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‘Good’ patient/‘bad’ patient: clinical learning and the entrenching of inequality Eeva Sointu

Department of Sociology, Smith College, Massachusetts, USA

Abstract This article develops sociological understanding of the reproduction of inequality in medicine. The material is drawn from a longitudinal study of student experiences of clinical learning that entailed 72 qualitative in-depth interviews with 27 medical students from five medical schools in the USA. To highlight the subtle, yet powerful, ways in which inequality gets entrenched, this article analyses ideas of the ‘good’ and the ‘bad’ patient. Bad patients question not only biomedical knowledge but also medical students’ commitment to helping people. Good patients engage with medical students in a manner that upholds biomedical knowledge and enables students to assume the role of the healer and the expert. At the same time, good patients possess cultural skills that align with those of medical practitioners. This alignment is, furthermore, central to definitions of the good patient. Distinctions drawn between good and bad patients thus both embody as well as enforce social inequality. The subtle reproduction of inequality is, however, difficult to discern because judgements about patients entwine with emotion.

Keywords: inequality, medical education, cultural health capital, emotion

Introduction

A hidden curriculum of ‘tacit and context specific rules about how doctors should behave, think and feel’ (Jaye et al. 2006: 142), instructs medical students on patient worth (Higashi et al. 2013). Further, perceptions of patients that are based on a ‘moral economy’ of ‘values, behavioral norms and ethical assumptions’ matter greatly in guiding interaction with patients and decisions about their care (Higashi et al. 2013: 13). Much research has shown that clini- cian perceptions of patients draw from a repertoire of social stereotypes with understandings of patient character and capacity also featuring centrally in uneven access to health care (Barr 2008, Feagin and Bennefield 2014, Roberts 2011, Street et al. 2007, van Ryn et al. 2011, van Ryn and Burke 2000). Despite some notable exceptions (Dingwall and Murray 1983, Jeffery 1979), doctor perceptions of the ‘good’ and the ‘bad’ patient have received little scholarly attention. While good patients are medically interesting and allow the honing of clinical skills (Jeffery 1979, Stimson 1976), bad patients refuse the responsibilities of the ‘sick role’ (Ding- wall and Murray 1983, Parsons 1975), have ailments that fall outside the sick role (Freidson 1970, Stimson 1976) and are often characterised as being ‘willfully ill’ and responsible for their ailment (Jeffery 1979: 105).

Sociology of Health & Illness Vol. 39 No. 1 2017 ISSN 0141-9889, pp. 63–77 doi: 10.1111/1467-9566.12487

This article underscores the significance of social identities in definitions of the good and the bad patient. I argue that doctor and medical student perceptions of patients are shaped by an alignment, or dislocation, between individual behaviour and interactive styles, and broader social institutions. Pierre Bourdieu (1984) coined the term ‘cultural capital’ to refer to habitual and embodied behaviour and skills that can be utilised ‘to produce meaningful situational advantages’ because these behaviours and skills match ‘the standards of dominant institutions’ (Calarco 2011: 863). Following Bourdieu, ‘cultural health capital’ refers to a ‘repertoire of cul- tural skills, verbal and nonverbal competencies, and interactional styles that can influence health care interactions’ (Shim 2010: 2). Patients, who share with their physicians an unstated understanding of the doctor-patient encounter, navigate the clinical environment with more ease (Dubbin et al. 2013, Shim 2010, Willems et al. 2005). Ultimately, however, ‘cultural capital contributes to the accumulation and exercise of power and the maintenance of inequal- ity’ (Shim 2010: 2). Accordingly, this article understands ideas of the good and the bad patient as ‘devices of distancing and distinction’ that subtly ‘legitimate the position and interests of those who draw the distance’ (Skeggs and Loveday 2012: 473).

The influence of ‘devices of distancing and distinction’ (Skeggs and Loveday 2012: 473) lies, in part, in the manner in which judgement entwines with emotion. Even though its power can be hard to discern, emotion plays an important role in decision-making (Burkitt 2014, Cromby 2007, 2011, Wetherell 2012). The role of emotion in decision-making is, however, incompatible with the valorising of impartial rationality that suffuses the project of western modernity (Cromby 2007, Wetherell 2012). The capacity of emotion to shape judgement is especially veiled in medicine due to an emphasis on ‘affective neutrality’ as central to the role of the doctor (Nettleton et al. 2008, Smith and Kleinman 1989: 56). Emotions, simultaneously, draw ‘from the thickness of sociality itself’ (Ahmed 2004: 28). Even though situational and subject to change, private affective experience also incorporates social and cultural values, judgements and representations (Burkitt 2014, Wetherell 2012). As such, this article contends that to more fully understand the reproduction of inequality medicine, we must not only see the distinctions between good and bad patients as capturing relations of power; we must also begin to trace the power that these distinctions hold in their entanglement with emotion. The intertwining of the social with emotion, and the import of emotion in doctor perceptions and judgements, constitute missing pieces in making sense of how social representations and stereo- types suffuse and shape a field explicitly heeding the ideal of scientific objectivity and the equal treatment of all patients.

