PII:
Soc. Sci. Med. Vol. 47, No. 9, pp. 1267±1276, 1998
# 1998 Elsevier Science Ltd. All rights reserved
Printed in Great Britain
S0277-9536(98)00192-0
0277-9536/98 $19.00 + 0.00
DOCTOR TALK AND DIABETES: TOWARDS AN
ANALYSIS OF THE CLINICAL CONSTRUCTION OF
CHRONIC ILLNESS
RONALD LOEWE,1* JOHN SCHWARTZMAN,2 JOSHUA FREEMAN,3
LAURIE QUINN4 and STEVE ZUCKERMAN5
Department of Family Practice, Cook County Hospital and the Department of Medical Education,
University of Illinois at Chicago, Chicago, IL, U.S.A., 2Christian Industrial League and the
Department of Psychiatry, University of Chicago, Chicago, IL, U.S.A., 3Department of Family
Practice, College of Medicine, University of Texas Health Science Center at San Antonio, San Antonio,
TX, U.S.A., 4College of Nursing, University of Illinois at Chicago, Chicago, IL, U.S.A. and
5
Department of Family Practice, Ravenswood Hospital, Chicago, IL, U.S.A.
1
AbstractÐDuring the last two decades the illness narrative has emerged as a popular North American
literary form. Through poignant stories, well-educated patients have recounted their struggle with disabling diseases as well as with the hospitals and health care bureaucracies from whom they seek service.
However, much less has been written about the doctor's narrative construction of chronic diseases
either in the process of learning medicine or through diagnosing, treating and counseling chronically ill
patients. Indeed, following Kleinman's lead, the physician's narrative has been narrowly viewed as a
discourse on the veri®able manifestations of pathophysiology. Drawing on contemporary theories of
storytelling Ð including the conception of narrative as conversational interaction Ð the present paper
argues that doctor narratives are equally complex if quite di€erent than patient stories. Indeed, through
an analysis of doctor talk centering on diabetes mellitus collected in several distinct venues Ð case presentations, narrative interviews and medical consultations Ð it is argued that physician stories not only
employ very evocative tropes, but that these stories combine didactic, rhetorical and soterological elements in the telling. The research was conducted at two, urban family practice training sites in Chicago. # 1998 Elsevier Science Ltd. All rights reserved
Key wordsÐnarrative, discourse analysis, diabetes, chronic illness, doctor±patient relations
INTRODUCTION
Over the last twenty years the illness narrative or
illness biography has emerged as a popular North
American literary form as well as a primary data
source for medical ethnography. Through vivid
accounts of their struggle with chronic or disabling
diseases, patients have attempted to educate doctors
and other health care professionals about the
impact of major diseases on their family life, identity and self-image as well as detail their travails
with the medical establishment. A short list of such
works would no doubt include Norman Cousin's
two popular volumes, The Anatomy of an Illness
(1979) and The Healing Heart (1983), The Body
Silent by Robert Murphy (1990), and At the Will of
the Body (1991) by the sociologist Arthur Frank.
Even physicians have contributed to this literature,
although in their roles as patients. In A Leg to
Stand On (1984), for example, the neurologist
Oliver Sacks describes in Go€manesque terms the
ritual quality of his communication with the sur*Author for correspondence.
{(See also A. Broyard, 1993).
geon who sewed his leg back on, and the isolation
and reprobation he felt as a convalescing patient.{
Through narratives such as these the complexity
of the illness experience is seen. Unlike the standard
medical history which reduces the patient's experience to a chronology of symptoms and signs, the illness narrative is a multistranded discourse, an
individual attempt to constitute a meaningful explanation of disease by drawing on cultural and personal resources at hand; religion, family history,
and folklore as well as aspects of biomedicine that
are familiar to the patient.
Much less has been written about the doctor's
narrative construction of chronic diseases either in
the process of learning medicine or through diagnosing, treating and counseling chronically ill
patients. Only recently have scholars (Sharf, 1990;
Hunter, 1991; Mishler, 1995a) begun to think of the
medical interview, the case presentation or the
morning report as a story, a speech event which is
amenable to the principles of narrative analysis.
While Arthur Kleinman does include physician stories in The Illness Narratives: Su€ering, Healing and
the Human Condition (1988), unlike the patient stories (or explanatory models generally), these vignettes are not built up around particular disease
1267
1268
R. Loewe et al.
episodes, but are broadly biographical and, therefore, do not shed much light on problems which
emerge in clinical encounters between physicians
and chronically ill patients. Secondly, as Barbara
Sharf notes, Kleinman continues to de®ne the physician's disease narrative, as stories which are ``narrowly focused on the veri®able manifestations of
pathophysiology (Sharf, 1990, 222)''. While there is
certainly an element of truth to this description of
physician talk, it strikes us as overly simplistic.
Indeed, notwithstanding Kleinman's avowed interest in reforming medical practice, we believe such a
view ultimately reinforces the image of the physician as a neutral observer of physical processes, an
observer unfettered by the cultural or moral lenses
which direct the gaze of others.
