a l i z e d to some extent to accept the medical or technical necessity f o r t h i s procedure. This stands as an apology f o r making the i n s u l t i n g implication that s t a f f are gratuitously or f o r voyeuristic purposes expos-ing her gen i t a l area. In his dramaturgical study of pelvic examinations i n a private o f f i c e , James Henslin found t h i s same lay concern with the sexual overtones of the pos i t i o n they must assume f o r the examination and d e l i v e r y . Thigh Behavior. American g i r l s are given early and continued s o c i a l i z a t i o n i n "limb d i s c i p l i n e , " being taught at a very early age to keep t h e i r legs close together while they are s i t t i n g or r e t r i e v i n g a r t i c l e s from the ground (but, see Suttles 1968: 67 f o r possible ethnic d i f f e r e n c e s ) . They receive such cautions from t h e i r mothers as, "Keep your dress down," "Put your legs together," and "Nice g i r l s don't l e t t h e i r panties show." Evidence of s o c i a l i z a t i o n into "acceptable" thigh behavior shows up i n the vaginal exam-in a t i o n while the women are positioned on the examination table and waiting f o r the doctor to a r r i v e . They do not l e t t h e i r thighs f a l l outwards i n a relaxed position, but t r y to hold t h e i r upper or midthighs together u n t i l the doctor a r r i v e s . They do t h i s even i n cases where i t i s very d i f f i c u l t f o r them to do so, such as when the patient i s i n her l a t e months of pregnancy. Although the scene has been played such that desexualization i s taking place, and although the patient i s being depersonalized such that when the doctor returns, he primarily has a pel v i c to deal with and not a person, at t h i s point i n the i n t e r -action sequence, the patient i s s t i l l holding onto her sexuality and "personality" as demonstrated by her "proper" thigh behavior. Only l a t e r , when the doctor reenters the scene w i l l she f u l l y consent to the desexualized and depersonalized r o l e and l e t her thighs f a l l outwards.36 Henslin implies that a f t e r the a r r i v a l of the doctor, a l l patients are invariably so well s o c i a l i z e d i n the medical perspective that they always consent to t h i s v i o l a t i o n of lay modesty without protest or resistance. However, t h i s example 278 I have just described i n the delivery room demonstrates how a patient does not necessarily see herself as thoroughly "desexualized and depersonalized," nor does she always consent without protesting i t as a v i o l a t i o n simply because the medical s t a f f are present. In the c l i n i c p e lvic examinations I observed, many patients voiced protests and embarrassment even a f t e r the doctor began the examination, or otherwise pointed out the sexual overtones of the a c t i v i t y . In f a c t , i t appeared to be a continual management task with many patients to have them keep t h e i r legs apart a f t e r the examination had begun, requiring repeated reminders to the patient to " l e t her legs f a l l apart." Thus I found, unlike Henslin, that many patients t r i e d to exercise "leg d i s c i p l i n e " throughout t h e i r time i n the s t i r r u p s . This implies that most were not as s o c i a l i z e d i n the medical perspective as Henslin assumes and continued to regard the pelv i c as having obvious sexual overtones. The case of the protesting midwife i n the de l i v e r y room suggests that, indeed, even when medical s t a f f are themselves subjected to the same treatment as patients, they too are not able or w i l l i n g to merely assume a "depersonalized and desexualized r o l e . " In the description of the c l i n i c area, I pointed out how the younger residents and interns, using a "technical approach" to patient treatment, were les s circumspect about preventing sexual connotations from a r i s i n g and guarding the patient's modesty. Also, I found the younger s t a f f there were less s k i l l e d i n exercising moral control over the patient i n 279 t h i s regard because they treated the patient as a f u l l c o p a r t i c i -pant i n t a l k , providing i n the "give and take" of conversation an opportunity f o r her to introduce the lay perspective on the p e l v i c examination as a sexual scene. In the delivery room, I found the same difference i n management techniques, or lack of them. As i n the c l i n i c area, the younger s t a f f themselves would even introduce these connotations. For example, i n the following case a young intern t r i e s to apologize f o r taking a long time i n sewing up the episiotomy i n c i s i o n and assures her that no complications have taken place which would require such a lengthy sewing period. (The patient's doctor has already l e f t . ) Intern: "I'm taking so long because I'm doing a l i t t l e p l a s t i c surgery. Ha! Ha!" Patient: " W i l l I be more b e a u t i f u l down there? Ha! Ha!" Intern: "Best looking bottom i n town." Husband (who has been witnessing the d e l i v e r y ) : " I ' l l buy that! Ha! Ha!" Intern: x "A l i t t l e candid commentary. Remember that when he's looking at a l l those 20-year olds." Patient ( i r r i t a t e d ) : "You t a l k from experience." Here the inte r n uses a humorous remark to apologize. The humor, however, derives from the sexual overtones of his sewing opera-t i o n . The patient c l e a r l y hears his remark as having sexual connotations and shows t h i s by j o i n i n g i n to treat i t as a sexual event. The husband counters the intern's praise f o r his wife's g e n i t a l area ("Best looking bottom i n town.") by implying only he i s p r i v i l e g e d to make such a sexual appraisal 280 ( " I ' l l buy t h a t . " ) . The intern then mildly chastises his implied, though humorous, sanction by characterizing i t as "candid commentary" and suggesting to the patient that her husband's praise may just be f l a t t e r y because of his presumed appreciation of other women. The patient seems i r r i t a t e d at what she apparently hears as his implied accusation of her husband as being " u n f a i t h f u l " i n his attention to her. She counters his remark by sanctioning him wherein she accuses him of attending to the sexual attractiveness of his patients. Thus, by introducing the sexual connotations of his treatment, the i n t e r n provokes a disruption or confrontation where the husband implies that " i t i s none of his business" (suggesting overtones of jealousy) and an exchange of accusations of "promiscuous" prurient i n t e r e s t follows. Again, older, more experienced s t a f f t y p i c a l l y are more circumspect about such matters and appear to avoid acknowledging sexual overtones introduced by the patient and mentioning such implications themselves. In f a c t , one o b s t e t r i c i a n pointed out to me how sen s i t i v e he was to the heightened sexual overtones when the husband i s excluded from the prenatal examinations and d e l i v e r y room. He voiced a concern to reduce t h i s assumed jealousy by allowing the husband to oversee his wife's treatment i n the delivery room. At the same time, he suggests some patients are aggressively seductive, giving husbands grounds f o r jealousy. It's l i k e l y a l o t of husbands are jealous of the doctor, although they don't express i t to him e x p l i c i t l y . Once a husband t o l d me i n a tone of l e v i t y with a barb i n i t , "You doctors! My wife i s i n love with you." Wives are threatening i n another way and more so. No wonder husbands are jealous. Their wives keep coming to me, but the husband has no access and i s n ' t t o l d much of what goes on. So i t ' s good f o r the husband's f i d e l i t y and f e e l i n g he's a part and has a l i t t l e r e s p o n s i b i l i t y , i f he's there, even i f only to observe the d e l i v e r y . Most doctors f e e l the pressure of jealousy. I found the older doctors more aware of the "pressure of jealousy" while t r e a t i n g the patient i n front of the husband i n the d e l i v e r y room i n that they were p a r t i c u l a r l y circumspect i n t a l k and behavior to prevent disruptions and accusations due to jealousy than the younger doctors and interns, such as the one described above. Normalizing Troubles When "trouble" or "complications" i n labor a c t u a l l y occur, s t a f f generally cooperate to conceal i t from the patient 37 as much as possible. However, often i t s occurrence warrants t r e a t i n g the patient i n some non-routine manner which may suggest to the patient that "something i s wrong." For example, the appearance i n the delivery room and use of forceps can be a sign of serious trouble to the patient, so s t a f f work to reduce or eliminate t h i s i m p l i c a t i o n . One frequently used method involves t r e a t i n g the use of a non-routine procedure humorously. For example, i n the following case a doctor does not warn the patient beforehand of the necessity of a forceps delivery, but instead humorously mentions i t to the patient while she i s a c t i v e l y pushing out the baby. Presumably she w i l l be too preoccupied with following his instructions to push 282 to be able to voice alarm or protest. Nurse: "Deep breath and have i t out i n two minutes. I t ' s coming." Dr.: "I see I have an adversary. I ' l l have to use forceps! Ha! Ha! I'm on your side. Keep i t up! That's a g i r l . " However, the presence of the mirror which allows the patient to view her g e n i t a l area while l y i n g f l a t on her back may be seen by s t a f f as p o t e n t i a l l y undermining t h e i r e f f o r t s to reduce the v i s i b i l i t y of such non-routine procedures as forceps delivery and some routine ones l i k e the episiotomy which pro-duce a good deal of blood, suggesting some d i f f i c u l t y or com-p l i c a t i o n may ensue. This s t a f f ' s view i s also shared by a private o b s t e t r i c i a n who re l a t e s how he found i t necessary to t r y to persuade the patient to shut her eyes to avoid (pre-sumably) alarming her. She (the patient) was quiet, frightened. She t r i e d to bear down when I t o l d her to, but the baby didn't move. The widest part of i t s head wasn't coming out. "I'm going to put on the forceps to help the baby's head come out, Bonnie." I wondered whether the mirror was such a good idea a f t e r a l l . "Why don't you stop looking f o r a minute." "It's okay," she whispered. "I want to see!" . . . I pulled gently against the forceps handles. The head moved down, and I released. Then I pulled again, holding the head against the vagina, which was relaxed and stretching enormously, as i t does. "Bonnie," I said, "I'm going to cut the episiotomy, and i t ' s not ,the p r e t t i e s t thing i n the world. Why don't you close your eyes a minute. T h e r e ' l l be some blood." "I want to see," she said stubbornly. 