The Quest for Normalcy and its Drama in the Doctor-Patient Interaction

…I began to realize that although medical labels had the same shiny surface as my childhood labels, with a luster capable of illuminating the darkness of disease, they also had the same sticky underside. (1)

Physicians by nature realize the humanity in healing. However, physicians do not leave “self” at the door. Not completely blind to social status distinction, this magnified distance in the doctor’s office may be overcome through discourse and a shared appreciation of worth. A very tall order… This sounds far too easy to do. Physicians are asked in each visit of a face-to-face interaction with a patient to optimize the success of each visit under a number of constraints. HMO’s demand this. Patients expect this. Recognizing the immense opportunity each interaction may hold in the health of the patient, the importance of maximizing each communicative discourse becomes more important. Certainly this thesis cries for the existence of a medical home and a history of a continued relationship between patient and doctor. It is hoped that this would not merely be a one-night only performance. If a doctor and patient are so fortunate to have this continuity of care (or less satisfactorily a one-shot visit), using Erving Goffman’s thesis of the person as a drama player with a splash of Butler’s performativity can be applied in ensuring better success in clinical discourse.

Goffman presents “dramaturgy” in human interaction as a theatrical event, with scenes, roles and players (2). There is no understudy for the physician. The doctor knows his or her role. This meeting of doctor and patient is inherently social. Socialization in this case, according to dramaturgy, is a form of ritualized theatrics (3). Once the patient dons a hospital gown awaiting the physician, he is in the role of patient. This means that a patient may play a character of “patient” with more ease than having her true self scrutinized. The true self is flawed for many, being imperfect and open to ridicule. When discerning of meaning for other’s judgment when other appropriate evidence is unavailable, the doctor must use “signs” given by the patient (4). A silent patient leads to an evaluation of a mute actor by the physician based on the “performance” given. Personalities notwithstanding, the patient actors may be evaluated on the basis of phenotype: be it race, creed, or intelligence (5; 6). Goffman would say that following the dramatic performance of the doctor-patient interaction gives emotional grounding to these social interactions (7). It is emotive. But is it realistic to expect the patient to purge his or her soul and construct a shared morality in this environment?

Goffman reinforces the prejudice permeating in the 1950’s (that still remains) that held shamed characters in comparison to the gold-standard of the normal and nondeviant (8). Goffman made quite clear his demarcation of normal and deviant; through his use of “we normals” throughout the Stigma piece, he casts himself as “normal” (9). The patient only seeks a return to a quality of normalcy. They ask to be fixed. They ask for their old well “selves.” And that operationalization of normal may not coalesce with the physician’s recommendations. It may be wholly unrealistic clinically. Stigma is correlated to self-hood, as society has created stigma to cope with the dissonance- causing gaps in knowledge of others (10; 11; 12; 13). Serving the purpose of validating or invalidating self-worth, the symbolism of language allows us to create a reality from the outside inward. However, individuals may save face by silence or speak mistruths during the medical visit, whereby projecting what is expected from the patient “audience” (14). Stigma works self-reflexively, necessitating a social construction of a private and public self (15).

Case in point, can a patient not be aware of this stigmatization? Raj (16) powerful describes the use of medical labeling by practitioners. Raj (17) presents the case of becoming the diagnosis. To heal and make healthy a patient equates with a similar move to “normalcy.” The presence of disease is not. Physicians are asked to arbitrate what is arrantly wrong with the health of the patient. If only a less severe physical deterrent or public outings (or none at all) of illness were enough for society to avoid stigmatizing. As a label of diagnosis, HIV and Hepatitis then become unwanted albatrosses in the public sphere (18;19; 20).

Goffman certainly believed in a moral right in performing a role in society, explicitly calling for obligation and respect as an actor/performer (21). Whether a moral right or not, must each of us fill the role of “patient”? The body deteriorates making this a nearly absolute possibility. In doing so, each patient and doctor become team members by making manageable impressions and upholding the actors’ covenantal rules of engagement of that particular illness. The acting appearance reflects a perceived status and this will be linked to the quality of the patient and doctor’s performances (22). Judith Butler (23) asserts that performativity deconstructs power and social relationships. How the patient chooses to navigate the discourse may then call for the use of performativity. But I would argue that the medical visit would only allow for a conception of meaning within that staged performance.

