Media images of physicians and nurses in the United States

Sot. .%I. .Med. Vol. 22. So. 9. pp. 93L952. I986 OTT-9536.86 53.00 + 0.00 Pnnted in Great Britain Pergamon Journals Ltd

MEDIA IlMAGES OF PHYSICIANS AND NURSES IN THE UNITED STATES

NORA J. KRA~TZLER

Human Resources Agency. County of Santa Cruz, Santa Cruz. CA 95061, U.S.A.

Abstract-This paper analyzes images of physicians and nurses presented in advertisements in the medical and nursing journals J.-l.Wrl (Journal of I/W American Medical Association) and AJ.V (dmericun Journal I2fNursing). Advertisements are viewed as hyper-ritualized displays of symbols and rituals associated with medical and nursing practice. both reflecting and reaffirming stereotypes and beliefs that are widely held in the society at large. Trends ober the past few decades show that medical advertisements are dropping some traditional symbols (such as the white coat and stethoscope) in favor of depicting science-in-action and high technolo,gy. Sursing advertisements. however, are more frequently utilizing the symbols formerly reserved for physlclans. Both physicians and nurses are depicted in their respective journals as existing largely independent of one another. While these advertisements clearly do not depict social reality, they present a fictionalized version which reflects and reproduces some of the expressed ideals in medical and nursing practice.

The mass media affirm widely held beliefs, values, and stereotypes. and serve as agents of socialization [I. 21. and, on an international level, as instruments of “cultural pollution” by “imposing a few standardized. mass-produced. and cheapened cultures every- where” [3].

In the United States researchers have studied the images of health care professionals in television [4] but have paid little attention to images presented to the professionals themselves. Advertisements form a significant component of the major journals for physicians and nurses. “Advertising in medical periodicals is a matter second in importance only to the scientific contents”, according to an editorial in the Journal of the American Medical Association (JA.LlA ) [5]. Phar- maceutical companies spend over 52 billion a year on advertising [6]. In 1983, the AMA’s anticipated reve- nues were exceeded by $8 million and an editorial in JAM.4 specified, “Advertising in AIMA publications is at record-setting levels. This. combined with the postponement of a postal rate increase, created a favorable variance from the original budget” [7].

One physician wrote:

Perhaps the drug advertisements are not quite comparable to Saturday morning children’s television, but it seems undeniable that they are a major channel for the expression of images of illness and medical practice, of patient and physician stereotypes, and of attitudes toward drugs. One often hears that physicians are too well-trained scientifically to be influenced by Madison Arenue techniques; why, then, haven’t the advertisers given up after all these years’? Advertisers invest thousands of dollars in these techniques, yet the medical profession has remained largely uninterested in what these techniques may be doing to medical practice

@I.

Actually, concern about the mass media has been expressed in both physician and nursing journals. and

Supported by S.I.M.H. Grant x:0. T32MH1461-l for Postdoctoral Training in Medical Anthropology. John A. Burns School of Medicine. University of Hawaii at Manoa, Honolulu. Hawaii.

the JAMA and the American Journal of Xursing (AJN) have editorial policies regarding advertisements [9]. The AMA’s concern has been to mod- erate the style of pharmaceutical advertisements, although it is the manufacturer’s responsibility to comply with the Food and Drug Administration’s legal requirements concerning their content. Re- cently, articles in the AJN have concerned the ‘nega- tive’ images of nurses in the media [IO] and suggested strategies for improving them [I I].

This paper explores the advertisements from two journals-the American Journal of Nursing (AJN) and the Journal of the American Medical Association (JAMA). I will consider: (I) the predominant symbols used to depict physicians and nurses; (2) how these have changed over time; (3) how relationships to patients and other health care professionals are depicted; and (4) what the content of the ads says about the ways physicians and nurses are perceived. The intent of the paper is to present a commentary on general trends.

.MEDICAL ADVERTISEMENTS

“I’ve been X-rayed, ECG’d, EEG’d, CT scanned, had blood put in and blood taken out, fluoroscoped, cjstoscoped. heart monitored, treated ultrasonically. I’ve come a long way since sticking out my tongue and saying ‘ah!“’ (121.