More interesting, in our view, is Kleinman's contention in an earlier work (cf. Patients and Healers
in the Context of Culture, (1980)) that doctors and
patients are able to communicate only because the
actual medical consultation deviates greatly from
the medical model. How does it di€er? What
speci®cally facilitates communication? Why does
communication about chronic conditions remain so
frustrating for both parties? And how is our understanding of a medical consultation transformed if
the medical consultation is viewed as an exchange
of narratives?
Nor has much been written on the way doctors
and patients' stories meld or fail to meld although
this is certainly one way to account for problems
which occur in the management of chronic illnesses
like diabetes mellitus. Notable exceptions include
Elliot Mishler's recent writing on narrative and the
discussion by Cheryl Mattingly (1994) of ``therapeutic emplotment''.
Building on these works this paper argues that
doctor narratives are equally complex, if quite
di€erent than, patient stories. In particular, through
an analysis of doctor talk centering on diabetes
mellitus collected in several distinct venues Ð case
presentations, narrative interviews and medical consultations Ð it is argued that physician stories not
only employ very evocative tropes, but that these
stories combine didactic, rhetorical and soterological elements in the telling. Finally, the paper calls
attention to some of the ways in which doctors'
stories about diabetes are shaped by the cultural
and class di€erences between patient and provider.
NARRATIVE IN A NUTSHELL
As several writers have noted (Langellier, 1989;
Riessman, 1993; Mishler, 1995b) the paradigm for
analyzing orally produced texts is found in a study
by Labov and Waletsky (1967), which examined
stories that Black teenagers tell to members of their
peer group (as well as Labov). According to this
paradigm, narrative is a very restricted category of
speech. To be considered narrative, in even a mini-
mal sense, a speech event must contain a story
about a speci®c past event which is remarkable,
unusual, dangerous or strange in some way. A fully
formed narrative, in their view, contains six additional formal and functional attributes: (1) an
abstract, a summary or overview of the content
which follows, (2) an orientation, a description of
the setting including time, place, characters, etc., (3)
a complicating action or sequence of events (e.g., a
plot), (4) an evaluation, a statement by the narrator
which interprets the meaning or signi®cance of the
events described, (5) a resolution, an account of
how things turned out, and (6) a coda, a statement
which returns the listener or audience to present
time.
From Labov and Waletsky's standpoint narrative
is representational rather than constitutive of reality. Elements of a narrative follow a chronology
which mirrors the order of events in the narrated
world. Events move in a linear way through time
and the ``order can not be changed without changing the inferred sequence of events in the original
semantic interpretation (Labov and Waletsky, 1967,
21)''.
While the elements of Labov and Waletsky's
model remain central to narrative analysis, they
have also been criticized for failure to consider the
context in which narrative texts are produced,
speci®cally the relationships between the narrator
and the researcher and the narrator and his peers.
As Langellier asks:
Which features of the Labovian model, for example, are
by-products of the interview context? Is the presence of
the abstract basically a summary response to an interview
question for which narrative is an elaboration? Does the
frequently absent coda signal the way in which the interview and the naturally-occurring conversation di€er?
What e€ect does the interviewer's outsider status have on
the evaluative function (Langellier, 1989, 248).
The idea that narrative events mirror or recapitulate ``actual events'', is even more problematic.
How would we know that the events described in a
narrative ever occurred, except through some other
narrative? And how, then, are we to adjudicate
between di€erent narratives? Are some narratives
privileged over others? The fact that narratives are
by de®nition evaluative, e.g., that they embody the
narrator's viewpoint or interest, suggests that there
is no Archimedean point on which to test correspondence theories of reality.
Nor is it clear why narratives are limited to stories about past events. Why can't narratives also be
stories about events which are deemed likely to
occur in the future, such as a doctor's prognosis?
As Beach and Japp argue in another context, this
view of temporality is overly restrictive, and ignores
the ``way interactants switch from one time frame
to another, from what has happened to what might
happen (In Langellier, 1989, 258)''.
Doctor talk and diabetes
From criticisms such as these other modes of narrative analysis have emerged. Of particular interest
to us are studies which fall broadly under the rubric
of narrative as conversational interaction or personal interaction (Langellier, 1989). Associated with
writers like Clark and Mishler (1992), Polanyi
(1985), Sacks (1986) and Je€erson (1978) this perspective situates narrative in naturally occurring interactions which would, of course, include medical
consultations, case presentations or a faculty precepting sessions. Rather than viewing narrative as a
discrete unit of discourse, or a performance by a
virtuoso speaker, personal narrative is mutually
constructed by participants according to shared interaction rules (In Langellier, 1989). In fact, scholars working in this vein have been particularly
interested in examining how the storytelling function is distributed among multiple speakers in larger
discursive frames. Do they compete for the speaker's role, co-narrate the story, or just listen?
While this approach implies that there are certain
mutually understood rules governing the interaction, and the allocation of turns, it does not
require that turns or time be distributed equally. As
Polanyi points out, the recipient (e.g., the patient)
of conversational storytelling is obliged to: (1) hear
the story if it is proposed, or present a reason why
it should not be told, (2) refrain from taking a turn
except to ask a question or acknowledge that the
story is being understood, and (3) demonstrate that
the main point is grasped by making a comment, or
by telling the next story (In Langellier, 1989, 258).