A diagnosis innately defines a self as an “other,” someone different from the healthful and productive. The diagnosis does not automatically remove the personal consequences wrought on the patient. Goffman has realized that acting runs the development of social interaction, where the dramatic depiction can ring true or be falsified. Following the dramatic turn with transcendence, as theorized by Goffman, would salvage Jane or the patient when no other solution could be found. When Jane Eyre wrote, “reader, I married him (Rochester),” she culminated her drama. Will a patient be able to say he divorced AIDS? No, it remains a chronic reality.

Medicine is a profession that is shrouded in a mystique that can make a patient-doctor relationship more complicated to navigate. That is a heavy burden to shoulder. I understand that there are many signs given by patients. Could that person without perceived blemish fully adhere to the medical expectations required of both sides in this possibly stigmatic dyad? I wonder if Percy Bysshe Shelley was at all knowledgeable of his stigma as a philanderer. I would surmise not; he simply “was” Percy. Society gave his actions a label. Shelley gained far too much prominence from his love poetry for this to be of consequence. Society’s acceptance of his work, mine included, reinforced his sense of self. Shame was trumped by society’s notions of importance of this literary gift.

I ask what gift is left to the patient in this call of full disclosure. At times the gift of healing is left unopened. Certainly, this disclosure is with absolute purpose of healing. Again, I ask, what comfort is gained in complete personal nakedness when the other part (doctor) does not reciprocate this favor? In order to maintain ethical care, the focus, but shared culpability, should fall on the fellow actor, the patient. Do we reward our patients’ performances? I stress the heightened responsibility of the physician to heed this inequality of circumstance and remain mindful of the supporting cast’s “process.” This process may in turn reaffirm the humanity of the medical care being offered. But isn’t that the point?

Notes

(1) Raj, Y. (November 2005). Lessons from a label maker. Annuals of internal medicine, 143 (9), 687.
(2) Goffman, E. (1973). The presentation of self in everyday life. Woodstock, NY: Overlook Press.
(3) Goffman, E. (1973), previously cited.
(4) Tunc, T. (2008). Female urinary incontinence and the construction of nineteenth-century stigmatized womanhood. Urology, 71, 767-770.
(5) Shapiro, J. (2002). Self and other through the prism of AIDS: a literary examination of relationships with patients. Microbes and Infection, 4, 111-117.
(6) Goffman, E. (1973), previously cited.
(7) Goffman, E. (1963). Stigma: Notes on the Management of a Spoiled Identity. Englewood Cliffs, N.J.: Prentice-Hall.
(8) Goffman, E. (1963), previously cited.
(9) Goffman, E. (1963), previously cited.
(10) Goffman, E. (1973), previously cited.
(11) Rintamaki, L., Scott, A., Kosenko, K., & Jensen, R. (2007). Male patient perceptions of HIV stigma in health care contexts. AIDS Patient Care and STD’s. 21(12), 956-969.
(12) Shapiro, J. (2002), previously cited.
(13) Goffman, E. (1973), previously cited.
(14) Goffman, E. (1963), previously cited.
(15) Raj, Y.(2005), previously cited.
(16) Raj, Y. (2005), previously cited.
(17) Shapiro, J. (2002), previously cited.
(18) Klitzman, R. & Greenberg, J. (2002). Patterns of Communication between gay and lesbian patients and their health care providers. Journal of Homosexuality, 42(4), 65-75.
(19) Schafer, A., Scheurlen, M., Felten, M., & Kraus, M. (December 2005). Physician-patient relationship and disclosure behavior in chronic hepatitis C in a group of German outpatients. European Journal of Gastroenterology & Hepatology. 17(12), 1387-1394.
(20) Goffman, E. (1973), previously cited.
(21) Goffman, E. (1973), previously cited.
(22) Butler, J. (1999). Gender trouble: feminism and subversion of identity. New York: Routledge.
(23) Shapiro, J. (2002), previously cited.

This piece was originally published in the Yale Journal for Humanities in Medicine.

Featured image courtesy of The Library of Congress.