Methods

Study design The material presented here emerges from a qualitative longitudinal study exploring medical student experiences of clinical rotations1 in the USA. The project was premised on the notion that emotion constitutes an important, yet under-studied element of medical education (McNaughton 2013). The study centred on clinical rotations because the clinical years entail processes of professional socialisation that transmit to students ‘normative expectations for behaviour and emotions’ (Jaye et al. 2010: 60). The study began from two broad research questions: what kinds of experience do clinical rotations give rise to? And how do emotions feature in the experiences of medical students undertaking clinical rotations? The research cen- tred on the lived experience of rotations and adopted a phenomenological approach (Creswell 2013). With a total of 72 interviews conducted with 27 participants over 2 years, the study aimed at producing in-depth understanding of the rotations as they were experienced by the © 2016 Foundation for the Sociology of Health & Illness

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participants. The longitudinal character of the study (Thomson and Holland 2003) further facil- itated the search for in-depth insight.

The researcher has no background in medical education beyond scholarly interest. The lon- gitudinal structure of the study and the use of in-depth interviews were aimed at addressing this lack of insider knowledge on her part. Her outsider status proved meaningful in at least two respects. First, participants went to great lengths to describe their experiences to the researcher as she was seen to lack understanding of the training process. Second, being an out- sider allowed her to ask questions that could have been seen to be self-evident to an individual immersed in medical education.

The first interview started with questions: ‘Can you tell me what brought you to medicine?’ and ‘Can you tell me about your experience of rotations so far?’ As the study progressed it became clear that encounters with patients generated complex feelings. The importance of patient encounters frequently emerged in response to questions such as ‘Can you tell me about your best experience during the rotations so far?’ or ‘Can you tell me about the most difficult experience you have had during rotations?’ The significance of good and bad patients in participant responses generated the need to probe these categories further. Themes in the data – that bad patients have wrong priorities, little knowledge and are difficult to deal with, and that good patients are active, compliant2 and knowledgeable – were remarkably common among participants.

Importantly, this research could not access unmediated emotional experience. No interaction with patients was observed. Rather than emotion per se, the study focused on retrospective accounts of significant experiences. Participant interpretation of significant events – even though subjective, partial and retrospective – is meaningful and sociologically interesting (Luker 2008). Interviews, furthermore, ‘offer the most direct means by which individuals negotiate experience and through which we can approach and interpret this experience’ (M�ansson 2002: 25). Emotionally meaningful experiences and the ‘emotional labour’ (Hochs- child 1983) performed by students also in interviews are situated in the context of the ‘profes- sional feeling rules’ (Burkitt 2014: 139, Hochschild 1983) of medicine that tend towards ‘affective neutrality’ (Smith and Kleinman 1989).

Participants were recruited via a message posted on a medical student mailing list. Five students responded to this call for participants, with four forwarding a recruitment message and an informed consent letter to peers. Subsequently, a further 22 participants contacted the researcher directly. Apart from two interviews – that were cut short due to technical difficulties and participant availability – the interviews lasted 60–90 minutes. The interviews were con- ducted using Skype, which enabled interviewing participants across vast geographical dis- tances. All but four of the interviews took place in a setting such as private apartment or an empty hospital meeting room, where the interviewee was alone. The study design and materi- als were vetted and approved by the institutional review board at the author’s institution. Par- ticipants are identified by pseudonym only.

Coding and data analysis Interviews were recorded and transcribed verbatim. The initial coding took place when check- ing transcripts for accuracy by comparing the transcripts with the recordings. The transcripts were coded again through a close reading of the material. The codes reflected ‘significant statements’ or themes (Creswell 2013) with regard to rotations, patients and patient encounters. The themes were collected together in separate Word documents and later organised according to subthemes. For example, all participant discussions of the good patient were collected together before the material was organised into subthemes such as good patients being invested or active. These data then became the basis for the ‘textural description’ (Creswell 2013) included in the results section of this article.

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While the results section aims to capture participant experience and voice, the analysis draws on literature in medical education around notions such as the ‘hidden curriculum’ (Hafferty 1998, Hafferty and Hafler 2011, Jaye et al. 2006). As this research considers student identities as central to experiences of rotations and perceptions of patients, the analysis also turns to sociological material into the subtle reproduction of inequality through assumptions and ascriptions of knowledge and taste (Bourdieu 1984, Lawler 2005, Shim 2010, Skeggs and Loveday 2012). The themes presented in the results section are those that were most prevalent in the data. This study is, however, limited, as coding and analysis were conducted solely by the author.