As Irving Goffman wrote [13], commercial advertisements are a hyper-ritualization in which the stan- dardization, exaggeration and simplification of rituals are magnified. Medical advertisements comprise * a hyper-ritualization of diagnostic and patient man- agement strategies, and they reproduce the predominant symbols and values of physicians.

The Journal of the American Medical Association enjoys high status. Like the official journal of the American Nurses’ Association (the American Journal of ;Vursing), the cover of each issue has an illustra- tion. JAMA’s covers contain photographs of classical art. primarily paintings, with a one-page commentary inside describing the work and the artist. AJN’s covers show photographs of people-often. nurses at

933 s.s 4( 1: 9-o

93-l NORA J. KRASTZLER

stork-or cartoon-like dra\\ings related to one of the featurs articles. While the JAM,-1 covers represent ‘high culture’-demonstrating that ph>sicians have sophistication or ‘class’-the .4J,V covers create a

more mundane, 2ver)day appearance. As Devereaux and Weiner observe in discussing nursing as a female occupation, symbols of masculine tasks are often upper class (‘exploitive’), while feminine tasks are often symbolically lower class (‘drudgery’) [lb].

Both the J.izMA and the .4JN screen advertisements for acceptability. J,I.CIA policy states crite- ria for eligibility, for instance, which prohibit advertising of certain products (such as tobacco products or alcohol) [15]. As of 1984 [15], six categories of product types were eligible for inclusion: (1) drugs, (2) instruments and devices. (3) food products and vitamins, (4) institutional advertisements, (5) books and (6) miscellaneous products and services. I will analyze drug advertisements since they most often depict physicians and/or their work.

As of 1960, pharmaceutical products required New Drug Applications from the U.S. Food and Drug Administration and subsequent approval by the AMA’s Advertising Committee. The advertisement kvas required to stat2 the product’s full generic name, and to avoid deception, unfair comparisons, or s\veeping superlatives in advertising copy. Further, policy stated that advertisements must not appear to conflict with the principles of medical ethics. Claims for n2w products were to be substantiated by ‘scientific data’ in the form of reports of laboratory and clinical investigations of efficacy and relative safety. The Advertising Committee made use of consultants to help evaluate products and determine their eligibility.

The 1960 statement of standards for acceptance of advertisin_e in the AMA’s scientific journals followed the abohtlon in 1955 of the ‘stamp of approval’ formerly required for each product advertised and represented reassurance that controls were still operating. During this time, the pharmaceutical industry began to develop and expand as mechanization and mass production methods allowed a more economical and standardized way of preparing dosage forms of drugs [16]. During the 195Os, ‘antisubstitution’ laws were adopted by almost every state, preventing phar- macists from substituting generic equivalents when the physician prescribed a drug by its trade name- depriving the pharmacist of a traditional role and solidifying the brand name system of prescription drug marketing and dispensing in the U.S. for at least a quarter of a century [16]. In 1975, some states repealed this law.

Thus. since the early 195Os, physicians have exer- cised almost complete control over drug products and drug selection [16].

Symbols associated with physicians

In fact. the rendering of a prescription has become one of the predominant symbols of the therapeutic exchange between physician and patient. The term ‘medicine’ means, first, “a substance or preparation used in treating disease”; it is secondarily “the science and art dealing with the maintenance of health and the prevention, alleviation. or care of disease” 1171. As Hahn and Kleinman [I81 discern. the striking

thing about the definition of ‘medicine’ is the predominance of the concrete: “The primal senss of ‘medicine’ is ‘a drug’ “. This parallels the central concern of biomedicine: bodies in dissase. Indeed. ‘medicine’ (as distinct from surgery and the other ‘services’) is at the c2nt2r of biomedical practice. Because of this, practitioners on the periphery of biomedicine may manipulate such symbols as the use of drugs in their attempt to enter the c:nter [19]: for instance, drugs may become a symbol used to up- grade the psychiatrist’s image vis-ci-cis other physicians, though their use is perceived by some as a sign of insecurity.