In this frame, storytelling is also seen as a seamless part of the social relationships which exist or
are being formed between narrator(s) and the audience. Rather than viewing the interlocutors simply
as individuals occupying distinct speaker±listener
roles, partners enact roles which are marked by
di€erences in gender, race, status and class.
As with Labov, stories are evaluative, that is,
they are told to make a speci®c point. For Polanyi,
however, the story is only really e€ective if it is
occasioned by some prior comment which makes
the story pertinent. Or, as Langellier writes, ``a
competent narrator builds a bridge from what is
happening here and now in the ongoing talk to
some state of a€airs in the storyworld and back to
the conversation again by relating the storyworld
*One clinic is located on Chicago's near west side and
serves an indigent, predominantly African±American
population. The other clinic is located in Little Village
on Chicago's southwest side, and serves a low-income,
predominantly Latino population. While normally only
interns are required to present their patients to the
attending physicians, all residents were asked to present their diabetic patients when a member of the
research team was present.
{In one case, we blurred the conventional categories by
interviewing a medical student who has had diabetes
since age ®ve.
1269
and the interactional context (Langellier, 1989,
257)''. Therefore, good storytellers are not necessarily people with the best presentational skills, but
individuals who can ad lib e€ectively, narrators
who can formulate a story or adjust it to particular
conversational context.
Finally, it should be reiterated that narrative
analysis need not be an end in itself. As Gee et al.
(1992) points out there are two rather distinct uses
of narrative or discourse analysis. In the ®rst category are studies which ``focus on the form, meaning and regularity of supersentence texts as
representative instances of particular discourse genres (Gee et al., 1992, 229)''. Here, analyzing the
structure of a text and comparing it to other genres
of text is the goal. The other approach, as Gee
notes, is to use discourse analysis as evidence in the
investigation of some larger social or cognitive process. Our goal, in line with the second approach, is
eminently practical: to understand the world view
and practice of physicians treating diabetes as
revealed in their narratives and interactions, and to
learn why this is often such an unsatisfying process.
METHODS
As noted above, physician narratives were
sampled in a variety of clinical and non-clinical
contexts. In order to tap into the natural discourse
between physicians regarding Type 2 diabetes, clinical precepting sessions between attending physicians
and family practice residents were recorded at two
family practice training sites in Chicago.* In addition, several medical consultations involving residents or attending physicians and their diabetic
patients were videotaped and analyzed. This data
collection technique was, of course, limited by the
diculty of getting informed consent (and permission to videotape) from two individuals simultaneously (e.g., doctor and patient), but provided
the research team with an opportunity to compare
the intersubjective context of clinical care with
statements made about clinical care by physicians
and patients in narrative interviews. Finally, residents and attending physicians were interviewed
outside the clinic using a ``minimally structured''
interview guide (see Appendix A).{ These interviews
typically began with an invitation to discuss particular cases involving diabetic patients which the
interviewee found interesting or illuminating in
some way, and, thus, generated many rich stories
about clinical care.
By referring to precepting sessions between family
practice attendings and residents as natural discourse, the authors do not intend to suggest that
such sessions were not in any way a€ected by the
presence of an observer. Attendings and residents
were both aware of the observers, and attendings,
in some cases, were asked to clarify medical terminology between precepting sessions. The dialogues
1270
R. Loewe et al.
were, however, constrained by the fact that the residents were seeing actual patients at the time and,
therefore, focused on issues the two parties deemed
essential to patient care. In contrast, the interviews
we conducted with physicians seemed less constrained by the exigencies of the situation, and
enabled them to talk about patient care in a more
ideal or abstract manner. The fact that the interviewer/interlocutor was in most cases a Ph.D. rather
than a MD or a clinician also most likely a€ected
the nature of the narratives produced.
All of the speech events described above were
audiotaped or videotaped, transcribed in their
entirety and distributed to members of our research
team which included three anthropologists, two
family therapists, a family practice physician, a
clinical psychologist and an endocrinologist.* The
transcripts were, thus, coded and analyzed independently (in batches of ®ve or six) by each of the
members and then discussed in monthly data analysis sessions which were also tape-recorded. In these
meetings the interviewer/observer provided additional information about the context in which the
stories were recorded, noting circumstances which
may have a€ected the production of the text under
discussion. Through this process, and the development of several concept papers, the team identi®ed
a series of themes and strategies relating to problems in the management of diabetic patients, and
further re®ned the interview protocols.{
Our decision to elicit stories in multiple settings is
rooted in the belief that stories, like other forms of
social action, are sensitive to the context in which
they are told. It is also, however, a measure of our
*Both of the family therapists are also Ph.D. anthropologists. A few months after the project began, the endocrinologist left and was replaced by a Ph.D. in Nursing
who is also a certi®ed diabetes educator.