2 8 3 The epidural (a l o c a l , s p i n a l anesthesia) had made a l o c a l anesthetic unnecessary. I held the forceps with my l e f t hand and when Dr. Richards handed me the s c i s s o r s , I cut the episiotomy. A crimson spurt of blood ran down the drapes beneath Bonnie's buttocks," Bonnie gasped.38 As with a lack of progress i n labor, s t a f f usually are circum-spect i n communicating "bad news" about complications to each other. T y p i c a l l y , they speak very quietly away from the de l i v e r y table or simply monitor each other's treatment of the patient to obviate t a l k i n g about the d i f f i c u l t y . When they have to perform some non-routine or even f a i r l y routine pro-cedure i n dealing with the trouble, they often account f o r i t as i n f a c t a routine or non-pathological event, i . e_., normal-i z e or r o u t i n i z e i t . Sometimes they simply do not mention why they are performing the procedure or announce beforehand what they intend to do. I f the patient demands an account, they may normalize or r o u t i n i z e the procedure, as I just described, or else vaguely and euphemistically describe the trouble while pr a i s i n g or exaggerating the e f f i c a c y of the procedure being employed to remedy i t . These observations at City are supported by the experiences of a private o b s t e t r i c i a n i n New York who r e l a t e s how he dealt with a patient whose baby i s diagnosed i n "trouble" i n the labor room, and l a t e r a f t e r she i s rushed to the d e l i v e r y room. The labor nurse checked with us more frequently now to see how things were progressing. Shortly before I expected we'd have caput, I asked Miss O'Brien (the labor nurse) to stay with Jean (the patient) and t o l d Ed (the husband) to come with me. I wanted to get caps and masks and show him how to put his shoe covers on before he came into the delivery room. 284 When we came back the nurse motioned me aside. "Dr. Sweeney, the l a s t time I took the f e t a l heart, i t was 125." "Check i t a f t e r the next contraction," I s a i d . Abnormal f e t a l or baby's heart beat i s 140. A f e t a l heart of 125 i s n ' t dangerous, and i t may only s i g n i f y a transient d i s t r e s s — f r o m pressure on the cord, f o r example—which causes the rate to drop during each contraction. But during labor i f anything changes from the norm, we a l l get a wary f e e l i n g . The nurse l i s t e n e d a f t e r the next contraction and I stood at her side, reading her entry i n the chart: 11:15 a.m.— f e t a l heart 115. . . . "Get a blood pressure and pulse," I t o l d the nurse. The notations she made i n the chart were normal. Blood pressure was 110/70 and pulse was 80. Motioning Ed back, I examined Jean v a g i n a l l y . The membranes were bulging into the vagina i n front of the baby's head. "Jean, I'm going to rupture your membranes now," I s a i d . I t won't hurt. There are no nerves there, and i t w i l l speed things up a l i t t l e . " A c tually, the main reason I was doing t h i s was to check the amniotic f l u i d , or water surrounding the baby, f o r meconium s t a i n s , (a test to see i f the baby's i n d i s t r e s s ; the test reveals no s t a i n s — J . E . F . ) . . . I had a stethoscope on Jean's abdomen, waiting as she f i n i s h e d another contraction. The baby's heart rate had dropped to 104 and that was close enough. "Give her some oxygen," I t o l d the nurse. The nurse grabbed the portable oxygen tank i n the corner next to the labor cot, pulled out the mask, and opened the valve. "We're going to give you some oxygen, Jean," I s a i d . "I don't want you to f i g h t i t , just breathe normally." I put the mask down over her face, and her hands came up, t r y i n g to get r i d of the mask so she could t a l k . The nurse grabbed her hands and I said, "Jean, l i s t e n to me. This i s just oxygen. We're having a l i t t l e trouble with the baby's heart-beat and the more oxygen you breathe, the better i t i s f o r the baby." She stopped f i g h t i n g but 285 her eyes were wide open with panic. How do you reassure a mother at that point? "We're t r y i n g to increase the baby's oxygenation and the pure oxygen you take w i l l reach him through the placenta." I wondered i f doctors would soon prove whether or not t h i s oxygen i s of any r e a l value. "Now just breathe normally," I t o l d her. I looked at the nurse: "Hit the buzzer." (a gloss f o r the emergency buzzer) (They rush the patient to the del i v e r y room.) "Okay, Jean, I'm r i g h t here," I said, i d e n t i f y i n g myself behind the mask. I was drying as f a s t as I could and getting into my s t e r i l e gear. As soon as she heard me, Jean reached f o r the oxygen mask covering her nose and mouth so she could t a l k . "Grab her hands," I sa i d . The i n t e r n held her wrists and she started to shake and twist her head f r a n t i c a l l y . "Jean, l i s t e n to me. You're going to be a l l r i g h t . We just have to get the baby out a l i t t l e sooner than we thought." She stopped twisting her head and stared at me, frightened to death. "We don't have to strap your hands down i f y o u ' l l keep them by your sides, do you understand? You can't move them around or y o u ' l l get i n our way."39 Note that the nurse does not announce the drop i n f e t a l heart-beat i n front of the patient, but instead "motions the doctor aside." Next, the doctor reads the nurse's entry i n the hist o r y chart rather than ask her i n front of the patient f o r the heart beat rate and the mother's pulse and blood pressure. He rou-t i n i z e s his rupturing the membranes as done to "speed things up a l i t t l e " to prevent her from seeing t h i s as a sign of trouble. When the d i f f i c u l t y warrants employing obviously non-routine procedure (giving the oxygen), he puts the mask over her without t e l l i n g her the reason, nor does he allow her an opportunity to demand a warrant f o r t h i s procedure. When she seems to require an account, he euphmistically describes the 286 trouble ("We're having a l i t t l e trouble with the baby's heart beat.") and exaggerates the e f f i c a c y of the procedure to remedy (the oxygen). Note that he waits u n t i l she has the mask held over her mouth before d e l i v e r i n g the "bad news." Presumably t h i s serves to prevent the patient from loudly expressing alarm and demanding more s p e c i f i c (and negative) d e t a i l s of the baby's condition, and forces her to l i s t e n to his euphemis-t i c account. When they a r r i v e i n the delivery room, again the mask i s used to enforce the patient's l i m i t e d r i g h t s to speak and thereby prevent her from voicing alarm and demanding an account. By t h i s time, the baby's heartbeat has f a l l e n to a dangerously low l e v e l (92), but the doctor glosses i t s con-d i t i o n to an even greater extent than before ("We just have to get the baby out a l i t t l e sooner than we thought."). At C i t y " s t a f f " or " c l i n i c " patients are delivered by residents who take turns every two months. When d i f f i c u l t i e s a r i s e i n the labor of a s t a f f patient, the resident whose "month" i t i s usually deals with i t . However, i f he happens to be home or busy with another case, sometimes the teaching resident, Dr. Sands, comes from the c l i n i c with his student doctors. Thus, a troublesome labor i n the delivery room becomes a teaching session where Sands t r i e s to deal with the emergency, account f o r i t to the patient, and lecture the students on the medical f a c t s of the case a l l at the same time. As I described i n the c l i n i c , Sands and other "tec h n i c a l l y oriented" residents do not schedule t h e i r lectures on a patient's case f o r before or a f t e r the p e l v i c examination. Thus, they show t h e i r concern f o r the p r i o r i t y of the teaching function over "personal" care f o r the patient by l e c t u r i n g about the patient i n her presence. In the case of the p e l v i c examination, t h i s leads to faux pas or frank descriptions of the patient's case which could alarm her. Likewise, i n the labor and delivery rooms the concern f o r i n s t r u c t i n g the students about the p a r t i c u l a r patient's d i f f i -c u l t i e s also r e s u l t s i n f a c t s being available f o r the patient to hear which could be heard as "bad news." This becomes p a r t i c u l a r l y i n t e r e s t i n g i n l i g h t of the e f f o r t s that Sands also makes, l i k e other doctors and s t a f f , to gloss and conceal the "trouble" which warrants her non-routine procedure. Thus, he frequently undermines his own e f f o r t s at c o n t r o l l i n g the v i s i b i l i t y of "bad news" by his t e c h n i c a l l y complete and frank lectures to the students while t r e a t i n g the patient. For example, on one occasion, he brought his students along when ca l l e d to do an emergency f e t a l monitoring of a s t a f f patient of I t a l i a n extraction i n the delivery room, while the s t a f f resident i n charge of the delivery f l o o r was s t i l l at home. This procedure involves attaching an electrode to the fetus i n utero so i t s " v i t a l signs" could be monitored on d i a l s and scopes outside the delivery room as well as taking a f e t a l blood sample. In t h i s case, the patient has had a l o t of bleeding which warrants the non-routine procedure. The resident suspects a possible abruption or mislocated placenta which could r e s u l t i n a massive and f a t a l hemorrhage at any time. 288 Resident: "Having much pain, dear?" Patient: " I t hurts." Resident: "Okay. That's why we're looking a f t e r you." Patient: "Where's my doctor?" Resident: "You're not going to be delivered yet. Dr. B. has asked me to look at your baby." Patient: (whining and groaning) "Oh God, my back." Resident to students: "She's had pain and l o t s of bleeding since morning. We've taken her blood sample and f e l t f o r the baby. She had blood i n her urine. She's 38 years o l d . I t ' s her f i r s t b i r t h . We expect a very d i f f i c u l t d e l i v e r y . 