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ASA Section on Body & Embodiment
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Crafting the Physician-Body in Contemporary Medical Education

2/28/2017

1 Comment

 
Picture
by Kelly Underman, PhD
Postdoctoral Research Associate
Department of Medical Education
University of Illinois at Chicago



In classic studies of socialization in medical school, scholars wrote of the anatomy lab as a foundational experience for the formation of the physician-in-the-making’s self (see Becker, et al, 1961; Fox, 1988; Smith and Kleinman, 1988; Hafferty, 1991). By working with dead bodies during cadaver dissection, the medical student learned how to hide feelings of anxiety, disgust, and sadness. These formative experiences prepared future physicians for working with patients as passive objects under the medical gaze.

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Thomas Eakins, The Agnew Clinic (1889), Source: Atlas of Science
And yet, there has been a massive transformation in medical education in the past two to three decades. A range of simulation technologies now add to or fully substitute for cadaver dissection. Medical students work with simulated or standardized patients (real people who roleplay as patients for the purposes of teaching and evaluation), haptic simulators (plastic models with pressure-plates that feed information to a computer), virtual reality technology, and so forth. Furthermore, gone is the old model of physician authority that demands passive patient-objects. Patients are to be engaged with, and empathy is to be valued, not suppressed (Underman and Hirshfield, 2016). In fact, in order to be a licensed physician in the United States today, medical students have to pass an exam that tests their ability to effectively and empathetically communicate with patients. During this exam (called “Step 2”), medical students interact with standardized patients who pretend to have an illness or injury, and the medical student’s performance is graded by both the standardized patients and a board of medical experts.
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Students observe an interview with a simulated patient, Source: C3NY.org
Simply put, the world of medical education has changed. The kinds of bodies medical students interact with as part of their training are more varied than ever, and the meanings attached to these bodies are radically different. And yet, few scholars have considered what this means for theories of socialization in medical school. How might new theories of the body and embodiment help explain contemporary medical education?
 
Critiques of (bio)medicine in the past three decades have advanced the idea that the patient’s body is socially constructed. Drawing on path-breaking works such as Michel Foucault’s Birth of the Clinic, scholars have demonstrated that the patient-body is produced as an object under the medical gaze through a range of techniques, practices, and discourses. As such, critics of biomedicine have unpacked how the patient-body is constructed in a myriad of contexts. In more applied contexts, scholars in the health humanities and health professions education have attempted to re-instill notions of the patient as more than just a body-object into medical trainees. However, while the construction of the patient-body has been thoroughly interrogated, few scholars have considered the construction of the physician-body in biomedicine.
 
I consider this very question through the lens of the medical habitus (Underman, 2015). The medical habitus “allows scholars to move beyond purely cognitive models of socialization to consider the transformation of thoughts, perceptions, feelings, and embodiment of medical students as they adapt to medical culture” (Underman, 2015: 181). Previously, scholars of socialization in medical education examined how the medical student learns to play “his” role in the clinic, as in Howard Becker et al’s classic study Boys in White. Other scholars, such as Frederic Hafferty, described the role of the hidden curriculum in medical student socialization, demonstrating how latent rules and norms transmit lessons about medical values. While these perspectives are important, I argue that using the medical habitus as a framework to understand the adoption of a professional (clinical) identity better captures the embodied and emotional (or affective) dimensions of this medical socialization.
 
My research examines how medical students learn the pelvic exam on a specially-trained layperson called a gynecological teaching associate (GTA) I selected GTA programs as a case study to understand how simulated patient experiences lead to the adoption of the medical habitus. I show in my work that GTA programs emerged in the 1970s and 1980s in response to critiques in the Women’s Health Movement about how medical students were taught the pelvic exam—usually on indigent clinic patients. Around the same time, medical educators were launching similar critiques of how the pelvic exam was taught. These educators argued that existing models were ineffective because students were often too nervous or unable to ask questions of either their faculty or the person they were examining. GTA programs addressed these critiques by using trained laypeople to teach the pelvic exam. In a typical session, a GTA will walk a group of two to three medical students through a complete, patient-friendly pelvic exam using the GTA’s own body as the model (Underman, 2011). These programs have become ubiquitous, with over 90% of medical schools in the United States and Canada using GTAs (Beckmann, et al, 1988).
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Students work with a gynecological teaching associate, Source: The Washington Post
GTAs are one type of simulated patient encounter that today’s medical students experience. As I show in my work, the use of simulation allows medical students to practice and develop their clinical skills, dispositions, and attitudes in a low-risk environment. Because GTAs are not ‘real’ patients, they allow medical students to explore the performance of a pelvic exam in a much more in-depth fashion, while at the same time offering feedback and instructing the students about anatomy. The GTA session is particularly interesting to study because the pelvic exam is so emotionally-fraught. Medical students are often extremely nervous about hurting the patient or embarrassing themselves (or the patient). Not only that, but reproductive anatomy and female bodies evoke uncomfortable associations with sexuality that medical students must learn to manage if they will successfully become ‘professional’ physicians.
 