{As the data set grew to unmanageable proportions the
transcripts were entered in Nud.ist, a qualitative data
management system, and indexed according to format
(e.g., precepting session, interview, etc.), speaker attributes (e.g., ethnicity, gender, professional status, etc.)
clinical site, and other features. This procedure not
only enables us to quickly identify units of text relating
to a particular theme, but to compare the use of key
concepts like ``control'' across a variety of speakers.
{In this regard, we note that an important aspect of residency training involves teaching doctors to restrict
``doctor talk'' to doctors. For example, in the course of
preparing a workshop on doctor/patient communication, the Director of the pediatrics residency complained to one of the authors about a resident who
reveled over the clarity of an EKG during a pediatric
cardiology consultation. ``I'm sure the family didn't
hear a word after the resident mentioned that the
EKG came out crystal clear, but they have a very sick
kid.'' A second intern, according to the Director, had
to be admonished for telling a man that one of his
relatives had died, ``but in perfect Harvard balance''.
(Personal communication, Director of Pediatrics,
September, 1996, Department of Pediatrics, Chicago,
IL).
dissatisfaction with the direction in which qualitative health research has moved in recent years.
While we are grati®ed to see that other researchers
have been making the case for the use of qualitative
methods in health care research, we are disappointed by the tendency to reduce qualitative
research to semi-structured interviews or to focus
groups. While these are clearly more ecient ways
of collecting data and facilitate comparisons across
sites and across researchers, they ultimately produce
a set of ``representations'' (Durkheim, 1915), ``ideal
types'' (Weber, 1968), or ``doxa'' (Bourdieu, 1977),
and tell us little or nothing about the more ine€able
realm of practice.{
Listening to medical stories in diverse settings
also aids in the interpretive process. For example,
after reviewing numerous precepting sessions where
residents justi®ed their interventions to attending
physicians on the basis of medical tests and epidemiological information, it is easy to understand
why Dr. M (below) thinks that presenting statistics
to her diabetic patients is an e€ective rhetorical
stratagem for motivating poorly controlled diabetics, even though her supervising attending would
disagree. Similarly, Dr. M's complaint, incomprehensible to the Ph.D. interviewer, that ``[patients]
really aren't aware that dieting doesn't do any good
without exercising three times a week and getting
your heart rate up to 220 minus your age times
0.7'', serves as an analog of the problematic consultation. It exempli®es the diculty that this doctor
has adjusting the message to audiences with less
medical knowledge. In short, operating in multiple
research venues enabled us to see how physicians
sometimes innocently transfer one rhetorical strategm
from a setting where it is appropriate to one in which
it is inappropriate or incomprehensible.
Similarly, the physician interviews not only produced stories which were qualitatively di€erent
from those that emerged in precepting sessions or
medical consultations; they served as meta-narratives as well, or as we discuss in Section 5, commentaries on what constitutes a good story in the
context of a diabetes consultation.
ELEMENTS OF NARRATIVE
Time and agency
Patient stories generally begin with the discovery
that they have diabetes, or one of the events leading
up to their diagnosis, and move forward in time to
the present or an inde®nite future. Physician narratives, on the other hand, begin at the moment of
onset, at media res as Hippocrates suggested
(Hunter, 1991), and move forward toward a more
or less predictable future, either because the patient
is thought to have little e€ective control over the
Doctor talk and diabetes
disease (i.e., biology and genetics supersede selfregulation) or the patient is unable or unwilling to
regulate him or herself (i.e., environment and culture supersede self-regulation). In¯uenced by statistical reasoning, physician time becomes ``organic''
time in the sense that it is marked by the progressive and relatively predictable breakdown of speci®c
organ systems.
...so nephropathy we believe is related to the length of
time the person has had diabetes and the control they've
had over the years.* There's some study that suggests that
other things come into rule like genetics and race... but
that's all theory... so its important to identify early, uhhh
whether a patient's having [proteinuria] or not, because
once a patient has gross proteinuria end stage renal failure
or kidney transplant is within ®ve years... what I've heard
from the nephrologist is once you have microalbuminuria
it's like a ®fteen year type of progression from microalbuminuria to end stage renal disease, but its di€erent for all
patients... 50% of the patients that have diabetes for
longer than 25 years had some signs of peripheral neuropathy... the ophthalmologists at Rush believe that anyone
who's had diabetes over ten years, you can detect some
degree of retinopathy [Taken from a presentation by a 3rd
year medical student to a group of attendings and family
practice residents.]
But if the doctor's narrative tends to be progressive and episodic, a timeline which can be presented
back to the patient who is ``caught up in the act of
daily life'', there is also a de®nite tension between
this aspect of narrative construction and other
aspects of medical ideology and practice, namely
the emphasis on intervention and individual responsibility. Touching on the issue of individual responsibility, Dr. G., a third year resident remarked:
I tell them that the main, key player is themself, the
patient. And all these people who are around, they should
help him or her to improve themself, but like in our exercise program, I make it very clear that I cannot have a
diet for you, you know. And I remember that one patient
told me, ``Well'', he said, ``you are telling me to exercise.
How come you don't do it yourself?'' I said, ``I'm not diabetic.'' You know, [laughing] the whole point is that I
always make sure that they are the people who can control
the disease.
