Appendix 14a - Great Expectations

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

Patients often do not live up to students' expectations. In a Hasting's Center Report a third year student is quoted as saying, "Often in the hospital setting I feel I intrude into people's lives, take what I want, and move on," to which the authors respond, "as much as hospital education may be viewed as intruding, taking and moving on, it is also about submitting, losing, and leaving behind" as students are, "frustrated by their incapacity to make their interactions with patients conform to the idealized roles of the knowledgeable-and-kind 'helping hand' and the autonomous-yet-grateful recipient of care."[198]

The first code of ethics published by the AMA actually proscribed the gratitude:

A patient should, after his recovery, entertain a just and enduring sense of the value of the services rendered him by his physician; for these are of such character, that no mere pecuniary acknowledgment can repay or cancel them.[199]

If you want to keep your memories, you first have to live them; And if you go out to heal the sick, you first have to forgive them - Bob Dylan

In a sociological study entitled "Good Patients and Problem Patients," ideal patients were seen by interns as, "introverted, emotional, and weak-willed."[200]

There is a tacit contract here, where the doctor's part reads: 'I will be strong if you will be weak. I will be sane/sober/logical/continent if you will be mad/drunk/confused/ miscreant. I will support, guide, and protect you so long as you are helpless and obedient.... Reciprocally, the patient's role in such collusion reads: 'If you will be my Grown-up then I will make you feel potent, clever, and important. To make sure that is so, I will be passive, aimless and dependent.'[201]

Good Patient

From a medical sociology text:

Inpatient care imposes on patients a role characterized by submission to professional authority, enforced cooperation, and depersonalized status.... For the medical staff, the more like a helpless object the patient is, the easier they find it to do their job. But if the patient cannot be rendered insensate, or his or her views not ignored completely, the routinization of work is helped when the patient is objective, instrumental, emotionally neutral, completely trusting, and obedient.

Ease of management was the basic criterion for a label of good patient, and the patients who took time and attention felt to be unwarranted by their illness tended to be labeled problem patients.... In short, the less of a doctor's time the patient took, the better he or she was viewed.[202]

The conclusion of an article called "Good Patients and Problem Patients":

The patients who make no trouble at all, we who do not interrupt the smoothness of medical routines, are likely to be considered good patients by the medical staff.... Thus, the consequences of deliberate deviance in the general hospital can be medical neglect or a stigmatizing label, while conformity to good patient norms is usually a return home with only a surgical scar.[203]

The next appendix explores the methods in which patients are marginalized into submission.


[198] Feudtner, C and DA Christakis. "Making the Rounds." Hasting's Center Report 1994(January-February):6-12.

[199] Brody, H. The Healer's Power Danbury: Yale University, 1992.

[200] Sparr, LF et al. "The Doctor-Patient Relationship During Medical Internship." Social Science and Medicine 26(1988):1095-1101.

[201] Zigmond, D. "Physician Heal Thyself." British Journal of Holistic Healing 1(1984):63-71.

[202] Medical Sociology:220.

[203] Lorber, J. "Good Patients and Problem Patients." Journal of Health and Social Behavior 16(1975):213-225.

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