Participants The study sample was self-selected. Accordingly, only perspectives from students wanting to share their experience are included. However, each participant received a $50 gift card per interview to thank them for taking part. While the sum was not big enough to coerce participa- tion (Hewison and Haines 2006), this stipend is thought to have encouraged participation among students who may otherwise have not considered taking part.

Thirteen participants were male, 14 female. All participants were in their twenties and had completed a bachelor’s degree. While defining social class is complex (Bourdieu 1984, Lati- mer and Munro 2015, Lawler 2005), in this study assumptions about participant social class were arrived at through three different means: level of education, self-defined social class and parental occupation. Participants had not only gained a bachelor’s degree but were upwardly mobile in accessing a higher degree. Of the 27 participants, 26 were asked for their parents’ occupations, and to self-define their social class. All self-defined their social class middle, upper-middle or upper class. Parental occupations – (in order of prevalence physician, financial consultant, teacher, attorney, engineer, professor, and small business owner) – also locate par- ticipants in the higher social classes. Of the participants 18 were white and five Asian or South-Asian American. Importantly, no African-American or Latino/a students responded to the call for participants.

Results

Below, I first outline interview data capturing the importance of the ‘hidden curriculum’ (Hafferty 1998, Hafferty and Hafler 2011, Jaye et al. 2006) in medical student learning. I then present data on the good and the bad patient. Following the phenomenological approach (Cres- well 2013), the material below constitutes textural description that highlights the most promi- nent themes in the data and aims to capture student voice and experience.

Learning about the good and the bad patient During clinical rotations, you ‘learn on the job’ (Amar). Much important material is, however, ‘not something they teach you. But it is something that you learn’ (Amar). In addition to acquiring medical and scientific knowledge, students learn rules that are ‘unspoken but very obvious and well known, you know, like the hierarchies and the punishments for violating them’ (Beth). Relationships within medical teams are strictly hierarchical. Accordingly, ‘any- one can tell a medical student what to do. So you’re the lowest’ (Stephen). This hierarchy instructs students on how to behave: ‘I think whenever somebody higher-up says something, we just kind of go along with it’ (Jessica).

The informal and hidden curricula that subtly instruct medical students on appropriate beha- viour are integral also to the culture of medical school and to peer interactions: ‘a lot of third © 2016 Foundation for the Sociology of Health & Illness

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year is learning from other people’s mistakes’ (Sullivan). Discomfort and a desire to avoid being chastised or humiliated encourage students to act according to the largely unarticulated rules around appropriate behaviour: ‘You hear these stories and you’re like, uuh, it’s so uncomfortable’ (Sullivan). Stories of failure among peers give rise to ‘that self-conscious feel- ing’ (Isabel) that, in turn, plays an important role in students learning to act according to the hidden rules.

There are powerful messages about patients – messages that are excluded from the formal curriculum – that medical students encounter. Understandings of the good and the bad patient are conveyed through interactions within medical teams. With bad patients, residents3 and attendings4 ‘seem very jaded. They seem like, “Oh, we can’t do anything about them, so what- ever”, you know, they don’t care’ (Clare). Gestures can be revealing: ‘I think a lot of it is like, you know, the face that they’ll make afterwards or an eye roll or something like that’ (Mary). Sometimes disproval is explicitly stated to members of the medical team:

The wife of this guy was crying ’cause her husband had been through a lot. He’d been in the hospital for a long time without insurance. And she was like, ‘Oh, I just want to go home, when can he go home?’ And the surgeon’s like ‘He can go home when I say he’s ready’. And when we were leaving, he’s like ‘stupid fucking people’ and like rolls his eyes. And the other doctors laughed. (Monica)

Residents and attendings speak differently of patients seen as good or bad:

For good patients, it’s usually like, when they present the patient, they’re like, ‘This lady’s super sweet, this guy is super sweet, I feel really bad for him’. And if it’s a bad patient, it’ll start out with an eye roll and ‘Oh, our favorite patient’. Like, some sort of sarcastic com- ment about them. But it’s pretty evident from the start, their feelings on the patient. It’s not really hidden in any way. (Isabel)

Messages about patients are also subtly conveyed in casual conversations within medical teams: ‘Sometimes we talk about like, how it’s interesting that patients on Medicaid that don’t work at all, so they’re like living on welfare, and they say they can’t afford their prescriptions, have iPhones. And leather purses’ (Chloe). Throwaway remarks convey what is expected of patients beyond health behaviour. As Beth observes: ‘If I had a dollar for every time, on OB [obstetrics], when I heard “this is America, we speak English”, I could pay my tuition upfront for the rest of the school term’ (Beth).