In short, while ambivalence about the bene®ts of
glycemic control and a pervasive doubt that
patients will exercise or eat well, leads to the formulation of a weak, unheroic subject, other ideals of
medical practice and culture place the diabetic subject back at the helm. Or do they?
Here it should be noted that following the soliloquy on ``responsibility'' cited above, the resident
went on to discuss the great lengths he goes to in
order to control his out of control patients.
*The diabetes control and complications trial (Diabetes
Control and Complications Trial Research Group,
1993) has shown that nephropathy, neuropathy and
retinopathy can be slowed or prevented by good blood
glucose control, but the bene®ts of tight control for
Type 2 diabetes remains questionable.
1271
RL: Uhh huh [pause] How often do you schedule appointments for diabetic patients, or does it depend on the severity of their illness?
Dr. G: Well it depends on how controlled they are... If it's
somebody who is not controlled and they have a problem
to monitor their sugar then I see them more frequently.
Another trick, trick that I've been using lately, especially
at [Little Village Clinic]... I ask them to come at least two
or three times a week to the clinic to have their glucose
checked by the nurse. Then they, most people come a
couple of times a week fasting, then we check... if they
have it [a glucose reading] in their chart or they write on a
piece of paper, then they bring it with them.
In light of this, it is easy to understand why
Matthew Timmerly, Arthur Kleinman's diabetic
patient, felt that the doctors were constantly
``switching signals'' on him.
They tell you to run with the ball and help plan the play,
then when the situation changes [the patient is out of control] they take the ball away from you and tell you to stay
out of the decision making, leave it to the experts. It can
be terribly frustrating (Kleinman, 1988, 171).
The larger question, however, is whether the idea
of ``taking responsibility'' makes sense to diabetics
or other chronically ill patients. Even if Dr. G. did
not attempt to ``tether'' his patients to the clinic by
having them come ``at least two or three times a
week'', would they feel capable of controlling their
bodies and their diabetes, or do chronically ill
patients begin to think that the body is ``alien to
the acting self (Good, 1994, 124)?'' As Byron Good
points out in the case of Brian, a patient diagnosed
with temporomandibular joint syndrome (or TMJ),
pain is what has agency. ``His body dominates consciousness, undermining his sense of being an `undivided total self' who is the `author' of activities,
threatening to unmake the everyday world (Good,
1994, 125)''. In other words, unlike the doctor, the
patient may not be able to separate herself into subjective and objective states Ð will and body Ð and
use the former to control the latter.
Rhetoric which cuts to the bone
A recurrent theme among the health care providers (physicians and physician assistants) interviewed, is the diculty of getting asymptomatic
patients to see the long term consequences of
uncontrolled diabetes. This not only requires that
patients accept the physicians' ``timeline'' noted
above, but that they begin to visualize the invisible
processes occurring in their bodies or their tangible
e€ects. As one physician assistant noted:
We can present all of the information, but are we gonna
present it in a way in which they can understand it, and
that can get through, you know, the 10 or 15 things that
are ahead of diabetes as being important? So I think that's
our problem as health care providers... they don't see that
the changes they make really a€ects their life and keeps
their kidneys and eyesight and everything. It's too far
along, in the future to see any immediate...
One solution to this dilemma, though clearly not
the only solution, is to highlight the connection
1272
R. Loewe et al.
between internal processes and external (i.e., visible)
states through vivid imagery and synecdoche. Thus,
rather than telling a common tale about the pancreas and insulin production, one experienced physician o€ered a very visceral tale about diabetes and
foot problems in the course of a medical consultation, thereby reducing a complex phenomena to a
highly cathected symbol. The patient, as Langellier
suggests, simply demonstrates his understanding of
the issues presented.
on an ``inner narrative'', a subject reserved for case
presentations and precepting sessions, at least one
third year resident felt they might be used to persuade non-compliant patients:
DR: O.K. when you're a diabetic you lose sensation in the
bottom of your feet sometimes so you may have a cut that
you don't even feel.
RL: Do you think that Ð you emphasize the science and
the statistics. Do you think that's really what motivates
them to comply?
PATIENT: Uh huh.
DR: ...but I think if you do use numbers also I think that
the people feel you have respect for them, that they have
some intelligence and that you're talking to them uh, not
in glittering generalities, but in numbers, I mean they are
numbers, but they're not that scienti®c and I think that
they have a little more respect for themselves and their
ability to control if they can measure sugars, do this and
that, and when you consider measure and write down
things, then people can see for themselves.
DR: And the only time you might notice it is when you
take your socks o€ and you notice pus in your socks and
by that time it's time for the knife.
PATIENT: Serious.
DR: You heard about diabetics losing their feet and stu€
like that?
PATIENT: Right.
DR: Well see that's why it happens because they don't
check their feet every single day because decreased sensation in your feet allows infections to go a long way
before you realize it is there.
DR: But it seems that if you back things up with numbers
sometimes, and say okay you have to exercise this many
times a week, this many minutes, with your heart rate at
such and such, then they seem to think it has a scienti®c
reason. And I always let them know it's not a beauty
issue, that this, this weight thing isn't meant to be a
beauty issue, that it's a health risk.