Balint [20] analyzes some of the ritual functions of prescriptions-‘prescribing a bottle’. in the British tradition. If the physician is too busy to see a patient,

One possible way out is to offer him another appointment at a mutually convenient time and to gi\e him a bottle. so calculated that it will just about be finished by then. Thus two birds are killed with one stone: the pa:ient will habe an additional reason to keep the appointment. and the doctor an easy, natural opening question: did ths medicine help? Alternatively. if for some reason or other the progress of the treatment has become blocked, and further probing is either unsuccessful or inadvisable for the time being, a well- calculated amount of medicine !\ill bring the patient back at a time when the atmosphere may be more favorable. Again, if the practitioner is uncertain whether the time has come to stop. arranging for the patient to come back for a new prescription or a check-up enables him to keep an ele on developments and to ‘start’ again if e\ents demand or suggest it.

Thus, prescribing serves to placate the patient, to buy time for the physician. and to maintain physician-patient contact.

Prescribing further serves as a symbol of the physician’s interest [II]. The prescription is a social object, the transfer of which is a u-ell-established ritual in the formal relations between physician and patient. By giving a prescription, physicians legiti- mize the patient’s act of coming to them for help and increase the patient’s dependence on them, which increases the liklihood that the patient will return: “Essentially, the prescription has become a reward, a ‘well-done’ from an ‘expert’ who -knows’. At the same time the physician is able to reu-ard himself, the prescription serving as an overt symbol of his ability to act-to perform his technical role” [?I, p. 107].

The prescription further helps the physician deal with time constraints by serving as a signal that it is time to leave [21, p. 1021. This ritual function of prescribing is utilized by and reinforced in advertisements for pharmaceutical products. demonstrating a ritualized pattern of social interaction (see, for example, Fig. I). Typically, drug advertisemerits (which may be as short as one page but are oftzn much longer) end with a sample prsscription form filled out, showing its proper form and reinforcing thr idea concretely. Control of the medication (‘Rx only’) symbolized control over the medication process itself. In fact, this symbolic nature of the prescription may be used in joking form to advertise non-prescription items as a way of suggesting superior quality (as sren in Fig. 2). In such a way, everydab practices and products may be medicalized.

In advertisements depicting physicians, the white

coat and stethoscopr have predominated as idsnci- fying symbols [I?]. As Tab12 I shows. thzss s)-mbols have undergone some changes in the past t\vo decades. Whik in 1965 th2 white coat and stethoscope clearly predominatsd as physician idsntifiers. their us2 decreased in IYSZ with a rise in ths dzpiction of physicians in streetclothes (suits or dresses). LVhen drugs ar2 advertised. the physician is more liksly to wrar a white coat and stethoscope; when busincss- related concerns arc advertised. these arc Iess like!!- to appear. This symbolically susg2sts the s2pa:aCon of healing from 2arninz mow>. parc of rh2 idsal image of mcdicme.

In both 1965 and 19S’_‘. i5.i adl,ertkm?n:< depicted nurses; thos? \\hlch did shoM2d a male ph>sician u-ith a fsmale RUrj2. IndCed. as hss bscn note2

abore and will bc elaborated in the section on nursing to foilow., a major symbol of physicianhood has been malerwss. In th2 1965 issu2. a11 of the physicians shotvn Lver2 mak. hIor recently. as more women entsr the ranks of medizinr-currwtlq about 30% Of entsrinz medical students ar2 women [23]-adv2rtGemsnts portray som2 female ohksicians. Ho!\txrr. likr m3ie nurws. female physicians are rareI) porrraqsd as ths sol2 physisians in an advertisement. This sugg2sts that the medical and nursing roles have taken the form of gsnder-based social identities. In this sense. all physicians are male and ail nurses. iemals. rcp:lrdless oi their anatom> [?a].