Students may not always agree with the messages about patients they encounter. The beha- viour of residents and attendings is, however, rarely openly criticised. Even when ‘people will make off-colour remarks about patients, which I don’t like’ the comments are commonly ‘nothing worth getting, getting bent out of shape over’ (Matthew). The importance of ignoring even troubling faculty behaviour relates, in part, to the role faculty play in the assessment of student performance and, furthermore, in the career trajectories of medical students: ‘You kind of don’t want to raise conflict because they’re evaluating you [yeah]. And your evaluation kind of determines your career’ (Isabel). The system of evaluation shapes the manner in which dis- comfort can be expressed: ‘Everybody above me in the rank order hierarchy is potentially interviewing or, you know, evaluating me at some point. And so you can’t really complain’ (Carla). The structure of assessment results in difficult experiences not being discussed. As Sullivan notes in regards to her feelings about a difficult patient: ‘I did want to talk to the attending about it, but she is the chief of our rotation. So, it’s something I think I might want to talk to her about when she isn’t grading me’ (Sullivan).

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While disagreement with resident and attending behaviour can be expressed to close friends or partners, the culture of medical school, generally, discourages being vocal about the unequal treatment observed. Vivan has, for example, noticed that ‘black patients are a little bit neglected’. However, noting this to faculty or peers is difficult: ‘I think people would think I was like pretending, or trying to act like a saint . . . I’d seem like a hypocrite’ (Vivan). Bring- ing up issues, such as racism, is avoided: ‘I don’t feel like I can talk about it because people will feel attacked’ (Beth).

As outlined above, medical students encounter pervasive messages about the good and the bad patient through their interactions within clinical environments. Below, I outline these mes- sages in more depth.

Good patient

Active The good patients are, first and foremost, seen as ‘active participants in their healthcare’ (Sulli- van). A good patient is ‘involved in his or her health, as opposed to just leaving it to the doc- tor’ (Amar). Good patients ‘want to figure out what’s happening and they’re motivated to like, learn about their disease and take charge of it’ (Monica). Good patients ‘seem open to dis- cussing their health problems and what they can do’ (Grace). Active engagement is, simultane- ously, thought to demonstrate when patients ‘want to help themselves get better’ (Grace). How engaged and active a patient is deemed to be is often assessed on the basis of interaction. Ask- ing questions ‘shows me that they, they want to take part in their care. And that they want to understand what’s going on’ (Myra). Good patients are experienced as ‘willing to let you help them as best you can’ (Bob). Simultaneously, a good patient ‘trusts and respects their doctor as well as the staff’ (Jessica) and ‘recognises that a doctor is someone who just wants to help them’ (Stephen).

Being invested in one’s health involves effort that good patients also show outside the medi- cal encounter. Good patients ‘find ways to maintain their health. Exercise. Try and eat as best as you can under the conditions you have’ (Ben). However, some participants also recognise that the ability to take care of oneself and one’s family entwines with privilege:

You need some level of income and some level of money, I guess, financial abilities to take care of yourself. So if you don’t have that, that’s also going to affect you not being a good patient. (Amar)

Compliant and knowledgeable In addition to being active and engaged, a good patient ‘wants to do what it takes to improve their health. Follows the doctor’s orders’ (Sarah). Good patients are, as such, compliant. A good patient:

[T]akes their medications as prescribed. Follows up on all the referrals and lab orders and imaging that was ordered. Comes to their follow-up appointments. Makes sure that they tell the doctor if anything is going on. (Jessica)

Simultaneously, a good patient is ‘grateful of the care that they’re receiving’ (Jessica). Know- ledge of one’s health is highly valued: ‘the most amazing patients are patients who are very knowledgeable in terms of their health’ (Amar). Vivan describes a good patient as ‘a good © 2016 Foundation for the Sociology of Health & Illness

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historian’ who is both open and ‘good at communicating’. The importance of the ability to recount medically relevant information is also conveyed in Vivan’s account of his best patient:

All his past medical history and any problems, he was very forthcoming with. And when it came time to explain, you know, what he had to do and how to handle his disease going forward, he was very receptive. He was listening. He asked good questions that kind of indicated that he knew what was going on and he was thankful that, you know, I took the time to explain stuff to him. (Vivan)

Knowing one’s medical history is seen to ‘demonstrate their, like, proactiveness and their self- interest in their healthcare’ (Bo). Compliance, simultaneously, enables doctors ‘to make sure that the patient gets the best care possible’ (Jessica). Positive patient involvement is deemed to make medicine easier: ‘having someone that’s invested in that decision-making process with you can make it easier’ (Bo). Yet some recognise that openness and compliance are not auto- matic. While ‘a good patient is honest and upfront’ (Beth), honesty is understood to rest on trust. Further, ‘some people are going to reasonably feel that they can’t be honest with their doctor’ (Beth).