9 hours of labor now. I think the metnbrane are ruptured. I don't f e e l any. The chart says she's been laboring f o r 3 days. Can we say that labor has started? No! Objectively, we can t e l l i f the cervix has started to d i l a t e and there are pains across the stomach. So, she's been r e a l l y labored. Patient: "Don't press down!" Resident: "This has to be done. Where does i t hurt? A l o t of i n s u l a t i o n there, so i t ' s hard to t e l l the f e t a l heart r a t e . Take the acid base from the f e t a l blood system." Patient: "I'd l i k e to go to the bathroom. I'd l i k e to go to the bathroom." Resident: "Okay. Go ahead, dear. Pass your water. This i s not going to hurt much. This might hurt a l i t t l e . Mrs., you understand me." (R. r a i s e s the delivery table) This i s going to be a bumpy ride f o r a while. There's the head and no membrane, (facetiously) See the l i t t l e boy!" Patient: "Big or l i t t l e boy?" Resident: "Okay, dear, breathe i n and out. Try not to move too much, (to the students) I t ' s hard 289 Patient: Resident: Patient: Resident: Patient: Resident: Patient: Resident: Patient: Resident: Patient: Resident: Patient: to explain to t h i s type of patient. Lower your bottom, dear. Lay s t i l l f o r a minute. We'll soon be f i n i s h e d . (Patient c r i e s and moans) Sh! Try not to move dear, i t ' s very important. Don't move! (to nurse) Give her a Ph t e s t . I f her Ph i s okay, we'll go ahead with d e l i v e r y . Don't move! You're doing very w e l l . That's a good g i r l ! (the patient has stopped exclaim-(the resident) scrubbed up yet? I thought t h i s was an emergency, (patient groans) Don't move! Breathe i n and out just a few minutes." "I can't." "You can! I have to take some blood from your hand. Hold s t i l l . " "Ouch! Oh God! Oh God! I can't! I can't!" (to students) "She's had an enema. She has l o t s of gas. Where does i t hurt?" ( l i s t e n s with the stethoscope f o r the f e t a l heartbeat) "Don't! What are you doing?" "We're l i s t e n i n g f o r the baby. It's very important." "I t hurts a l l over! Don't!" (to students) "Her abdomen i s tender a l l over and she doesn't l i k e me to touch her. Try to relax." "I can't relax because you're pressing!" "Take i t .easy! We're not pressing now. We're fin d i n g baby. When i t ' s the f i r s t baby, they don't just jump out, just r e l a x . You're i n pain, so don't get a l l t i r e d out. (R. watches fo r the patient's reaction as he introduces an instrument into her uterus.) Okay. We're doing t h i s to get a complete picture of baby." "Why i s n ' t Dr. B. here?" "Dr. B. doesn't do t h i s kind of work. He phoned me. Sorry i f I hurt your f e e l i n g s . " "Stop pressing me." nurse) Hasn't Dr. B. 290 Resident: "Give him a good spanking when he gets out for causing you pain." Patient: "I hope i t ' s a g i r l because boys cause a l o t of trouble." Resident: "You f e e l a l l those pains because the baby i s st a r t i n g to go down. Relax between pains. Pretend you're sleepy." Patient: (groans) " A l l those hands!" Resident: "It's only me. It's important to learn about your baby. Okay? One down (procedure), another one to go." Patient: (relieved) "Thank you. Thank you very much." Resident: "Ok dear, the worst i s over. Another uncomfort-able thing down there, (to students) I t a l i a n patients tend to be screamy. For I t a l i a n s , there hasn't been a quiet b i r t h recorded, (patient groans a l o t ) Okay, dear. I t won't be long." Patient: "I can't'.' Resident: "In a l i t t l e while I ' l l give you an i n j e c t i o n . It's too early." Patient: "Why?" Resident: "We'll f i n d out about baby f i r s t . Then we'll take care of the pain." Patient: "It hurts." Resident: "You have to put up with i t . This i s labor. I f you don't have pain, the baby won't come down." . • . (to students outside the delivery room) "It's highly c u l t u r a l , t h i s expression of emotion. I t ' s i n t e r e s t i n g how the patient adjusts to t h i s . A l o t of her pain i s psycho-genic, since she could f e e l the pain when the blood was taken from her hand. I t makes you wonder. A l l her pain should be i n her stomach and she shouldn't have the presence of mind to f e e l her hand. This contrasts with natural c h i l d b i r t h . That's r e a l l y i n t e r e s t i n g . This i s where the woman goes without morphine. I think t h i s i s a most wonderful t h i n g — t o breathe her way through c h i l d b i r t h . I t ' s a 291 question of mind co n t r o l . " Dr. B. (walks i n i r r i t a t e d ) "This was just an excuse to get me out of bed at 6:00. No abruption, just broken membranes. She complains a l o t ! " Resident: "I think i t ' s her n a t i o n a l i t y . " Dr. B.: "She's not bleeding, but she's started labor. She's been complaining a l o t during her pregnancy." At the outset, Sands asks a prefatory question about the patient's pain i n order to have the p a t i e n t — h e r s e l f — s e e what trouble warrants the monitoring. Sands already knows that the patient i s experiencing normal labor pains, but t r i e s to gloss the suspected trouble by t e l l i n g her i t i s her "pain." ("That's why we are looking a f t e r you.") When the patient asks f o r her "own doctor" (the resident whose turn i t i s to d e l i v e r s t a f f patients) Sands t r i e s to persuade her that she may not warrant-ably demand or "need" him u n t i l and unless she i s going to d e l i v e r . Then he t r i e s to support his warrant to care f o r her by asserting that she should accept his care because i t i s delegated by "her doctor." Actually, the chief of the service had Sands f i l l i n because the resident was s t i l l at home when the "emergency" arose. Presumably, to t e l l the patient that he i s a temporary substitute would imply that the procedure i s not routine. Despite his circumspection i n providing warrant f o r the procedure, he undermines i t when l e c t u r i n g the students i n front of the patient about her bleeding condition and the expected "very d i f f i c u l t d e l i v e r y . " When the patient protests the pressing on her stomach, Sands merely invokes a vague medical necessity f o r the procedure ("This has to be done.") rather than suggest exactly why or what trouble warrants the discomfort. In f a c e t i o u s l y describing the sex of the baby ("See the l i t t l e boy."), Sands makes a faux pas i n that s t a f f t y p i c a l l y do not mention or guess what the possible sex of the unborn may be because i t may "raise the hopes" of the patient and r i s k disappointment or r e j e c t i o n when the predicted gender does not a r r i v e . The patient's reaction ("Big or l i t t l e boy?") shows how a patient may take such a reference to gender seriously even when obviously done humorously. When the patient refuses to cooperate and l i e s t i l l , Sands makes a p o t e n t i a l l y i n s u l t i n g remark to the students about "this type of patient." His remarks to them and the nurse on the Ph t e s t and the absence of the resident at the "emergency" stand as an e a s i l y overhead faux pas, despite Sands routine assur-ances to the patient that she was doing "very w e l l . " When the patient f i n a l l y demands to know why the procedure i s being done, he glosses the trouble by again simply asserting i t s medical necessity ("It's very important."). Next he t r i e s to deflect blame f o r her discomfort from the procedure to the baby and the normal labor pains i t assertedly i s causing. In the process, he t r i e s to normalize her pain ("When i t ' s the f i r s t baby, they don't just jump out . . . .") and blames the baby f o r causing i t rather than his pressing on her ("Give him a good spanking when he gets out. . . . " ) . He does t h i s a f t e r already admitting to the students i n front of her that "Her abdomen i s tender a l l over and she doesn't l i k e me to touch her." He i s t r y i n g to get her cooperation or at l e a s t acquiesence i n s p i t e of the pain the procedure i s causing her. When the patient repeats her request f o r her own doctor, he t r i e s to warrant his presence and conceal the emergency by claiming expertise that i n f a c t i s not uniquely his ("Dr. B. doesn't do t h i s kind of work."). He apologizes f o r the sub-s t i t u t i o n while implying i t i s nothing more serious than a matter of hurting her f e e l i n g s . When her doctor f i n a l l y appears, Sands suggests to him that most of her "complaining" about labor pain i s p h y s i o l o g i c a l l y unwarranted ("It's her n a t i o n a l i t y . " ) . In his lecture to the students he shows how s t a f f t r y to teach t h i s organizationally prevalent view of "bad" or "screamy" or "complaining" patients as being the r e s u l t of "psychogenic" tendencies of c e r t a i n ethnic and personality types. This view provides the vocabulary of motives whereby the source of patient's complaints can be located i n the patient rather than the treatment procedures. Debunking "screams," crying, and protests of discomfort as gratuitous "complaining" provides i n t h i s case a way of accounting f o r the trouble he i s causing the patient that deflects the stu-dents' attention from his competence i n administering the procedure. In any event, the main point I wish to make con-cerning t h i s case i s that i t i l l u s t r a t e s how, when "tech n i c a l l y oriented" c l i n i c s t a f f use a labor "emergency" as a teaching occasion, the concern f o r teaching may undermine the routine attempts to conceal or reduce the v i s i b i l i t y of an occurrence 294 which probably would be received as "bad news" were i t known to the patient. S i m i l a r l y , when a b i o l o g i c a l l y troublesome baby i s delivered, s t a f f generally make ef f o r t s to reduce or conceal the "bad news" from the patient while she i s an immediate witness i n the delivery room. In other words, they use various i n t e r a c t i o n a l devices to "separate" the mother from the trouble-some event while i t i s available f o r her to d i r e c t l y observe. On the other hand, the husband w i l l be given a more frank, but s t i l l q u a l i f i e d , version of the event l a t e r , outside the delivery room. At City, the two most common troubles observed were premature and Rh negative babies. In most cases, the trouble was expected by the mother, yet nevertheless s t a f f t r i e d to describe or diagnose the baby as not being i n "trouble," when i n fa c t i t was. This glossing procedure was most evident i n Rh negative cases where often the baby may appear observably healthy, without the usually expected yellow coloration i n d i c a t i n g jaundice. The following are some t y p i c a l b i r t h announcements i n these cases. Dr.: "It's a l i t t l e g i r l , mother! After a l l that!' She's a l l r i g h t ! She's a l l r i g h t ! " Patient: "Is she yellow?" Dr.: "No! Marvelous! No enlarged l i v e r or spleen!" Patient: "What? Really?" Dr.: "How long abo was i t (the intrauterine blood transfusion?) 