Currsntlq. the irhitc coat is Lvorn bb man>’ rypes of personnzl M ho pork in hospitals. not just pkgicians. Ho~2~2r. xiierti.;_‘m2nrs in medical journals utilizing

For an effective program of personal hygiene;

E lather, rinse, and repeat as necessary,

Fig. 1

uhits Co;ltj tend to rijervs them t‘or phyjician de- complaints \\ill bc dealt with cornper,-:::;: [25]. Three pictions. For the physician. the t&hit< coat has been major origins for the whit? coat ha\z Pstn traced: thz thought to symbolize a sense o!^ seriousness of pur- operating room. the scientific laborzrzr) and the pose providiy rsajjur4ncs to patients that their hospital [72]. The introducGon oi Izk:~rory garb in

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.j3!3 ;Odtj‘. US2 Of [be lab co;l: &ii2pz2 ajsociat+j airh the incrrasing authorit>- of s;i2nc2. as th2 pro- f&on of m2dicinz nndwvent 3 tr3nsform3tion. ~StrUCturel! Xi@ilIld Lboratory sctence. in the ear!) 1 %)ijj. P?lL Sicians bscan;e stereotgxd as scientists :~earinp \\hite coats. AS Blumhaycn points out. .‘Th2 m2ssage of povv2r and protection smerge: while uear- ins ;1 \~.hi:e <oat the physician is a’ble to hand12 sai21> the dsadi) s:ourg2s that piague mankind and is abi2 to rend-r rhsm innocuous. One result of this perception of i.‘aUw vvas that phvsicisn-scientists vvcrc granted trencndous authority” [Xl. 3

If thr :rhite coat symbolizes the physician‘s sci2ntifc authority. the stethoscope symbolizes one of the roots of this authority: th2 ability to makr a definitivs diagnosis. Shryock [26] notes that the phy- simians prior to 1SOO uhsercrrf their patients; there- aftsr. th2> bsgan to r.r~minr them. In the early 1800s diagnosis aas revolutionized by Lainnec’s invention of the st2thoscope [I;].

Sot onlv was diagnosis revolutionized, but Laennec’s &e of ths stethoscope changed the value attributsd to the clinical sign [Xl. \Vhereas before, in order to produce a certain diagnosis, a stgn had to belong to a convsrpsnr szriss and it was ths confi~uratron of the u-hole that mattered. now the sign cou!? Sp2ak alone. As detected by auscultation (!istening to th2 sounds made by the various body structures ,:s a means of diagnosis [29]). it alone could designate disease without any possibiiicy of error. Li’heress or2viousl~. a sign was not different from a s>mptom. HOW the symptom could easily remain srlent 125. p. 1621.

To est3biish these signs is to project upon the living body “a \v hoie network of anatomo-pathological mappings: to draw the dotted outline of the futurz autops>-” [3S, p. 1621. The clinical gaze. in Foucault’s terms. became the ‘anatomo-clinician’s’ gaze which had to ma? 3 volume: for the first time, it dealt with spatial d.tt3 requiring the us2 of hearing and touch in addition to sight. The stethoscope thus symbolizes ths physici3n’s increased povvers of observation-and at the s3m2 time. Social and personal distance from rhr patient. As rules of etiquette przvented the physician from comfortably laying ear to breast (particu- larly to female breast). Latnnec developed the stetho- sCOp2 as 3 means of listening from 3 distance. Foucault observes that the kev feature of clinical anatom) 2nd the medicine deri&g from it is that of invisible \isibilit)-. the ear and h3r.d acting as substi- tutes for th2 2~2 until death makes vision possible.

The centrality of ths st2thoscope to the physician’s image is “.tL> e *--t d to bl its pervasiveness in medical garb-both in the media and in clinical settings themselv2s. Johnson [19] maintains that. in clinical szttings. ths prominunse with which the stethoscope is displa>~d vr-hen not in us2 is dixctly related to the nerd to A;xar ‘m;rdiA’. For exampl2. medical students t\-picAly carrv thsirs draped over thsir n2ck and Shouldsrs. u. hi12 t&r -atwAng’ physicians ksep theirs :n :h,-ir pock~rs. Similxiy. adv2rtiszments Shovv bo!h: in nurs:ng journal ady.2:tis2m2nts. nurses LVith SI?th.~s:optZs t2nd to ha\2 rhcm displa!-cd prom- inentlb. ~+i!le ma:: ads in rzedioal journals sho\l.

h-.7er-s;u$&$ : .e .erston of rituais and j>;*t:iois com- mom> Jssociated with physrcxn-patient 2xount2rs. such 3s prsssr:b:ng drugs 2nd \v2Aring ‘.r hit2 Coats and stethoscopes. The> address ara’~ k..h oi ctxsrtaint\ in medical practice-making a diJgnosis: choosing a treatment: maintaining rapport with patients; start- ing and stopping patient interactions-and provide 3 form of ongoing socialization throuph dissemination of drug information and. more subtly. through \.isuai e.~ampie.