Engenders positive feeling The good patient engenders positive feeling in medical students: ‘there’s a certain portion of people who are, like, “Okay, doctor said to do this, this is what we’re doing,” and that’s great. I love that’ (Michael). Patient engagement can, furthermore, generate care: ‘I love patients who are like eager to learn about why they’re at the doctor’ (Bo). While participants readily emphasised that every patient is afforded a similar level of assistance, being proactive and compliant is also often seen to yield results. If doctors ‘know the patient has done whatever they can and they are taking steps alongside themselves, they are more willing to help’ (Amar). Ability to help generates further positive feeling: ‘it’s nice to have a win in the doc- tor’s category and say, “I really helped this person today”’ (Chris).

There is also often a sense of ease to encounters with good patients: ‘a good patient is someone that you can talk easily with. Yeah, and just be able to enjoy the visit while doing the things that you need to be doing as well’ (Sarah). With a good patient, ‘you really feel like this is a team effort, you know. The doctor and the patient are working together towards this goal. And I think it’s wonderful’ (Clare). Connections forged with patients shape medical stu- dents’ relationships with patients. A sense of connection is important in providing extra care: ‘If you care about somebody then that means you’re going to go above and beyond what you have to’ (Mary).

Bad patient

Wrong priorities A patient who ‘abuses the system to get, you know, drugs’ (Mary) is frequently considered a bad patient. Additionally, bad patients ‘try to sell their medications to someone else and then lie to us that, “Oh yeah, my medication dose, I lost it”’ (Myra). The bad patient is also resis- tant to doctor’s recommendations: ‘The bad patient doesn’t take their medications. Doesn’t go to follow-up appointments’ (Sarah). The lack of compliance is, furthermore, seen to underlie a need for further medical intervention: ‘They have the need for more extensive medical care because they weren’t doing the things that could have prevented this’ (Sarah).

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Bad patients make bad choices. As Lou explains, rather than his prescription, a bad patient ‘bought cigarettes and his medication would have been four dollars’ (Lou). The wrong priori- ties are often seen to relate to a lack of care for one’s health; a bad patient ‘isn’t very invested in their own health’ (Jessica). A bad patient is ‘uninterested in making any changes that they might need to in order to change their health outcome’ (Bo). Additionally, bad patients ‘expect everything to be made better and they’re not taking an active part in their healthcare’ (Stephen). Bad patients are also not communicative:

You ask them a question and they kind of stare at you or give you a one word answer, or like seem to have no idea what’s going on with their health. (Grace)

With uncommunicative patients ‘it’s really hard for us to kind of get a deeper understanding of why they’re there’ (Myra). Bad patients can also be outright aggressive and rude: ‘Bad patients are hostile . . . they just kind of treat everyone poorly’ (Isabel). Aggression is, however, also at times seen as understandable: ‘I think for a lot of patients who don’t follow up or seem like bad patients, it’s really just because of fear and not because they don’t care’ (Jessica).

Limited knowledge and resources The unhealthy behaviour of bad patients is often seen to relate to their ‘not really realizing the importance of what the doctor is trying to do for them’ (Jessica). Many bad patients are thought to lack education and ‘if they have low levels of education, it’s hard to have high levels of health literacy’ (Grace). At the same time, however, a ‘bad patient is somebody who questions the motives, questions the knowledge’ of doctors (Stephen).

While bad patients are seen to prioritise unhealthy behaviour, many medical students under- stand that the patients’ ability to follow doctors’ orders relies on resources. Bad patients ‘just can’t follow up, financially’ (Jessica). Furthermore:

If you can’t get yourself the care that the doctor wants you to do, if you don’t have money to do that, that unintentionally puts you in the bad patient category. (Amar)

And yet being a bad patient also limits options for care: ‘If you don’t want to be a good patient, if you don’t want to take care of yourself, that automatically puts you in an inferior entitlement of treatment’ (Amar). Bad patients are simultaneously seen as both constrained by their circumstances and unwilling to engage in healthy behaviour: ‘They don’t have enough money to buy vegetables and fruit and stuff like that. And they, like, a lot of them don’t wanna change’ (Chloe). Some participants understand healthy behaviour as a choice. As Ste- phen explains:

You can go to any drug store and buy a blood pressure cuff. It’s not always a very good blood pressure cuff, but you can get one. Any person can be taught where to put the blood pressure cuff, any person can be taught how to take somebody else’s blood pressure as long as they have a stethoscope and a blood pressure cuff. (Stephen)

Access to technology to improve health, such as a blood pressure cuff is, furthermore, seen as ‘pretty much universally available’ (Stephen).