10 days ago. Well healed (the scar from the transfusion injection) Getting f a n c i e r a l l the time, Betty." 295 Patient: "It's happening!" Nurse: "It's a l i t t l e boy, dear! Not a very l i t t l e boy, eit h e r . Intern: "It's an amazing pink!" Nurse (to another nurse loudly): "It's b e a u t i f u l , i s n ' t i t ? " In these cases of no observable trouble, s t a f f w i l l sometimes even hold the baby up f o r the patient's inspection just a f t e r i t has been completely expelled. However, when the news of the d e l i v e r y was conveyed to the waiting father i n these cases, the doctor usually gave a more pessimistic view of the baby's condition. For example, the doctor walks into the waiting room and the husband meets him at the entrance, anxious fo r news. Husband: "How's the baby?" Dr.: "We're giving i t an exchange but i t ' s pretty good. It' s a g i r l . We f e e l optimistic but we can't guarantee anything, es p e c i a l l y f o r the f i r s t 24 to 48 hours. Husband: "How much did she weigh?" Dr.: "9 grams." Husband: "Good. Over the danger l e v e l of 7 to 8 grams. Was i t yellow?" Dr.: "The skin was okay, but a f t e r the f i r s t h a l f hour i t becomes yellow. (The Dr. did not mention t h i s to the patient when he praised the baby's skin color i n the delivery room.) The cord was a l l jaundiced." Husband: "I guess I better stop standing around here. But I don't want to get i n the way u p s t a i r s . Can I see her?" Dr.: "She's i n the delivery room f o r one hour, so you 2 9 6 go up l a t e r . I t was crying when i t f i r s t came out." (I was t o l d that t h i s was of l i t t l e medical s i g n i f i -cance—J.E.F.) Husband: "That's supposed to be a good sign, but maybe that's an old wives t a l e . " (This i s what s t a f f c a l l e d i t — J . E . F . ) Dr.: " I t was breathing a l l r i g h t and the skin wasn't too bad." Husband: "No brain damage i f i t ' s breathing." Dr.: "I went to the p e d i a t r i c i a n and asked him what I should say. He said t e l l him he's o p t i m i s t i c . " Husband: "Anything else wrong? Any beauty marks from the transfusion you gave the kid?" Dr.: "None appeared. That transfusion w i l l help the red blood c e l l count. The baby has a good chance and born i n f a i r l y good shape." Husband: "The hemoglobin ( i n the transfusion) helps, doesn't i t ? " Dr.: "It helps the condition of the oxygen, yes." Husband: "You gave i t l a s t week." Dr.: ( i r r i t a t e d ) " I t s t i l l helped a l o t ! You seem very knowledgeable about the problems." Husband: "I'm interested i n the complications. Thanks a l o t . I ' l l go get a cup of coffee before I see her. Dr.: "Congratulations. . ."(shakes the husband's hand and leaves). The husband's f i r s t question on the baby's health shows that l i k e his wife, he too was expecting a b i o l o g i c a l l y troublesome baby. Ordin a r i l y , the father's f i r s t question to the doctor w i l l be about the sex of the c h i l d and then about the health of the patient and baby. Nevertheless, the doctor attends to his f i r s t utterance as the normal s l o t f o r t h i s news by p r o f f e r i n g the baby's sex. The doctor hedges his i n i t i a l 297 f a i r l y p o s i t i v e prognosis by qualifying i t as not a certainty ("we can't guarantee anything. . . . " ) . However, the doctor s t i l l proceeds to compensate f o r t h i s negative q u a l i f i c a t i o n and the remark about jaundice (which he never mentioned to the patient) by pointing out that the baby was crying. The father, however, who i s a planner f o r the h o s p i t a l , gives the medically sophisticated characterization of that as f a l s e reassurance or an "old wives t a l e . " The doctor p e r s i s t s and counters these negative and presumptuous remarks (for a lay patient) by i n d i -cating that the baby was breathing and q u a l i f y i n g his e a r l i e r — negative—observations on the condition of the skin. Also, he invokes the vague prognosis of the p e d i a t r i c i a n ("optimistic") although he had not i n f a c t consulted him before t a l k i n g to the father. The father s t i l l does not act reassured and instead makes some authoritative statements on the medical s i g n i f i c a n c e of the breathing and transfusion f o r the baby's prognosis. F i n a l l y , apparently i r r i t a t e d by the husband's presumptuousness and r e f u s a l to be reassured, the doctor "puts him i n his place" by s a r c a s t i c a l l y remarking on his authoritative stance to h i s wife's case ("You seem very knowledgeable."). The p r i n c i p a l point I wish to make from t h i s case i s that i t i l l u s t r a t e s how s t a f f endeavor to conceal and gloss "bad news" i n the delivery room while more frankly describing the baby's condi-t i o n to the husband outside. However, even i n informing the husband, the doctor s t i l l q u a l i f i e s t h i s "bad news" by pointing out the hopefully compensating features of the baby's condition. 298 I f a r e l a t i v e refuses to be appropriately reassured, despite a q u a l i f i e d or hedged p o s i t i v e prognosis and diagnosis, doc-tors tend to treat t h i s as a sanctionable matter. Likewise, i f the patient herself f a i l s to appear reassured by the s t a f f ' s praises of her baby's health and appearance, then s t a f f may treat t h i s response as sanctionable. For example, when a patient remarks on the baby's lack of cry-ing and movement, the doctor seems to "mishear" or redefine her observation as a sanctionable display of maternal r e j e c t i o n and proceeds to normalize i t s lack of a c t i v i t y . Patient: "She seems to lack s p i r i t . " Dr.: "Going to keep her, eh? Some are slow s t a r t e r s . " Thus, i n addition to glossing a b i o l o g i c a l l y troublesome baby with outright praise and s e l e c t i v e l y reporting compensating " p o s i t i v e " signs to the patient and husband, s t a f f also employ various (positive and negative) sanctions to persuade them to adopt and sustain the prescribed optimistic and happy outlook and thereby avoid possible disruptive behavior by an alarmed mother or father. One method s t a f f also use to emphasize to the mother i n the d e l i v e r y room the p o s i t i v e good health of the a f f l i c t e d baby involves doing a dramatically performed examination of i t wherein they proclaim loudly i t ' s p o s i t i v e "signs" of health while neglecting to mention symptoms of i t s a f f l i c t i o n . In most cases of expected trouble, a p e d i a t r i c i a n stands by with weighing scales and r e s u s c i t a t o r . It i s usually h i s task to 299 perform t h i s elaborate examination. For example, when the p e d i a t r i c i a n reports the p o s i t i v e r e s u l t s of various t e s t s , he not only loudly announces them but characterizes them as being very strong. Pe d i a t r i c i a n (very loudly as he holds the stethoscope to the baby's chest) "The f e t a l heart beat i s 150! I t i s so hard i t hurts my ears!" (normal rate i s 140) As with news about complications or lack of progress i n labor, s t a f f usually t r y not to mention the baby's problem i n the mother's presence, except i n hushed tones o f f to the side of the d e l i v e r y room. However, as i n these other attempts to control information available to the patient, the younger s t a f f members t y p i c a l l y commit more faux pas i n t h e i r communications to and i n front of the patient. For example, i n the case of a Rh negative baby who has already been praised as healthy, an i n t e r n audibly describes the pathological condition to the doctor. Intern to Dr.: "No doubt we have an involved baby." Patient (alarmed): "Is she a l l r i g h t ? " Dr.: "Yes. We'll give i t an exchange but there's no hurry. We'll do i t i n the next h a l f hour." Patient: "I am so glad she's a l l r i g h t . " Dr.: "Good f o r you! We're going to have a r e a l good baby f o r you!" Patient: "I can't get over how pink she was. I thought she would be a l l yellow." The patient overhears t h i s negative diagnosis and, alarmed, she inquires again as to the baby's health. In response, the doctor t r i e s to "repair" the intern's mistake by repeating his e a r l i e r p o s i t i v e diagnosis. Although he informs her of the need f o r a non-routine blood transfusion, he q u a l i f i e s t h i s p o t e n t i a l l y "bad news" by implying i t i s not an emergency and therefore there i s no pressing, serious problem. The doctor p o s i t i v e l y sanctions her acceptance of t h i s news as reassuring ("Good f o r you") by praising her and strongly promising a p o s i t i v e outcome of t h e i r treatment procedures. ("We're going to have a r e a l good baby f o r you!"). Note that s t a f f do not correct her apparent b e l i e f that the patient i s not jaundiced because the skin was not yellow. In f a c t , they never e x p l i c -i t l y diagnosed the baby as not jaundiced but merely l e t the patient draw t h i s conclusion from the normal pink skin color when the baby was f i r s t expelled. This information control was more d i f f i c u l t and, con-sequently, the i n t e r a c t i o n a l problems more severe when a baby was born v i s i b l y "troubled," as was the case with many under-sized premature infants