The framework of the medical habitus is useful here because it allows me to focus on the range of embodied dispositions and attitudes that medical students adopt during the GTA session, especially with regard to emotion. Norms and values about centering the patient in the pelvic exam and involving the patient actively in their own healthcare become embodied in complicated and sometimes contradictory ways. This is especially important, as there has been a shift recently toward an increased emphasis on empathy in the clinical encounter (Underman and Hirshfield, 2016). In the GTA session in particular, empathy is as much an affective state as it is a performance of skills and behaviors necessary for eliciting the patient’s cooperation. For example, during the speculum exam, medical students are taught strategies like using non-threatening language (“bills” instead of “blades”) and giving the patient a warning touch on the inner thigh before making contact with the genitals. These strategies ostensibly are for the patient’s comfort and relaxation. However, they also make the physician’s job of performing the exam easier, since a relaxed patient is more compliant.
 
The crafting of the physician-body in medical education is a fascinating topic and ought to be considered by more scholars studying the body and embodiment. Scholars in science and technology studies (Prentice, 2012; Harris, 2016) have considered this more in-depth, and it remains an important topic for consideration. Through my work, I argue that we should consider how it is that patient-bodies and physician-bodies are constructed through an entanglement of discourses, practices, and techniques in medical education. We know that bodies don’t exist in isolation of the social practices and structures within which they move, and medical school is no exception. By exploring new technologies of simulation and drawing from new theoretical tools, I intend to more fully understand what happens to the medical gaze when the patient sits up and talks back.

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Kelly Underman, PhD,
is a Postdoctoral Research Associate in the Department of Medical Education at the University of Illinois at Chicago. Her research interests include medical education, the body and embodiment, affect studies, and the politics of knowledge production. Her work has been published in Social Science & Medicine, Gender & Society, Social Studies of Science, and Sociology Compass.


Citations
 
Becker, Howard S., Blanche, Geer, Everett, C. Hughes, Anselm, L. Strauss, 1961. Boys
in White: Student Culture in Medical School. University of Chicago Press: Chicago.
 
Beckmann, Charles R. B., B. M. Barzansky, B. F. Sharf, and K. Meyers. 1988. “Teaching Gynaecological Teaching Associates.” Medical Education, 22 (2): 124-31.
 
Fox, Renee C., 1988. Essays in Medical Sociology: Journeys into the Field. Transaction
Books: New Brunswick, NJ.
 
Hafferty, Frederic W., 1991. Into the Valley: Death and the Socialization of Medical
Students. Yale University Press: New Haven.
 
Harris, Anna. 2016. "Listening-touch, Affect and the Crafting of Medical Bodies through Percussion." Body & Society, 22(1): 31-61.
 
Prentice, Rachel. 2012. Bodies in Formation: An Ethnography of Anatomy and Surgery
Education. Duke University Press: Durham, NC.
 
Smith, Allen C., Kleinman, Sherryl, 1989. “Managing Emotions in Medical School:
Students’ Contacts with the Living and the Dead.” Social Psychology Quarterly, 52(1), 56-69.
 
Underman, Kelly. 2011. “’It's the Knowledge that Puts You in Control’: The Embodied
Labor of Gynecological Educators.” Gender & Society, 25(4), 431-450.
 
Underman, Kelly, 2015. “Playing Doctor: Simulation in Medical School as Affective
Practice.” Social Science & Medicine, 136-137: 180-188.
 
Underman, Kelly, and Laura E. Hirshfield. 2016. "Detached Concern?: Emotional Socialization in Twenty-First Century Medical Education." Social Science & Medicine, 160: 94-101.

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Botox, Body Entrepreneurship, and Economic Inequality

2/1/2017

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Picture
by Dana Berkowitz, PhD
Associate Professor of Sociology
and Women's & Gender Studies,
Louisiana State University



The perfect combination of prom queen-pretty with sophisticated conservatism, Dawn Goldstein is 5’9”, has big blue eyes and a perfectly coiffed blonde mane. As a former beauty queen, Dawn Goldstein was socialized early on to learn that her social currency largely derived from her ability to achieve and maintain a youthful, beautiful face and body. From a very young age, Dawn was taught how to cultivate her appearances through exercise, dieting, make-up, and other kinds of bodywork in order to look young, healthy, and pretty. When Dawn was twelve years old, she was sent to a plastic surgeon by her father to have her ears pinned back. When she was fifteen she learned to count calories. When she was twenty-eight, she had laser hair removal on her bikini area, legs, and underarms. And when she was thirty-three, she began using Botox.

I met Dawn in 2012 when I was collecting research for my book, Botox Nation: Changing the Face of America (NYU Press).
On the surface, Dawn Goldstein fulfilled every societal stereotype of a woman who would use Botox in her 30s. She was a former beauty queen, she was always impeccably groomed, and she was thin, tall, and attractive.  However, my three-hour conversation with Dawn proved that such one-dimensional assessments and stereotypes miss some critical insights about women who use Botox, obscuring the complexities of women’s social psychological decision making about their aesthetic labor. 