Such a view, of course, assumes that the scientism
of the physician is shared by the patient and that
quanti®cation provides the best window onto reality.
PATIENT: Uh huh.
DR: And by the time you realize it's there a strain of pus
is already to the bone and it's time for the man with the
knife in his hand to have a stab at your foot. That right.
PATIENT: O.K.
DR: And once they start cutting generally they cut a little
bit here, cut a little bit there and next thing you know
they're up to your knee and once you get one leg cut o€
generally the other leg is cut o€ within ®ve years because
if you don't move around the circulation goes bad in the
other leg real quickly.
PATIENT: O.K. in real life you see what the reading is
today.
Therefore, while ``educating the patient'' is the
phrase most commonly used by physicians to
describe what they do in the context of a diabetes
consultation, education does not simply involve presenting information to poorly educated diabetics Ð
as several physicians imply Ð or even reminding
patients of the things they repeatedly forget (e.g.,
proper nutrition), but returning to the things
patients know best. Indeed, a second physician's
comments about ``fear'' could serve as a commentary on the ®rst:
Well fear's always there. I hate to say always a good tool
to me, sometimes, but umm I think that that's one thing
especially `cause most diabetics will know someone who had
to get an amputation, you know. They de®nitely associate
that with diabetes.
Statistics as rhetoric
In other cases, a more impersonal rhetoric is
employed. While the discussion of numbers, hemoglobin A1C and creatinine levels, is generally part
The physician as dramatis personae: the educator,
the nagging wife, the compulsive doer and god
In the course of interviewing physicians and
eavesdropping on clinical precepting sessions, the
authors were privy to a variety of di€erent comments and re¯ections on the doctor's role in the
diabetes drama, and their de®nition of the doctor±
patient relationship. While several physicians discussed the importance of negotiating with patients
to get them to eat fewer sugary treats, and one
practitioner even spoke of forming a ``therapeutic
alliance'' with her patients, several physicians told
stories which portrayed the doctor as an adversary
or authority ®gure.
This self-characterization was particularly common when physicians chose to talk about the di€erences between themselves and other providers (e.g.,
nurses, dieticians) who work with diabetic patients.
While most of the physicians interviewed would
readily admit that they learned little about diet and
nutrition in medical school, a good part of the diabetes consultation was devoted to discussing this
issue, notwithstanding the presence of dieticians
and the severe constraints that a crowded public
hospital or clinic places on a physician's time. The
rather unremarkable revelation, as one resident stated, is that the physician speaks with the authoritative voice of medicine.
It'll be great if some of those things the dietician is going
to tell them, that we tell them, because some of them
takes what we tell them as the gospel truth, [but] they take
the dietician as a dietician.
Doctor talk and diabetes
A second physician, however, was less sure of
whether she spoke with the ``authoritative voice of
medicine'', or the voice of a nagging mother*:
I guess what strikes me is it's just sort of a real bummer
to be asking people to change their lifestyle and watch
what they eat `cause it's just not very fun for them, and
you just kinda feel sorry for them for being in that position, ummm it's just sorta like you're their mom, nagging
them over and over again...
What are the implications of this attitude for the
management of diabetic patients?
Likewise the need to intervene, to ``do something'', is noted by one physician and team member
during a discussion about the absence of scienti®c
evidence showing that tight glycemic control prevents many of the more common complications
from developing:
Ð the blood sugar's a marker of one of the manifestations
of diabetes, but they're only manifestations of diabetes,
and it isn't clear that by stepping on one [symptom], that
you prevent the others, that by bringing down the fever in
a cold you prevent them from having running noses... and
I think you'll never convince doctors that controlling
blood sugar doesn't help, because nobody's gonna do a
study to try and prove it, and until we ®nd something else
that we can watch to control, it helps... I certainly want to
believe that John, because I can do something, that's something I can impact on...
Indeed this comment echos a poignant remark
made by the British physician Oliver Sacks after he
sustained a leg injury which required a long period
of convalescence and inactivity. Re¯ecting on his
pre-injury status as a physician, Sacks states that he
believed: ``in the noonday light of reason that whatever was worth accomplishing in life could be
accomplished, by that strong masculine sense...
enterprise... vigilance and activity which had
characterized my previous endeavors (Sacks, 1984,
88)''. After the injury he was much less sure.
What are the implications of this attitude for the
care of diabetic patients?
THE CONSULTATION AND ITS CONUNDRUMS: WHAT
SHOULD THE PATIENT HEAR?
Diabetes narratives not only convey a certain
mood, but are told with certain purposes in mind.
They can be used to frighten patients, to humor
them, or to give them hope. Thus, one thing we
learn through stories is the physician's view of
human nature, what he or she believes motivates
patients to action. By having physicians comment
on these stories (in the course of an interview), we
*While this somewhat negative, self-characterization might
be viewed as a dilemma speci®c to female physicians,
the concept of the physician as a nagging parent is
echoed by male practitioners as well.