and those Rh negative babies who were discernably yellow from jaundice. In these cases the doctor just announces the sex of the baby without praise of any kind and does not hold i t up f o r her examination. Instead, he quickly hands i t to the p e d i a t r i c i a n who quietly examines the baby with his back toward the mother so she cannot see i t . The doctor usually does not bring up the topic of the baby's health and t r i e s to engage the patient i n conversation on other, less " r i s k y " topics, such as whether the baby's sex 301 was the desired or expected one or how quickly and smoothly her labor had proceeded (even when i t had not). Meanwhile, the p e d i a t r i c i a n i s quickly and quietly weighing, diagnosing, and t r e a t i n g the distressed infant without announcing any signs of health, p o s i t i v e or negative. Eventually, the patient, who has expected trouble, usually inquires i n an alarmed fashion about the health of the baby. Then, either the doctor or p e d i a t r i c i a n t e l l her the baby's condition and prognosis i n a highly q u a l i f i e d manner. I f i t i s f a i r l y negative, they usually describe i t s problem i n very vague and general terms with the usual q u a l i f i c a t i o n that " i t i s too soon to t e l l anything f o r sure." Likewise, i f i t i s f a i r l y p o s i t i v e , they s t i l l append t h i s same hedge to a vague, general diagnosis and prognosis. Again, the v i s i b l y healthy Rh negative baby may be equally distressed but because of i t s appearance the s t a f f may more e a s i l y conceal and gloss the "bad news" while emphasizing the " p o s i t i v e " symptoms of health. A private o b s t e t r i c i a n i n New York lends support to my observations at C i t y i n his de s c r i p t i o n of how he and a p e d i a t r i c i a n dealt with a patient and her husband i n the case of an undersized premature baby. Here the patient i s delivered of a "tiny premature male in f a n t , " but before the doctor could make the announcement of i t s sex, the patient develops severe bleeding and f a i n t s . The doctor works to stop the bleeding while the p e d i a t r i c i a n examines and revives the baby. When the patient regains consciousness and the bleeding i s stopped, the p e d i a t r i c i a n brings the baby over 302 to her. "(Where i s ) the baby?" Dr. Rogan (the ped i a t r i c i a n ) was j u s t coming over with t h e i r l i t t l e boy a l l but hidden i n swaddling clothes. He touched the baby to Marianne's breast and arm. "You have a boy," he said, "and I want to get him r i g h t down to the premature nursery." "He's so t i n y , " she whispered. Marianne and Dan (the husband) stared. A l l they could see of t h e i r baby was his face, with bulging eyes. Marianne looked past Dan's shoulder at me. Her eyes widened at a l l the blood on my gown. Then she looked at Dr. Rogan. "Please t e l l me i f our baby's going to be a l l r i g h t . " "I think h e ' l l be f i n e , " Dr. Rogan r e p l i e d . "We'll know a l o t more l a t e r on." • . . They took Marianne downstairs at 1 a.m. Dan and I went with her. He was gradually bel i e v i n g she was out of danger. Then I took him to the preemy nursery, because he had hardly had a chance to see his son. I explained that Dr. Rogan had wanted to get t h e i r baby into a warm incubator as quickly as possible: a f t e r months i n a hot uterus, any newborn infant i s cold i n the delivery room. The p e d i a t r i c s resident t o l d us Dr. Rogan had been there u n t i l a few minutes before. Dan appeared shocked as he looked at h i s naked baby through the window of the nursery. "He's so t i n y , " Dan said, "so t h i n . " . . . F i n a l l y Dan asked me the question I'd been expecting. "Is he going to be a l l r i g h t , Dr. Sweeney?" "It's too early to be sure, Dan. You can't just look at a preemy baby and prognosticate. He must be doing pretty well or Dr. Rogan wouldn't have l e f t him. T h e y ' l l know more tomorrow. The f i r s t twenty-four hours are the most important." "He looks so f r a g i l e and helpless. There should be some way I could give some s t r e n g t h — " Dan's voice broke and he stopped. "How much does he weigh?" At b i r t h he had weighed 2,200 grams, which i s 4 pounds and 7 ounces, but I t o l d Dan he would lose some weight at f i r s t . A l l babies do.40 303 Note that the p e d i a t r i c i a n had wrapped the baby before showing him to the parents so i t s t i n y body was concealed f o r the most part. In t h i s case, also, the doctor had not held the naked, newborn baby up f o r the mother's observation. The p e d i a t r i c i a n gives a general p o s i t i v e prognosis while hedging with the usual q u a l i f i e r , "We'll know a l o t more l a t e r on." When the doctor takes the husband to the "preemy" nursery, he t r i e s to normal-i z e the quick removal of his son to the incubator (". . . any newborn infant i s cold i n the delivery room. . . . " ) . Actually, babies ro u t i n e l y are kept i n the delivery room f o r ten minutes or longer f o r the patient to hold and admire. The husband i s shocked by complete exposure of the baby's undersized body, which suggests the e f f i c a c y of swaddling clothes to manage the "bad news" while i n the d e l i v e r y room. This provokes the hus-band to reinquire about the baby's prognosis. However, the doctor gives a more non-committal reply than did the p e d i a t r i c -ian i n the d e l i v e r y room. In f a c t , he undermines the p e d i a t r i c -ian's p o s i t i v e prognosis by claiming that a b r i e f examination of a "preemy" does not provide medical grounds to prognosticate. Nevertheless, he t r i e s to q u a l i f y t h i s negative reply by claiming the absence of the p e d i a t r i c i a n i s i n d i c a t i v e of a po s i t i v e prognosis. F i n a l l y , he anticipates the baby's weight loss and t r i e s to normalize i t . At C i t y I found that exceptions to these information control practices generally were made i n cases involving patients who were nurses or midwives by occupation. S t a f f 304 apparently assumed that they were knowledgeable of a l l the possible symptoms of complications of "troublesome" i n f a n t s . Accordingly, t h e i r diagnoses were made with greater s p e c i f i c -i t y and i n technical terms with l e s s attempt to conceal or downplay the "bad news." On the other hand, these patients were more apt to cooperate i n preventing and reducing i n t e r -a c t i o n a l problems by not pressing f o r news of the baby's con-d i t i o n while s t i l l i n the delivery room. For example, the following case involves a midwife who has had past d i f f i c u l t i e s with her newborn babies and here d e l i v e r s a premature, obviously jaundiced Rh negative baby. Dr.: "He's out! A l i t t l e boy! Is that what you wanted?" Patient: "I don't care as long as he's healthy." Dr.: "The baby's yours."(as he hands i t to the ped i a t r i c i a n ) (Pediatrician examines the baby with his back turned toward the patient so she can not see the yellow, undersized baby. Af t e r examining i t he announces:) "The heart beat i s better. I t was i r r e g u l a r f o r the f i r s t minutes. Not bad now." (sends baby to intensive care without showing i t to the mother.) Dr.: "The baby had jaundice l i k e you had. I t can cross over into the brain a f t e r a cer t a i n age. I t ' s not good. Anemic and has heart trouble but enough blood w i l l clear the pigments out. Five pounds, eleven ounces." Patient: "Pretty good." Dr.: "I knew i t wasn't a 'four pounder.'" Nurse: "Thirty weeks—okay. Very good." Dr.: "The bigger they are, the sooner the l i v e r s t a r t s to work." The doctor avoids any reference to the baby's health i n the b i r t h announcement. Instead, he t r i e s to get the mother to focus on the d e s i r a b i l i t y of the sex of the c h i l d . However, i n reply, the patient points out her primary concern f o r i t s health. Nevertheless, then and throughout her stay i n the delivery room, she r e f r a i n s from d i r e c t l y asking the doctor about i t s health or prognosis (none i s offered). On the other hand, a t y p i c a l l y (for troublesome cases) the doctor and p e d i a t r i c i a n introduce the baby's health as a t o p i c , pointing out i t s "positive" signs as well as giving s p e c i f i c , technical descriptions of the baby's condition. He t r i e s to "redeem" i t s l e s s than normal weight by creating a contrast conception of a "four pounder" against which i t can be f l a t t e r i n g l y com-pared. Although t h i s patient i s t o l d s p e c i f i c t e c h n i c a l information of i t s condition, she i s never shown i t nor does the p e d i a t r i c i a n discuss the f e t a l heart beat u n t i l i t has improved. Also, the doctor t r i e s to q u a l i f y his negative diagnosis of jaundice, anemia, and heart trouble by pointing out the e f f i c a c y of a transfusion i n r e p a i r i n g one (though minor) trouble, the baby's yellow coloration, which i t s e l f i s of l i t t l e medical concern except as a symptom of l i v e r dysfunc-t i o n . Thus, even where a patient i s f u l l y informed about her baby's troubles, the s t a f f are circumspect about not pointing out to the patient possibly t r a n s i t o r y troubles, such as the i n i t i a l low heartbeat rate, and i n q u a l i f y i n g any diagnosis of more permanent d i f f i c u l t i e s . At City, the most d i f f i c u l t and severe i n t e r a c t i o n a l problems arose with the delivery of a b i o l o g i c a l l y troublesome infant which was unexpected by the doctor or patient. Again, the' d i f f i c u l t i e s i n managing t h i s "bad news" varied with the v i s i b i l i t y of the trouble, the majority being v i s i b l y troubled. When a baby was p a l l i d and not breathing, f o r example, the doctor usually just announced the baby's sex and quickly took i t over to the side of the room and kept his body between i t and the mother while t r y i n g to revive i t . The mother i s not shown the baby u n t i l and unless i t i s f u l l y revived and i t s appearance improved. A p e d i a t r i c i a n i s not present because trouble was not anticipated, and must be summoned. U n t i l he a r r i v e s , the doctor alone must manage the patient's alarmed i n