Yet as one csamines the most current issues of the J~wnal c$ the .-f~~~ericmz .\id:‘d .~SSCX&Z~O~L the most startling thing is that depictions of actual physicians-at+ork are no longer necessary to do all of this. In current advertisements. physicians are manipulators oi technology behind the scenes. The! are rarely shown talking to patients. more rareI> yet talking to nurses or to each other. Recruitment ads for the military sssm to bc exceptions. perhaps due to the clear-cut social hierarchy uithin which on2 must practice there. The tendency is to shon brightly- colored. high-tech imagery. such as computer simu- lations. and to :;7cus on scientific c\-idcnce of sficacq (e.g. depicting sciencein-the-makin b> s’ho\ving a presumed scientist drawing a graph of Drug trial results).

Often. physicians are depicted looming Large in the background of a patient’s life. For example. the physician’s hand may be sholsn superimposed over the patient, s~:mbolically protecting or encompassing the patient (Fig. ii. Such advertisements susgest that the drug be used as an extension of-if no: a substi- tute for-the physician. By using powerful drugs. the physician becomes a powerful agent. The \i;ording formulates this concept. as the following esamples show

(1) “Free your angina patient.. from ssme constraints of beta-blocker therapy” (photograph show a man pla>ing golf, first trapped inside a glass box, then out in the open. shattered glass belo\c):

(2) “Trust Trsnxene (clorazepate depotassium) to lend a helping hand to the anxious patient”:

(3) “!Vhen your first move is a prescription for Clinoril. j-ou provide a highly efTective nonsteroidal anti-int?ammator)- agent” (photoyaph shows an older tvoman playing with a presumed grandchild).

?cfany advertisements characterize in exaggerated form the ‘typica! patient who uiil benem from the drug. with paraphernalia indicating their jobs (e.g. a hard-hat) or engaged in everyday activities (on the golf course. or playing with urandchiidren). As Stimson 1301 observes, by pIacinG people and their problems into c!early dehnable categories. the drug advertisem?nts rn:oura,oe at-a-glance diaznosis. Par- ticularly in adT.2rtising for ps>chotropic &ugs. diagnostic images x2 crsat2d b!: shoxinp certain types of people predisposed to certain problems. and by por- trabing certain !i;.< events and life situatio_s as caus- ing. or being found with, these problems (“Older. overwhAmed, depressed” is the caption 2:‘ one such advertisemen:!. These problems are then shown to be treatabLe b> phkiicians [JO]. Thus. usiny sr:r<otypic

938 NORA J. KRASTZLER

jI”;;z 2 ..,per-;ltcJiizs,! -,crj;,>:i 0. *; -3 ! ci!~~1;31 ieaiir:_

. .i.dizg the drug, lr-I: the typic31 FhyjikLifi. rh? i>p;Cai

i!inejj. [lh,c [;.pica{ 'cajt‘ .zf,.j itj Cd?:jCj . %ld :ht typica! outcome. The notion is fost?red that life priJ4!Arj can & i.L treatsd US~Z~ drugs.

Occasionail~ in J.-l.V,-l advertisements, physicians are depicted talking t0 patients jsce Fig. 4). By their pla~ment in the photograph. physicians‘ status and authorit!, is 3ffirmed. The? are usualiy positioned higher in the photograph tnan others. high physic31 place symbolizing high social place [l3]. Nurses are almost never shov\-n: the few who are 3re still depicted in subordinate roles-for inst3nce, looking on as the physician acts, or working in a clerical capacity. \Vhen physicians are shown touching patients, it 1s f0r utilin (examining or treating a condition). This is true u hsthzr the physician is male or female (see Fig. 5j. Photographs of nurses, on the other hand. show ritual (‘feminine’) touching (see Fig. 6). However. male nurses are shown touching for utility (see Fig. 7).