{How physicians' stories resonate with patients, or what
patients consider a good story, is unclear at this point.
These are questions we hope to answer in the next
phase of our research.
1273
create a meta-narrative, and learn more about what
a good story entails. What are the canons of good
storytelling in the context of a medical consultation,
of a diabetes consultation? What mood should the
storyteller create? While the research team encountered a variety of di€erent narrative styles, some
overarching similarities were also identi®ed. While
fear is often necessary or inevitable, and providing
hope is highly valued, providing ``false hope'' is
anathema. Finding the balance between fear and
hope is clearly the unstated key to being an e€ective
storyteller from the physician's standpoint.{
As one third year resident clearly stated:
The only problem is with fear, it can initiate actions, but I
don't know if it maintains actions, and so I'm not convinced that's the way to go,... it's helping her now, but
I'm not sure what it takes to maintain it. I think she's
gonna need some other support and back up to keep her
going because I think, you know, once the existence of
what it was that scared her wears o€ I'm not sure she'll be
able to continue... it has some bene®ts initiating, but I'm
not sure how much more.
What's most interesting about this aspect of the
diabetes narrative, is that it represents one area
where physicians do not want their diabetic patients
to share their perspective on the disease. Whether
because of their experience as medical students, or
because of the questions that remain about the
value of tight glycemic control in Type 2 diabetics,
many physicians were horri®ed by the disease, and
ambivalent about the standard medical treatment.
As one attending put it:
I think medical students get the experience of diabetes in
the hospital frequently, so they see diabetics that are having their second cardiac bypass, or having their legs cut
o€, or on dialysis. They see the worst end of diabetes
instead of seeing the beginning. And so we come into working with diabetics without a lot of hope, because what we
see when we're training is the end product of people with
uncontrolled diabetes... and so we sort of go, ``this is a
horrible disease''. And someone who is diabetic doesn't
want to hear that. They want to say, ``Oh there's lots of
things you can do to live a long happy life.'' But what
medical students get is this horrible picture of what a diabetic's life is. So, a lot of times we don't have a lot of
hope...
Similarly, other physicians and physician assistants we spoke with made invidious comparisons
between diabetes and cancer, or diabetes and
AIDS, and one third year resident we interviewed
refused to recount her pessimism while the tape
recorder was running.
Therefore, while the physicians in this study
clearly wanted their patients to recognize the progressive nature of the disease (without becoming
fatalistic) and to realize that they can be sick without feeling ill, the unenviable task Ð the key to
good storytelling Ð was to instill these perspectives
without, at the same time, conveying one's sense of
melancholy or pessimism.
1274
R. Loewe et al.
CONCLUSION
``When we hear stories'', Catherine Riessman
notes, ``we expect protagonists, inciting conditions
and culminating events (Riessman, 1993, 18)''. In
this way doctor narratives are like patient narratives
or the narratives of any other group of storytellers.
What's di€erent is the nature of the protagonists,
the conditions that do or don't incite them and how
events actually culminate. As always, the devil is in
the details. For this reason, we believe that it is
time for researchers to begin delving into the details
of doctor talk to learn why doctors and patients
talk past one another when it comes to the management of chronic illnesses like diabetes. Despite invocations to study up the vast majority of social
scienti®c research relating to health belief, action
and practice still focuses exclusively on the patient.
This study seeks to begin rectifying this problem.
While physicians generally describe their task as
``educating the patient'' about the risk of diabetes,
education is really a euphemism for a style of rhetoric or argumentation which involves graphic
descriptions of patients in advanced stages of the
disease, references to scienti®c reports, or entreaties
to observe shared cultural ideals such as personal
responsibility. In this regard it should be noted that
``control'', the centerpiece of many narratives, is a
cultural ideal as well as a measure of metabolic
functioning, and may be used in both ways in the
course of a single consultation.
While physician narratives are produced interactively and embody features of the setting in which
they are produced, there are a variety of external
factors which a€ect what gets told. One of the more
salient ones seems to be the experience young physicians had with diabetic patients during a hospital
rotation, or the stories he or she heard as a medical
student. As one senior physician noted, medical students hear a lot of ``locker room talk'' about the
diculty of changing patient behavior and ``come
out of school somewhat jaded''. Thus, physician
stories have a life of their own.
Given the numerous discussions of fatalism and
its implications for compliance in the anthropological literature it is also interesting to note the pessimistic tone which colors many physician narratives.
Either because the patient is thought to have little
e€ective control over the disease (i.e., biology and
genetics supersede self-regulation) or the patient is
*This point, in fact, is noted by others who have studied
interactions between physicians and diabetic patients
(Personal communication, Linda Hunt, at a panel discussion on diabetes at the Society of Medical
Anthropology in Seattle, Washington, March 5, 1997).
{This comment was made in a lecture titled, ``When the
Patient is a Linguist: Re¯ections on the Language of
Medicine'', at Rush Medical College in Chicago on
Thursday, January 8, 1997. The lecture was part of the
James Campbell Distinguished Lecture Series.
unable or unwilling to regulate him or herself (i.e.,
environment and culture supersedes self-regulation),
diabetes is thought to have a predictable and dire
course. Its course can be plotted and timed.