q u i r i e s about i t s health while also t r y i n g to concentrate on r e v i v i n g i t . He may simply not respond to the patient's questions or else just describe the treatment he i s administer-ing to i t . S i m i l a r l y , the delivery room s t a f f collaborate with him i n not t r e a t i n g her alarmed i n q u i r i e s as a question, but instead respond to them with repeated expressions of "Relax, Mrs. . The doctor i s taking care of the baby." In other words, the patient i s to be kept completely uninformed u n t i l the doctor decides on some sort of diagnosis and prognosis and the baby's condition can be improved. I f the baby cannot be adequately revived, then i t i s quickly removed to intensive care f o r further treatment without giving the patient a chance to see i t . Only when the baby has been taken away does the doctor t e l l the patient the "bad news" i n vague, general terms 307 and with the usual q u a l i f i c a t i o n such as "It's too soon to t e l l " or "We'll know a l o t more l a t e r on." In support of these observations at City, I would l i k e to r e l a t e a private obstetrician's attempts to deal with a patient when her baby i s unexpectedly born without healthy color and not breathing. The baby has been quickly delivered by forceps when i t s heart-beat rate had dropped to a dangerous l e v e l , although the patient was not informed s p e c i f i c a l l y of i t s problem. . . . I turned the baby, working as quickly as possible. The r i g h t or top shoulder came out f i r s t . Then I l i f t e d and eased out the l e f t one and the r e s t of the narrower, wet body followed without d i f f i c u l t y . "It's a boy," I said automatically, but I didn't l i k e the looks of t h i s just-born i n f a n t . Healthy babies are not pink, t h e i r ' r e blue when they f i r s t emerge . . . .But t h i s baby was p a l l i d , almost white, because his heart had been pumping blood at a reduced r a t e . And he was too limp. Even before a baby s t a r t s breathing, i t ' s got a ce r t a i n amount of muscle tone. I f you pick up the leg, i t doesn't just f l o p down again. The baby may even move i t s f i n g e r s . But t h i s infant wasn't well . . . ."Watch Mrs. Simpson," I t o l d Dr. O r s i n i (the r e s i d e n t ) . I carr i e d the motionless baby a few f a s t steps to a table along the wa l l . . . . Suddenly I hear Jean's (the mother) expectant voice. "Can I see my baby?" The silence i n answer to her question caused her to cry out sharply, "My baby!" "I've got him, honey," I sa i d . Anguish pierced her voice as t h i s made her r e a l i z e some-thing was t e r r i b l y wrong. "What's the matter?" Ed (the husband) answered steadily, "Dr. Sweeney's taking care of our baby, sweetheart." "What do you mean, taking care of him?" A note of hyst e r i a shattered her words. "What does that mean?" "We're giving him some oxygen, Jean," I said. 308 "Mrs. Simpson, l i e back. Please." I t was Dr. O r s i n i . Then Ed's voice covered h i s : "You'll hurt yourself, sweetheart. You've got to l i s t e n to Dr. O r s i n i . " (The p e d i a t r i c i a n arrives and takes charge of rev i v i n g the baby.) Jean stared at me as I came to the ta b l e . "Please t e l l me how our baby i s . " I can't l i e to a mother at t h i s point. Her baby wasn"t breathing. "He's not very good r i g h t now, Jean, but i t ' s too soon to t e l l anything." "Oh my God," she whispered and turned her face away, crying h e l p l e s s l y . "Oh God, l e t him be a l l r i g h t , please just l e t him be a l l r i g h t . " The fundus nurse said, "Her uterus i s contracted, Doctor." A minute l a t e r the placenta started to d e l i v e r , and Jean begged, "Please t e l l me how my baby i s . " "We w i l l , " I s a i d . "Just as soon as we know." (Later the baby s t a r t s to breathe and cry.) "Oh my God, I hear him, I can hear him," Jean c r i e d . Dr. Rogan (the pedia t r i c i a n ) brought t h e i r son over and put him on Jean's stomach. "He's a good l i t t l e boy," he s a i d . 41 The doctor only announces i t s sex and immediately s t a r t s t r y i n g to revive i t . He ignores her request to see her baby and does not t e l l her why, other than the f a c t that he has i t . Also, he ignores her d i r e c t question about i t s health ("What's the matter?"). The husband collaborates with the doctor i n concealing the problem by providing an evasive answer to her question wherein he merely assures her that the baby i s being taken care of by the doctor. Likewise, when the doctor r e p l i e s to her inquiry, "What does that mean?", obviously intended to 309 ascertain the trouble warranting the doctor's care, he merely answers i t l i t e r a l l y by t e l l i n g her he i s caring f o r the baby with oxygen. Then the resident and husband t r y to calm and quiet the patient while the doctor works on the baby. When the p e d i a t r i c i a n takes over care of the baby, the doctor f i n a l l y gives her a negative diagnosis i n highly q u a l i f i e d , vague terms. Apparently f i n d i n g his diagnosis l e s s than informative, the patient l a t e r repeats her question about the baby's health, but the doctor backs o f f from his vague diagnos-i s , claiming the s t a f f just did not know the baby's condition at the present time, when i n f a c t they know i t has not breathed yet. As I found at City, the intent i s to avoid giv i n g the patient any s p e c i f i c information on the baby's condition, so long as i t i s negative and the baby i s s t i l l i n the del i v e r y room. 3 1 0 FOOTNOTES 1 . William R. Rosengren, "Some S o c i a l Psychological Aspects of Delivery Room D i f f i c u l t i e s , " Journal of Nervous and Mental Disease, CXXXII (June, 1 9 6 1 ) , 5 1 5 - 5 2 1 . This quote taken from p. 5 1 5 . 2 . Ibid., p. 5 2 1 . 3 . A report i n a consumers1 newsletter, Monevsworth, IV (New York: May 27, 1 9 7 4 ) supports my f i n d i n g that the decision to induce a patient may be based on considerations of work scheduling: BIRTH OF A NATION: The Royal College of Midwives states that London doctors are inducing labor i n pregnant women i n order to permit more and more B r i t i s h babies to be born between 9 A.M. and 5 P.M. The process i s an attempt to cope with night s t a f f shortages i n B r i t i s h h o s p i t a l s . At the rate things are going, women w i l l have to be increasingly s e l e c t i v e about the time they choose to de l i v e r ; I f your doctor's out to lunch, chances are y o u ' l l be out of luck. 4. Marjorie Karmel, Thank You, Dr. Lamaze (Garden City, New York: Doubleday Dolphin, 1 9 6 5 ) , p. 1 6 3 . 5. William Sweeney, Woman's Doctor: A Year i n the L i f e of an Obstetrician-Gynecologist (New York: William Morrow, 1973T7 PP- 2 7 3 - 7 4 . 6. William Rosengren and S. DeVault, "The Sociology of Time and Space i n an Obs t e t r i c a l Hospital," i n E. Freidson, ed. The Hospital i n Modern Society (New York: Free Press, n.d.) pp. 2 8 2 - 2 8 3 . 7. International C h i l d b i r t h Education Association, " B i r t h Reports," (unpublished) Pomona, C a l i f o r n i a : Preparing Expectant Parents Library, 1 9 6 7 - 1 9 7 1 . 9. These patients are seen as candidates f o r c-section usually on the basis of a previous d e l i v e r y wherein they had a lengthy and p a i n f u l labor and d e l i v e r y . From s t a f f ' s point of view, a r e p e t i t i o n of t h i s sort of vaginal b i r t h 311 represents a r i s k to the newborn c h i l d , who may s u f f e r from the e f f e c t s of an overly long labor, and to t h e i r own competence and work schedules. Doctors may a t t r i b u t e the previous lengthy labor and d e l i v e r y to these patients' "lack" of a b i l i t y to control t h e i r emotions, p a r t i c u l a r l y i n expressing pain, which they f e e l seriously i n t e r f e r e s with t h e i r a b i l i t y to follow s t a f f ' s instructions to relax and push e f f e c t i v e l y i n d e l i v e r y i n g t h e i r babies. Thus, doctors may f e e l that they must take into account t h i s a b i l i t y (or lack of i t ) i n deciding on the type of d e l i v e r y of subsequent babies: s u r g i c a l or vaginal. 10. Roy Turner, "Occupational Routines: Some Demand Charac-t e r i s t i c s of Police Work," paper presented to the C. S. A. A., Toronto, June, 1969. 11. 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). 12. Phenomenologically, i t i s not the exact act of crying or complaining that nurses react to but the symbolic meanings attached to them by medical ideology. S p e c i f i c a l l y , medical texts and lectures describe f o r s t a f f the e f f e c t s that the d i l a t a t i o n of the cervix has on the nerves i n the p e l v i c region of the body: the greater the expansion of the cervix, the more l i k e l y i t i s that the patient w i l l experience (and therefore express) pain, p a r t i c u l a r l y during the stage of labor c a l l e d " t r a n s i t i o n " when the cervix i s f u l l y expanded and the baby i s beginning to be expelled from the uterus. 13. S h e i l a 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), p. 35. 14. I b i d . , p. I64. 15. Peter Rios, "The Vietnam Casualties are Prisoners of War f o r L i f e , " a r t i c l e i n The Los Angeles Times. June 3, 1973, pp. 3 and 6. 16. International C h i l d b i r t h Education Association, " B i r t h Reports." 17. I b i d . 18. " . . . I want some part i n t h i s . " may also be interpreted as the doctor's attempt at humor. In other words, one interpersonal management technique that s t a f f employ may involve t r y i n g to gain the patient's cooperation through 3 1 2 humor. See Emerson, 1 9 6 3 and 1 9 7 0 . 1 9 . International C h i l d b i r t h Education Association, "Birth Reports." 20. Ib i d . 2 1 . Sweeney, Woman's Doctor:,pp. 1 5 4 - 1 5 5 . 2 2 . Kitzinger, Giving B i r t h : , p. 4 3 . 23. International C h i l d b i r t h Education Association, " B i r t h Reports." 24. I b i d . 25. Again, t h i s plea i l l u s t r a t e s s t a f f ' s use of humor to gain the cooperation of patients by a t t r a c t i n g the patients' attention to the doctor's commands and to d i s t r a c t her, at least temporarily, from the stress of labor, which may be preventing her from complying. 2 6 . International C h i l d b i r t h Education Association, " B i r t h Reports." 