In summary, most medical advertisements are technology-oriented. Relatively few show physicians 3c all. and even fewer show them in social interactions with patients or colleagues. This is a significant trend, reflecting the growing dominance of technology in biomedicine. Concern among physicians over this trend was the subject of a series of articles in the _/.-~.U.-I in 1933 [I?, 311. Grouse [3l]. asking the question. “Has the machine become the physician?” argues that the increasing public alienation from physicians is direct!!- related to the development of an increusingly impersonal, technology-dominated system. Improvements in health do not have 3s much impact on patients 3s “the hidden message that the mschine has become the physician: the definitive adviser. The specialist-physician is metamorphosing into a technocrat and a businessman. The physician retreats behind the machine and becomes an extension of the machine” (Grouse [31]j. This trend is succinctly captured in the journal’s advertisements.

NCRSISG ADVERTISEMENTS

Sursing advertisements show a parallel trend: cur- rently. the nurse is shown in a nursing world. single- handed!>- caring for the patients in an increasingly ‘professional’ manner. Yet there is a critical difference: nursing ads have tended to be more per- sonalized. vvith a predominance of advertisements for recruitment and personal products (such as shoes. uniforms and hand lotion) (see Fig. S for an early example). This reflects the association of nursing with female gender-indeed, ‘nursing’, by definition. is something only women can do. Use of that term to describe the role reflects the socially postulated ‘natural’ afinity between femininity and certain types of work [32].

In keeping with this association. Warren [?3] points out that “Regardless of her class. job. salary. or marital status, the .\merican woman is socialized by th;r xior!d of advertising to lx the consumer”. as part of her presumed role as household manager. Xursing advertisements have reRecr:d this social fact. Indeed. nurs<s ha\a been the .household managers’ of bio-

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considered ‘pr;lfessio33l‘ [X] :jnd h:~i-e ~:=3t]y c,~n- rributed to nursing’s difficnlti~s in the prGfession;il world. .\dvertisements over the past Jesdtj :efletct the recent trend tovv3rd rejection of s.>me of the trapnings of tiaditional. gender-bass? nursing roles-the outward symbols-yet pose the problem of maintaining nursing‘s COTS idrntifyinc fzaturcs.

In this section I xiii considcr the symb0ls used to identify- nurses in advxtis,-ments in the .jnteric,~n Journal qfAVtrrsin,o and their changes over time. and the nays that nurses are depicted. .4s for ph;;sicians. advertisements depicting nurses represent hyper- ritualizarion of the rituals and symbols associated with nursing. I argue that the discourse ofadvertising in nursing journals is 3 discourse of gender-based symbols reflecting power relstionships. Xursing advertisements have begun to adopt symbols previously used only by phbsicians, in their attempt to present themselves as more affirmatively professional and. thereby. as closer to the center of biomedicine.

The AJ.V has been publish,-d since 19OO Its eariy issues contained few advertisements. In its fiftieth anniversary- issue. an anecdotal review of ‘Fifty Years of Journa! Ad\-ertising’ [35] reminisced:

A couple of pharmxzuticals, a ti)r,ic. a book ssr?. and 1 fountain pen manufacturer just about complete2 ihz advertising in the firsr isju:. There v~ere two other ads. beth sma!i. but u-orthy of nctr. One advertised champagne. which \V;ij then used by many JS B tonic. asd the other prxiaimed in rhyme the Superiorit> of its nurses’ aprons. caps. ai!ars and WI-k

Like the J.4.1f.4. the ‘4J.l’ has had a svmbiotic relationship with its advertisers. For exatxp-1,. while advertising helped t0 financialiy support the journal. the journal played an important role in the dexl- opment of the nurse uniform business-an industry begun in the early 1900s and adv,ertised primarily in the AJ.V. This industry continues to be among th? largest of the .U.V’s advertisers.