Physician narratives, in short, are teleological: they
reveal a bleak prognosis tempered only by the belief
that medical science will eventually rescue both the
doctor and the patient from this dilemma.
Such pessimism not only belies the more optimistic tone of the medical consultation, but leads to a
series of conundrums. For example, while physicians privately acknowledge their doubts about the
bene®ts of glycemic control, or even the possibility
of losing weight, they often end up blaming their
patients for poor compliance or negative outcomes.* As Suzanne Fleischman noted in a recent
lecture on the language of medicine at Rush
Medical College{ it is not unusual to uncover a
``metonymic slippage'' between the patient's a‚iction and the patient's personality in medical discourse. We would make the same point even more
forcefully by arguing that the diabetes narrative Ð
especially the emphasis on control Ð is part of a
larger social discourse in which disease (as poverty
or homelessness) is considered the result of an individual's failure to achieve autonomy. In short,
ambiguity over locus of control is the core feature of
the diabetes narrative.
Secondly, while physicians may encourage
patients to take control of their diabetes, they often
subtly, or not so subtly Ð as Dr. G. illustrated Ð
usurp the role of controlling agent as the drama
unfolds. And ®nally, while the physicians in this
study clearly wanted their patients to recognize the
``progressive'' nature of the disease and to realize
that they can be sick without feeling ill, they also
felt a need to instill these perspectives without, at
the same time, imparting a sense of melancholy or
fatalism. Herein, perhaps, lie some of the many
reasons why management of diabetes is frequently a
dicult and frustrating process for both parties.
AcknowledgementsÐWe would like to express our sincere
thanks to the American Academy of Family Physicians'
Foundation (AAFP/F) for the generous ®nancial support
they provided. Special thanks also go to DeAnn Pendry,
Barbara Sharf, Anne Larme and Linda Hunt who read
and commented on the manuscript, to Anamari Golf, who
helped design the interview guide and assisted in the data
collection process, to Mike Lieber, Eve Pinsker, Sean
O'Sullivan and Pam Stewart who participated in the
research design phase of this project and to Dionne Hart
who interviewed patients at one of the clinical sites.
Finally, we would like to acknowledge the tremendous
support of Stephanie Tillman who transcribed most of the
audio-tapes and helped coordinate group meetings and
other research activities.
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APPENDIX A
Health Care Provider Interview Guide
Introduction
This research project is designed to help us gain a better
understanding of the diculties of treating Type 2 diabetes. There are several components to our study. We will
be looking at both patient and physician perspectives on
diabetes. For now, however, we are spending time talking
to doctors and other health care practitioners in order to
better understand how they work with their diabetic
patients.
1276
R. Loewe et al.
Background Information
1. Tell me what it's like working with diabetic patients?
Perhaps, you've had some recent experiences with Type 2
diabetes patients which you consider signi®cant or typical.
Probes:
a. Does working with diabetic patients di€er from working with other types of patients?
b. Is there any such thing as a ``typical'' diabetes patient
[If yes, have the practitioner describe the typical diabetic. The point of this question is to elicit stories about
diabetic patients which encapsulate some of the diculties
in managing the disease and capture the practitioners conception of patient behavior, motivation, etc.]
2. Can you describe good treatment for diabetic
patients? Probes: What are the essential ingredients of
good treatment of diabetic patients? What advice would
you give to medical students (nursing students)?
[For interviewees who focus on medical outcomes, ask
them to describe what constitutes a good (e.g., e€ective)
relationship with their patients. Another possible probe
would be: Do you think of your relationship with
NIDDM patients in terms of some other type of relationship (e.g., student/teacher)? In this case, however, it would
be better not to suggest a type of relationship! Let them
come up with it.]
3. How often do you schedule routine visits for your
diabetic patients? How much time do you spend with diabetic patients during a routine visit? What do you do
during the course of a visit?
4. What's the most frustrating aspect of working with
NIDDM patients?
5. What are some of the factors which lead to poor
compliance?
6. Is there anything that health practitioners do which
may contribute to poor compliance?
7. What, if any, background information do you need
about your patients in order to manage their diabetes successfully?
Probes: How, if at all, does the patient's culture, ethnic
background or family a€ect management of this disease?
8. What, if anything, do you have to know about their
families?
Follow up questions:
(a) Do you know the family members of your diabetic
patients?
(b) Do you treat the family members of your diabetic
patients?
9. What should patients know about their diabetes?
Probes:
(a) Should the subtleties of diabetes be explained to the
patient?
[If yes, by whom?]
(b) Should the health practitioner explain that adhering
to a low glucose diet, taking medications, exercising, etc.,
may not result in improved outcomes?
10. What sorts of questions do patients come in with?
Can you describe some of the more surprising questions
you've been asked?
11. What were you taught in school (or during your
residency) about Type 2 diabetes and the treatment of
Type 2 patients?
12. How long have you been working with diabetic
patients?
13. [If the interview is being conducted in a setting
where there are a lot of diabetic patients, ask whether the
practitioner chose to work with a diabetic population.]