2 7 . I b i d . 2 8 . Kitzinger, Giving B i r t h : , pp. 1 7 3 - 1 7 4 . 29. International C h i l d b i r t h Education Association, " B i r t h Reports." 3 0 . I b i d . 3 1 . I b i d . 3 2 . I b i d . 3 3 . I b i d . 3 4 . Ibid. 3 5 . Sweeney, Woman's Doctor:, p. 1 7 5 . 3 6 . 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. 259-260. 3 7 . David Sudnow, Passing On (Englewood C l i f f s , New Jersey: Prentice-Hall, Inc., 1 9 ^ 7 ) , pp. 1 1 4 - 1 1 6 . 313 3 8 . Sweeney, Woman's Doctor:. pp. 177-178. 39. Ibid., pp. 55-59. 40. Ibid., pp. 233-234. 41. Ibid., pp. 60-63. 314 CHAPTER VI CONCLUSION This chapter w i l l attempt to p u l l together some important aspects of the d i s s e r t a t i o n and give the reader a f i n a l view of what i t has attempted, and what i t claims to have achieved. Hence, I w i l l f i r s t b r i e f l y describe the a n a l y t i c a l and methodological framework I chose to use i n t h i s study, and i t s advantages over other, more commonly used, approaches i n enabling me to obtain the findings reported i n t h i s d i s s e r t a -t i o n . Then, I w i l l conclude t h i s f i n a l chapter with a d i s -cussion of some of the substantive findings reported i n pre-ceding chapters. Framework The primary goal of t h i s d i s s e r t a t i o n has been to show how seemingly "technical" or "natural" events i n the h o s p i t a l (§.• £•» "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 r o u t i n e s — es p e c i a l l y those involving patient management—which they develop to cope with the p r a c t i c a l structure (e_. g., demand ch a r a c t e r i s t i c s ) of t h e i r everyday work. To t r y to achieve t h i s goal I chose the a n a l y t i c a l approach found i n the works of ethnomethodologists Roy Turner and David Sudnow.x Hence, I sought to analyze actual on-going 315 i n t e r a c t i o n between ho s p i t a l s t a f f members and patients i n terms of i t s constitutive, concrete organizational procedures and methods. I t r i e d to point out 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 . To produce data which could be u s e f u l l y analyzed with t h i s perspective, I followed Turner's conception of an ethno-2 graphic study of occupational routines as a general guide f o r the methodology of t h i s study. Hence, I acted as a non-participant observer i n order to provide as data a continuous record 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 . The resultant findings, reported i n preceding chapters, deal with the organization of work routines mainly i n terms of patient management techniques, d i f f e r e n t approaches or medical philosophies to the implementation of i d e o l o g i c a l ideals i n management routines, and the work exigencies or demand charac-t e r i s t i c s shaping the techniques i n use. These findings suggest how f o r some patients, p a r t i c u l a r l y , these techniques cause "problems," such as embarrassment and "lack of adequate atten-t i o n " to t h e i r i n d i v i d u a l medical and s o c i a l "needs." On the other hand, by acting as l e s s than "model" patients, these same patients often provoke s t a f f members to use these tech-niques. 316 The discovery of these management techniques and the organizational events and pressures which occasioned t h e i r development and use, I contend, was very much dependent on my adoption of an ethnographic research strategy—non-pa r t i c i p a n t observation—and a t h e o r e t i c a l approach to "tech-n i c a l " and "natural" events i n the hospital i n terms of t h e i r c o n s t i t u t i v e procedural bases i n everyday occupational rou-t i n e s (which I sum up by the phrase "doing o b s t e t r i c s " ) . The more commonly used s t r u c t u r a l survey-interview approach, on the other hand, has been concerned to f i n d the s o c i a l or c u l t u r a l components of " b i o l o g i c a l " and "technical" events, such as prenatal care and c h i l d b i r t h , as such components were made up of abstract, general norms, b e l i e f s , and attitudes (summed up by terms l i k e "doctor and patient r o l e s " ) . Methodologically, t h i s t h e o r e t i c a l approach translates into the quantitative measurement by surveys and interviews of the extent to which doctors and patients subscribe to various kinds of attitudes, b e l i e f s , norms and r o l e s , which they are assumed to follow as "programs" f o r action when ac t u a l l y i n t e r a c t i n g with one another and producing such " b i o l o g i c a l " events as labor and c h i l d b i r t h . Then, "problems" patients experience at the hands of doctors and the " d i f f i c u l t i e s " d i f f e r e n t types of patients cause s t a f f members are explained i n terms of the p a r t i c i p a n t s ' subscription to kinds of s o c i a l r o l e s and the degree to which these normative elements are "complementary" or " c o n f l i c t i n g . " My contention i s that by focusing almost exclusively on abstract normative elements i n 317 the actors' perspectives, t h i s research strategy overlooks the situated, p r a c t i c a l features of the organizational s e t t i n g that competent members must take into account i n t h e i r everyday encounters. Furthermore, the inadequacy of t h i s standard strategy may r e s u l t i n demonstrably spurious r e s u l t s by lead-ing the researcher to look only outside the actual organiza-t i o n a l features of i n t e r a c t i o n f o r explanations of "problems" or "inadequacies" i n the administration of medical "treatment." This contention i s supported i n Chapter IV, p a r t i c u l a r l y , where I compared the two research strategies as applied to "problems" i n labor and c h i l d b i r t h that a patient may experience, e_. g., "lengthy labor" and "caesarian section." As the reader w i l l r e c a l l , i n that Chapter I j u s t i f i e d my choice of an ethno-graphic approach^—and r e j e c t i o n of survey methodology—on the grounds that i t provides the data b a s e — d e t a i l s of everyday i n t e r a c t i o n —necessary f o r an adequate analysis of the s i g n i -f i c a n t r o l e of patient management routines i n shaping "natural" and " t e c h n i c a l " events i n labor and d e l i v e r y , g., "length of labor," "complications of d e l i v e r y , " "caesarian section," etc. In sum, what I am arguing f o r i s the necessity of study-ing the "natural s o c i a l order" of a h o s p i t a l (or any occupa-t i o n a l setting) i n any argument or characterization dealing with events occurring within i t . Substantive Findings In my chapters on the intake area of the C l i n i c I described s t a f f members' patient management routines and t h e i r view of themselves as having a mandate to in s t r u c t and lay the whole routine of prenatal care on patients, regardless of t h e i r s ituations and views. Many patients' "reactions" to s t a f f ' s "treatment" here and i n other areas of the hos p i t a l can index t h e i r character as "troublesome" f o r s t a f f . In other words, I found systematic attempts t o coerce patients to "shape up" so that i n the always-oriented-to f i n a l s t a g e s — l a b o r and d e l i v e r y — they w i l l (hopefully) be "good patients." Also, we saw s t a f f members protecting standardized routines—e_. g., requests f o r a female d o c t o r — g e t treated as organizationally d i s r u p t i v e . Also, I showed how the s o c i a l worker i n the C l i n i c i s occupa-t i o n a l l y t rained, 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 physicians, too, I showed how the medical shades o f f into concerns with "model middle-class family arrangements," and s t a f f seem to take f o r granted t h e i r mandate to enforce these. More s p e c i f i c a l l y , when patients who have had t h e i r babies i n a non-medical s e t t i n g (or voice int e n t i o n to have them i n non-medical settings) come to the C l i n i c f o r services over which medical personnel have a monopoly—registration of b i r t h , diagnosis of pregnancy, and general physical check-ups— s t a f f members use these occasions to check on t h e i r compliance with prenatal and post-natal medical care routines. I f they are found to be "negligent" parents or reluctant to accept prenatal care and del i v e r y i n the h o s p i t a l , s t a f f members use threats of l e g a l sanction and moral persuasion to "teach" them the value of medical care, which i s claimed to be necessary to meet t h e i r " r e s p o n s i b i l i t i e s " to the unborn or newborn c h i l d . In the intake and cubicle areas moral persuasion may involve attempts to scare or shock the patient with anecdotes of where, e. g., a non-medical delivery or "neglect" of prescribed pre-natal regimens resulted i n severe complications i n d e l i v e r y or even natal death. A l t e r n a t i v e l y , s t a f f members may t r y to persuade the patient to cooperate on the grounds of the "medical f a c t s " of her case, including some vague or implied threat of trouble f o r a patient of her "medical type"—§_. g., "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." I f patients w i l l not be persuaded to cooperate, they may be given an ultimatum by s t a f f whereby they accept the prescribed medical regimen or be turned away from the C l i n i c without the service they sought, §_. g., a diagnosis of whether they were pregnant, or a general prenatal physical check-up. In dealing with patients who threaten standardized r o u t i n e s — e . g., requests f o r a female d o c t o r — s t a f f may t r y to protect them (the routines) by r o u t i n i z i n g and normalizing the offending routines. I f patients do not respond i n the desired manner to t h i s technique, s t a f f then often r i d i c u l e and d i s -c r e d i t t h e i r objections as superfluous or unwarranted by v i r t u e of t h e i r lack of good moral character. Also, they t r e a t the r e c a l c i t r a n t patient's motives as problematic and hold her 320 p u b l i c l y accountable f o r them. F i n a l l y , i f the patient w i l l not be shamed or censured into foregoing her objections, s t a f f may issue an "ultimatum" s i m i l a r to that used with patients who w i l l not cooperate f u l l y with medical regimens i n prenatal or post-natal care. In order to t