Difficult to deal with and to care for Bad patients can be frustrating to deal with: ‘When you’re taking the time out of your day to explain and help them, sometimes they just don’t care, or they’re watching the TV. Or – that © 2016 Foundation for the Sociology of Health & Illness

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can be frustrating’ (Vivan). Their seeming disregard for doctors’ opinions and orders can also generate anger:

I do respect when a patients says, ‘Well I would rather not take this medication, I’d rather have a different medication’ or other things like that. But to disregard and question the motives, knowledge, and ability of somebody else that is doing nothing but trying to help them, infuriates me. (Stephen)

Communication problems with bad patients can also lead to uncomfortable encounters:

I would walk in the room and the [patient’s] mother would just give me one-word answers. And it was just, it was awkward. So I’d be in there for about 30 seconds because she wasn’t really saying anything before I would leave. (Chloe)

Encounters with bad patients generate not only frustration, but also feelings of powerlessness:

The one thing that is always hard for me is someone who’s just not interested. . . it’s hard to help those people. It really is. And you feel powerless. (John)

Bad patients are, accordingly, treated differently from good patients:

I’m not saying that they don’t help the patient that is a bad patient. But I mean, it’s obvious, if you think all your efforts are wasted, you are maybe unintentionally not going to put all your efforts in doing that for the patient. (Amar)

Bad patients are also at times afforded less sympathy:

It’s kind of disheartening to see somebody in that situation. It’s like ‘Oh well, I mean, I’m sorry you got lung cancer from smoking for 45 years’ but how sorry – I mean, it’s unfortu- nate. It’s unfortunate. And you never don’t think that. But at the same time, there’s a lot of steps you can do to prevent that. (Sarah)

Discussion

The power of hidden messages Even when, formally, all patients receive the same care, informally, medical students observe good patients being afforded time, care and appreciation that bad patients are thought not to deserve or want. Messages about the good and the bad patient are a part of the hidden and informal curricula (Hafferty 1998, Hafferty and Hafler 2011, Higashi et al. 2013, O’Donnell 2014) of medical school. Embedded in the hidden curriculum are also ‘professional feeling rules’ (Burkitt 2014: 139) shaped, in part, through an emphasis on ‘affective neutrality’ (Smith and Kleinman 1989: 57). Values beyond ‘affective neutrality’ are, however, also at play in the ‘professional feeling rules’ (Burkitt 2014: 139) acquired in medical school. The hidden cur- riculum also contains ascriptions of patient worth (Higashi et al. 2013). Interest and indiffer- ence on the part of residents and attendings convey to medical students who is, and who is not, worthy of extra effort. These messages are reproduced through peer interactions and the culture of medical school that defines health as an individual achievement and, through this,

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risks side-lining the impact of broader inequality on health and illness. The significance of understandings of the good and the bad patient is amplified through the power that residents and attendings conveying these messages hold. Disputing the hidden instruction carries sub- stantial danger: being seen as academically inept, hypocritical or aggressive.

Gestures such as ‘eye rolls’ can make students uncomfortable. There are, however, few ave- nues for airing feelings that arise in relation to challenging patient encounters or faculty beha- viour. Unease that is not articulated constitutes a part of medicine’s ‘null curriculum’ (O’Donnell 2014: 8) that, through trivialising emotion, asserts that emotional disquiet experi- enced during rotations is peripheral, detrimental even, to medical practice. Furthermore, in an educational context where confidence, toughness and assertiveness characterise the ideal doctor (Halpern 2014), ‘difficult emotions become objects of dread, to be avoided at all costs.’ (Sha- piro 2008: 14). Students can feel that emotional discomfort marks them as being unsuited to the practice of medicine and, accordingly, seek to hide uncomfortable feelings (McNaughton 2013). Learning the ‘professional feeling rules’ (Burkitt 2014: 139) that emphasise ‘affective neutrality’ (Smith and Kleinman 1989: 56) not only encourages hiding emotion but also makes discerning the social stereotypes that shape classification of patients more difficult.

Judgement and self-worth The power of the messages about good and bad patients rests, in part, on the way in which good patients enable doctors to help them and, as such, to perform a role that is experienced as central to medicine. Importantly, what is being recognised by good patients is not only the doctors’ expertise but also their commitment to helping people. Additionally, talking to a per- son who is receptive and appreciative is meaningful. Being seen as valid and valuable matters in the constitution of self-worth (Honneth 2001). Positive affect on the part of patients has, accordingly, been found to generate more positive communication from physicians (Street et al. 2007). Expressions of positive regard are, simultaneously, socially and culturally located. Patients’ messages of respect and gratitude need to align with the ideas of respect and appreci- ation among medical professionals for these messages to be perceived as such.