Dawn, a self-identified feminist, spoke at length about the tensions permeating her decision to use Botox and about her frustrations with the ubiquitous cultural pressure to accommodate to societal norms of feminine attractiveness. As a former beauty queen, Dawn always had to be very conscious of her face and her body.  Now, as an adult and a successful broadcast journalist, she was even more aware of the cultural pressure she faced to preserve her youth and beauty. Ultimately when she turned 33 and found that her monthly facials and expensive creams would no longer suffice, she resigned herself to trying Botox. Dawn was adamant that if she were not on television each day, if her career hadn’t depended on it, she would have likely made a different decision about using Botox in her thirties. Eventually, her desire to stay on television superseded both her feminist ethics and any desire to age without technological intervention.
 
Dawn’s experience mirrors that of so many other Botox users with whom I spoke. Like others, she engaged in a lifetime of bodywork, a sociological concept that refers to the efforts people exert on their own bodies to attain certain bodily ideals through diet, exercise, makeup, clothing choices, and cosmetic surgery in the hopes of achieving high social status (Gimlin 2002). Yet, that Dawn explicitly turned to Botox because of workplace concerns reveals the need for sociologists to consider how regular forms of body upkeep are distinct from those forms of bodywork used to present the body as a legitimate workplace commodity. 
 
Many of the women with whom I spoke articulated their decision to use Botox as a means for improving the enterprising self and as a practical and necessary upgrade to maintain their competitive edge in the workplace. Women in the service economy were especially likely to mention the importance of engaging in aesthetic labor for their careers. Katherine Turner, a manager at a Miami high-end boutique told me, “Appearances are central to this job. My face is like my business card. There is no way I can afford to look tired or old.” Sociologists Christine Williams and Catherine Connell (2010) have argued that the workers employed at upscale retail stores are a large component of what is purchased; they literally embody the intended cultural meanings associated with the products and services sold in the shop. In this way, the commodification of workers’ corporeality naturalizes those embodied distinctions that are shaped by social inequality.
 
As Dawn Goldstein’s story foreshadowed, the theme that Botox injections were a career investment was particularly evident among the broadcast journalists in my sample. Allison Harris, a broadcast journalist in Louisiana, shared that, “With my situation a lot of it does have to do with the job. I mean I want to be able to stay in this business for a while; I’m not independently wealthy. I need a job. And the longer I can preserve my appearance and as much youth as I can, the longer I’m going to be able to stay in the business for years and years and years.”
 
In order to succeed in their workplace, women felt they needed to look better, fresher, and more confident. As body entrepreneurs who strategically cultivate their appearances in order to enhance their social, cultural, and economic power, Botox users emphasize the legitimate desire for career advancement and workplace prosperity.  Reflective of American values of industriousness and hard labor, these women spoke about investing in their bodies to sustain their competitive edge in commercial economies. Couching their explanations of aesthetic labor within masculine tropes of competition, they fashioned themselves as ambitious and motivated careerists. Where on one end, aligning femininity with such brazen determination contrasts from stereotypical constructions of traditional middle-class femininity as docile and passive; however, that their source of power came from their beauty and bodies revealed how women’s entrée into male dominated occupations has not corresponded with the freedom to abandon the pursuit of the feminine beauty ideal.
 
My interviews with Botox users can tell us a great deal about the transmission of social inequality through bodies. Because bodies are read as signs of success, they can be used to access other avenues of success.  Through deliberate cultivation of their embodied cultural capital, individuals can also accumulate economic capital.  
 
Yet, it is important to keep in mind that regular Botox injections are out of reach for much of the population.  Most women do not have basic healthcare, let alone the disposable income to purchase Botox – a procedure that averages approximately $300–$400 for one round of injections.  Oh, and did I mention that Botox is only temporary?  So if you want any lasting effect, you are supposed to top it off two to three times a year. Most American women cannot afford anything close to what such a regimen requires. Thus, my research on Botox users reveals how some body modification practices can increase gendered social stratification by exacerbating existing economic inequalities.



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Dana Berkowitz, Ph.D., is an Associate Professor of Sociology and Women’s and Gender Studies at Louisiana State University.  She received her Ph.D. in Sociology with a certificate in Women’s and Gender Studies from the University of Florida in 2007. She is the author of Botox Nation: Changing the Face of America (NYU Press). Her scholarship has also appeared in high-impact journals such as Journal of Marriage and Family, Qualitative Health Research, Journal of Contemporary Ethnography, Qualitative Sociology, and Symbolic Interaction.


Works Cited:
Gimlin, Debra L. (2002).  Body Work: Beauty and Self-Image in American Culture.  Berkeley, CA: University of California Press.

Williams, Christine and Catherine Connell. (2010). “Looking Good and Sounding Right: Aesthetic Labor and Social Inequality in the Retail Industry,” Work and Occupation 37 no. 3: 349-77.






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