r y t o exert moral control over the patient's preparation f o r parenthood, including her f i n a n c i a l , occupational, and marital a f f a i r s , s t a f f may turn the intake interview and the medical interview i n the cubicle area into d i d a c t i c sessions. In these cases the s o c i a l worker or doctor may ask presumptuous "leading questions" and r h e t o r i c a l questions to encourage the patient to see d e f i c i e n c i e s i n her " l i f e s t y l e " and then they p r o f f e r advice as to what she "could" (to be heard by her as should) do about the "pressing" problem(s). S t a f f members then "follow up" these sessions with regular reminders to the patient of her "problems" and chastisements i f she does not follow t h e i r proffered a d v i c e — g . g., "What" S t i l l no job?" In my chapter on the cubicle area I showed how work exigencies such as 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 ide a l s of the medical ideology i n regard to patient management techniques (including the "necessity" to "teach" patients, t r e a t t h e i r " i n d i v i d u a l problems," and give proprietous care); an approach to patient "care" and the teaching of students I termed 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 i d e a l s i n everyday work routines. I described the organiza-t i o n a l problems and work orientations of medical students and young residents because they did most of the work i n the area. Also, I showed how they received "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 that downgraded the "technical approach," which was commonly followed i n c l i n i c work routines. However, I showed how students had 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 (§_. g., work scheduling and v i s i b l e compe-tence) once they get to the cubicles where they a c t u a l l y work with patients. More s p e c i f i c a l l y , the use of a "technical approach" to patient management by c l i n i c s t a f f resulted to some extent from t h e i r concern to l i m i t the work day and provide f o r regular work breaks—e_. g., "Everybody here i s i n here and out to coffee as f a s t as they can." Another demand c h a r a c t e r i s t i c making the implementation of ideals of patient management problematic i s the necessity to complete the medical history and the general physical examination i n les s than a h a l f an hour i n order to provide a v i s i b l y competent performance and cope with a heavy work load. In other words, most s t a f f members t y p i c a l l y do not prove patients' responses i n the interview f o r accuracy or t r y to "establish rapport" or give advice, due to the saliency i n t h e i r work orientation of "not taking too much time" with any one patient. This pressure r e s u l t s i n an emphasis even i n pedagogical "pep-talks" on performing only a "reasonable" general and p e l v i c examination to e s t a b l i s h "reasonable" health. Also, mitigating against the actual implementation of the "patient as person" approach, while paying " l i p - s e r v i c e " to i t i n lectures, was the f a c t that many younger s t a f f members treat the c l i n i c as primarily a teaching and learning s e t t i n g where the patient i s regarded as a "technical object," i . e., as a "pregnant g i r l " who exhibits a set of symptoms. Many s t a f f members, then, are not p a r t i c u l a r l y circumspect i n preventing sexual and moral connotations from a r i s i n g and not es p e c i a l l y concerned to seek out and deal with the patient's " s o c i a l problems," e_. g., they may ask the patient at the beginning of the p e l v i c examination to "spread your legs," or t r y to persuade the patient not to press "family problems" on them. Also, as a r e s u l t , they may not exercise "team d i s c i p l i n e " and circumspection i n discuss-ing a patient's case i n front of her, including voicing d i f f e r -ences of opinion as to how she i s to be treated. Patients, i n these cases, may become alarmed or insulted by what they are able to discern about t h e i r case from the doctors' "technical t a l k . " F i n a l l y , a "technical approach" to patient management may also r e s u l t from s t a f f members' lack of experience with "handling" patients or lack of f a m i l i a r i t y with medical l i t e r -ature supporting the consistent implementation of "patient as person" i d e a l s . I found i n my study that older, more experienced doctors d i f f e r e d from "raw r e c r u i t " students and 323 younger residents not so much i n t e c h n i c a l s k i l l s and know-ledge, but i n s k i l l s i n exercising moral control over the patient, e. g., younger s t a f f members were not as adept at t i g h t l y managing i n t e r a c t i o n so that patients were not treated as equal co-participants i n conversations. T y p i c a l l y , there was more "give and take" i n these encounters, providing more opportunities f o r patients to introduce sexual and moral conno-t a t i o n s . Furthermore, younger s t a f f members were found to provoke more frequently moral reactions from patients by t h e i r " a r t l e s s , " "crude," questions and comments, which i n v i t e d moral implications—e_. g., Student: "Have you had intercourse r e g u l a r l y ? " Patient: "Yeah. I'm married. Ha! Ha!" Likewise, when t r y i n g to employ small t a l k as a management technique to " d i s t r a c t " the patient from the sexual and p a i n f u l implications of the p e l v i c examination, younger s t a f f members were found to be l e s s circumspect and a r t f u l i n the s e l e c t i o n of topics and i n i t i a t i n g conversations. In Chapter V I documented the intransigence of labor and d e l i v e r y f o r organizational programming, as well as the patient management routines developed to cope with the naturally d i f f i c u l t features of these processes i n terms of the demand ch 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. S p e c i f i c a l l y , I found that s t a f f members used medical procedures—pitocin, anesthesia, forceps, caesarian section, e t c . , — t o control "length of labor" and manage organizationally 324 troublesome patients. These methods of physical intervention were often e x p l i c i t l y j u s t i f i e d to the patient as medically warranted as being "for her own good." S t a f f members also t r i e d to " f i t " the process of labor into the supervising doc-tor's work and l e i s u r e schedule by summoning him only when the l a s t stage of labor had begun. In order to do so they r e l i e d on normal labor t y p i f i c a t i o n s of the average length of labor and behavioral displays by patients. Besides using methods of physical intervention, s t a f f members t r i e d to coerce cooperation by "guiding" the patient to get maximum eff e c t of each labor contraction. These i n t e r -a c t i o n a l management techniques included instructions to the patient on how to " c o r r e c t l y " push, as well as "pressuring" her to follow these i n s t r u c t i o n s and exert maximum e f f o r t i n pushing out the baby. Also, the s t a f f worked as a team to persuade the patient to adopt and display the "right a t t i t u d e , " i . e., "a relaxed, happy mental approach," so she does not "lose c o n t r o l " under the "stress" of labor. Conversely, when s t a f f members desired to delay the d e l i v e r y to allow (e_. g.) the supervising physician time to a r r i v e and "take part" i n i t , they may i n s t r u c t and exhort the patient to "hold" the baby and not to push i t out, even though she may have a strong desire to do so. Like physical methods, these i n t e r a c t i o n a l techniques were e x p l i c i t l y j u s t i f i e d on medical grounds as being warranted by the patient's (or baby's) p a r t i c u l a r p h y s i o l o g i c a l problems i n labor and d e l i v e r y . 325 In "pressuring" a patient to push harder and more e f f e c t i v e l y , s t a f f often would loudly command her to do s o — e. g., "Let's have t h i s baby I" When the patient i s viewed as being "negligent" i n pushing, s t a f f may cajole ("Come on, you!"), name-call ("You're a lazy thing!"), or t r y to f r i g h t e n the patient by describing possible "complications" that might occur i f she f a i l s to cooperate with t h e i r instructions ("If you could l i s t e n to the f e t a l heart beat, you would f i n d i t ' s loud because there's pressure on the baby's head. . . please push to bring i t s head down!") St a f f members develop s i m i l a r i n t e r a c t i o n a l management techniques to quiet "noisy" and "complaining" patients—thereby rendering them "good patients" who w i l l (hopefully) be able to respond " c o r r e c t l y " to t h e i r e f f o r t s to "pressure" her to be a "good pusher" during the f i n a l stage of labor: commands to "stop making noise" and "get i t a l l under co n t r o l , " verbal and physical sanctions (§_. g., s t i f l i n g the patient when she makes "noise"), promises of a short labor, reassurances of having made "good progress" i n labor and that there are no medical troubles warranting her "loss of c o n t r o l . " As i n the C l i n i c , younger doctors and s t a f f members d i f f e r e d from more experienced personnel mainly i n t h e i r s k i l l i n exercising moral control over patients so as to produce organizationally "good patients" i n labor and d e l i v e r y . F i n a l l y , to ensure a happy, relaxed attitude on the part of the patient when phys i o l o g i c a l troubles occur i n labor or d e l i v e r y or with the newborn infant, and to avoid possible 326 disruption, s t a f f develop methods of reducing the v i s i b i l i t y and s i g n i f i c a n c e of t h i s "bad news" f o r the patient. These techniques of information control involve attempts to normalize and r o u t i n i z e such p o t e n t i a l l y disruptive events, as well as simply t r y i n g to conceal symptoms and signs of trouble from the patient. FOOTNOTES 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 ; and David Sudnow, Passing On (Englewood C l i f f s , New Jersey: Prentice-Hall, Inc., 1 9 6 7 ) . I b i d . 3 2 8 BIBLIOGRAPHY 329 BIBLIOGRAPHY Anonymous M.D. Confessions of a Gynecologist. New York: Doubleday and Company, 1972. Baird, D. 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