Implicitly, the compliance of good patients also upholds the authority of the doctor while bad patients do not comply with the ‘sick role’ (Dingwall and Murray 1983, Jeffery 1979, Parsons 1975) or accept doctors’ expertise. Not only do good patients allow the doctor to act as the healer and the expert, good patients espouse the orientation towards action that suffuses biomedicine (Lupton 2012). The valuing of dialogue that is present in participant accounts of good patients also embodies a trend in medicine whereby paternalistic attitudes are giving way to increased patient involvement (Heritage and Maynard 2006, Lupton 2012). A focus on dia- logue, simultaneously, calls on patients to shoulder more responsibility. Dialogue can ease some of the burden of making decisions that lies on the shoulders of the expert. The drive towards patient involvement, simultaneously, risks making patient reflexivity an unstated requirement that serves to separate good and worthy patients from patients seen as less com- mitted to their health and, accordingly, as less deserving of the additional care given to good patients.

Judgement and the reproduction of inequality Importantly, good patients possess cultural health capital: ‘linguistic facility, a proactive atti- tude toward accumulating knowledge, the ability to understand and use biomedical informa- tion, and an instrumental approach to disease management’ (Shim 2010: 2). Good patients are skilled at navigating the biomedical sphere. Negotiating the health arena entails showing trust in the biomedical expert and possessing the interactive skills that align with medical practition- ers’ unstated and often unrealised expectations. This alignment facilitates more fluent © 2016 Foundation for the Sociology of Health & Illness

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exchanges, feelings of ease and, frequently, greater care and attention. As research indicates, patients seen as ‘better communicators’ are met with more positive affect (Street et al. 2007: 594). At the same time, those without cultural health capital encounter less reassurance, listen- ing and empathy (Smith et al. 2009). While questions that good patients ask are seen as appro- priate and respectful, the seemingly laconic answers given by bad patients are interpreted as signifying a lack of interest or understanding. Asking biomedically relevant questions and dis- closing pertinent information can, indisputably, help doctors. The capacity to ask relevant questions is, however, also seen to convey responsibility and, further, worth and deservedness. Even though cultural health capital is unevenly available (Shim 2010), the possession of cul- tural health capital comes to entwine with perceptions of positive moral character.

While good patients are characterised as motivated to learn about and to control their condi- tion, bad patients often refuse to act in a manner expected of patients (Jeffery 1979). Impor- tantly, these expectations also relate to values around ideal subjectivity in today’s neoliberal societies. The indifference that bad patients are thought to display challenges the ideal of self- responsibility and signals someone falling short on the level of ideal personhood (Rose 1999). By not displaying self-responsible selfhood, bad patients can, simultaneously, be considered guilty of causing their illness through personal negligence. Thus, in a subtle but powerful way, inequality is reproduced ‘through symbolic and cultural forms – through, for example, the means by which people become judged as morally worthwhile, or as having the right kind of knowledge or ‘taste’ (Lawler 2005: 797).

The requirement for active involvement also normalises and privileges the interactional and emotional skills of patients able to display reflexivity (Giddens 1991). Reflexivity, however, is an aptitude more aligned with middle class dispositions and with cultural and economic capital that facilitate authoring one’s life (Adkins 2002, Skeggs 1997, 2004). This is especially true in the USA, where ‘society’s white-racist roots and contemporary structural-racist realities’ (Fea- gin and Bennefield 2014: 6) curtail access to economic, cultural and political resources on the part of people of color. The valorising of reflexivity also subtly reproduces white privilege. Due to complex histories of racism, the cultural and emotional capital that is normalised and valued are more readily available to whites. Furthermore, when concern for one’s health is understood to equate with following doctor’s orders and engaging in thoughtful dialogue, rea- sons underlying mistrust in medical authority – that shape communication and that stem from continuing marginalisation and centuries of injustice – can be side-lined. Lack of reflexivity is cast simply as an individual failing that hinders health. Simultaneously, self-responsibility and self-management:

[B]ecome the mechanisms by which class [and race] inequality is reproduced and refigured, individualized as a marker of personal volition and inclusion, excluding groups from belonging and participation through assumptions about their own take up of a particular form of agency, one to which they do not have access. (Skeggs 2004: 60)

Hiding the classed and racialised roots of interaction and behaviour that are valued in medicine risks blaming and disenfranchising patients whose cultural and economic resources misalign with what is deemed valuable within medical institutions. Medicine is, by the same token, positioned as a neutral field outside the social and the historical while the seeming impartiality of medicine helps to hide the subtle judgements that draw on and reproduce inequality.

The idea of the good patient is also entwined with the ability to undertake and sustain a healthy lifestyle. Many participants understand the capacity to choose healthy behaviour pri- marily as an individual accomplishment rather than something shaped by social location. Hall- way conversations about patients who use their limited resources on clothes and technology,

Entrenching inequality in clinical learning 73

rather than on medicine, consolidate the idea that those with less means are irresponsible and, accordingly, guilty of causing their own ill health. It is unlikely that the wealthier patients’ non-medical purchases would be perceived in a similar manner as signs of irresponsibility or ignorance.

Familiarity, feeling, and the reproduction of inequality In interactions within medical teams, some patients are explicitly identified as sweet or, alternatively, bad and difficult. Statements that profess sympathy for the good patient identify and justify worth, but also embody a sense of connection. The plight of the good patient is easier to recognise. Feelings of care engender investment in a patient’s wellbe- ing and generate further effort, also outside what is customarily expected of medical practitioners.

Emotions felt about patients are not, however, purely internal nor do emotions exist inde- pendently of complex and changing social meaning (Ahmed 2004, Burkitt 2014, Cromby 2007, 2011, Wetherell 2012). Feelings ‘rehearse associations that are already in place’ (Ahmed 2004: 39). Much research indicates that social stereotypes influence doctor-patient interaction and seemingly neutral decisions around diagnosis and treatment (Barr 2008, Feagin and Bennefield 2014, Roberts 2011, Street et al. 2007, van Ryn et al. 2011). What is felt towards a patient – whether a patient is understood as pleasant or not – entwines with the familiarity that doctors and medical students feel towards patients. Importantly, familiarity generates understanding (Bourdieu 1999). The racial and socioeconomic background of doc- tors and medical students is crucially important here. While the participants were not asked to define their good patients according to race or social class, good patients were characterised by the possession of cultural health capital that is associated with higher socioeconomic stand- ing (Shim 2010).

The good patients are afforded sympathy that, while partially based on a desire not to see another human suffer, also rests on social familiarity. Judgement premised on feeling is, in turn, both subtle and powerful in reproducing inequality. Even when they are difficult to dis- cern, emotions ‘both motivate and organise activity’ (Cromby 2007: 99). Feelings about patients entwine with what is often a sincere commitment to helping people and with the diffi- culty of helping patients whose ailments spring from myriad inequalities outside the scope of biomedicine. Bad patients who cannot be helped bring into focus the limits of medicine in a profoundly unequal world. These patients embody inequality that medicine alone cannot resolve. Understanding emotions engendered by patient encounters as shaped by class and race-based familiarity is challenging also because emotion remains marginal in the context of medical education (McNaughton 2013). This marginality, furthermore, continues to erode our means of fully appreciating the entwining of social stereotypes with emotion and with clinical judgement.

Conclusions

While good patients validate medical students’ commitment to medicine and to helping people, the challenge of bad patients relates to the impact of interactional distance, as well as to the difficulty of helping patients whose problems stem from causes outside the biomedical frame. Simultaneously, perceptions of good and bad patients capture ideas of normal and ideal self- hood, and constitute ‘devices of distancing and distinction’ (Skeggs and Loveday 2012: 473) that ascertain worth according to a patient’s possession of cultural health capital. As such, the distinction between good and bad patients both embodies and enforces inequality. The hidden © 2016 Foundation for the Sociology of Health & Illness

74 Eeva Sointu

and the informal curricula that convey messages about patient worth (Higashi et al. 2013) are thus central to the reproduction of inequality in medicine from early on in student doctors’ careers.

To more fully understand the manner in which inequality is reproduced in medicine we must not only conceptualise ideas of the good and the bad patient as ‘devices of distancing and distinction’ (Skeggs and Loveday 2012: 473), we must also consider the manner in which judgement entwines with emotion. Making space not only for emotion but also for the entwin- ing of emotion with social stereotypes is a tremendous feat due to the side-lining of emotion in western modernity in general, and in medical education and medicine in particular. This, however, is a challenge that needs to be met to produce more nuanced and, ultimately, more useful understanding of the subtle yet powerful reproduction of inequality in medicine and access to health care. While social stereotypes shaping perceptions of patients suffuse society more generally, by remaining unaware of the roots and the implications of distinctions between good and bad patients, clinical learning contributes to the reproduction of inequality that continues to resonate through medicine.

Address for correspondence: Eeva Sointu, Sociology, Smith College, 106 Tyler Annex Smith College, Northampton MA, 01063, United States. E-mail: [email protected]

Acknowledgements

I am enormously grateful to the medical students who took part in this research, the anonymous review- ers whose insightful comments improved this article considerably, and colleagues in the Sociology Department at Smith College and the Department of Sociology at the University of York. This research was generously funded by Smith College CFCD research grants.

Notes

1 Rotations refer to the 2–8 week clinical placements in fields such as family medicine, obstetrics and gynaecology, paediatrics, surgery, internal medicine, psychiatry, neurology and radiology that students undertake during the third and fourth year of medical school.

2 Terms such as adherence and concordance commonly replace the notion of compliance in much soci- ology today. The terms allocate responsibility differently, with non-compliance indicating individual failure on the part of the patient and the lack of concordance referring to a failed consultation (Arm- strong 2014).

3 A resident has graduated from medical school and is undertaking postgraduate training in their chosen field under the supervision of an attending physician.

4 An attending physician has completed residency and supervises medical students and residents.

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