Qnbols associated nit/x nursing

Advertising seemed to increase in the i3jOs. In- deed. the number of subscribers to the journal jumped from 1100 in 1900 to 31,000 in 1935 and 11 j.000 in 1950 (351. Table 2 shovvs the symbols one is likely to see in advertisements sho;+ing nz:ses in the AJN in a 1952 issue compared with those in a 1932 issue. In 1952. the white uniform and cap were the predominant symbols used to depict nurses. There were no nurses shown Hearing white ~03;~ x stethoscopes. All the nurses depicted were u-omen. Only one ad in the 1952 issue showed a nurse with a physician-notably. an Xmy recruitment advertisement. In fact. recruitment advertisements for the armed services consistently sh0\v nurses together with physicians. from the 1950s to the l990s--just as such advertisements in medical journals shox physicians working with co!leagues.

In the 1980s. the white uniform is still a dominant symbol. but its form has changed. Nursing uniforms are advsrtised as ‘profcssioxi fashions’ &nd take a wide variety of forms, from knee-length drejj<j 1~2

slacks with matching white colts [Fig. SL%~ and (B)]

--...

[30]. Nursing .fashions‘ are presented as professional wardrobes. not simply as uniforms: their di\srsit> reflects the desire not merely for respectability but for professional status. As has already bern shown. this is occurring as the whit2 coat which has characrsrizsd media images of physicians over the past sei-era1 decades is often shed for evsrvday clothiny and a more subtle use of symbols. Similarly, nurse uniforms are tending to approximate 2vsrkday clothing stllss in the 1980s (Fig. 10) compared with the 1950s (Fig. 1 I). As these evamplss sho\v, the emphasis in 1352 was on creating a professional but feminine imags. In 1982 we see a similar ploy, but with more zmphasis on fashion.

In 1982. several nea- symbols appear in depictions of nurses-especially, the white coat and stethoscope, previously the prosince of the physician. Further. whereas in the 1952 issue all nurses uer2 Lvomen. in 19SZ a few male nurses also appear. Ho\vsier. they usually appear together Lvith female nurses-not as the only nurses shoivn in an advsrtisement. This is not true in 193-t: an ad appeared in the .U.V sh+Ming only a male nurse with a patient-notably. a male child (Fig. 7). Patients of nurses in x!\ertissments are frequently childrrn rather than adults-Jzain reflecting the origins of secular nursing in which the care of children \vas defined as a ‘na:ural‘ attribute of Lvomen [3?]. Shouing a ma le nurse with a ma:,- child calls up the prssumed speck! closeness of father 2nd son in ‘typical nuclear family strucwre.

Female gsnder is, by and large. the majar symbol associated with nursing. A male nurs2 k;r.:nts this situation:

Just as a female doctor must prove constant!) 5tr she is brilliant or be though: the opposite. a male nurse z.ust bend oxcx backwards to shw kindness. so detp-rw::d is the assumpiion that he irili be slight11 uncaring.. Being ZI nurj5. tar :t man. is i:!i! ~~l&iy seen 35 an ackncx., ‘-dgment of f-a1lcr: [37].

He also points to th: ‘myth of homosezua!i:!‘ of male nurses: male nurses are considsred not quir: ‘masculine’. De\ereauu and V.‘siner [32] sugges: :kis belief may have its historical roots in ths Xliiiie Aprs.

lvhen care of the ill \\as the function primatiI> of nuns and monks, bvho had renounced their s2~al role. kIal2 nurses are pcrcsived. in a s2ns?. as king akin to hrrdmhes among th2 Mohave and Plain; Indians [38] or $r’&fit~es in Samoa: institutionalized forms of homosexualit) emphssizinp public pexder displays. This is the image male nurses furl they are forced into. Indeed. in terms of ad\ertissrr.-nt, male nurses hsv2 until rx,-ntly besn ‘in the class:‘. In fact. they ha\e comprissd the smallest minority i:. nursing. Only I”0 of all actiw nurses in 1360 LVTi? x312. and in 1972 men s:il! constitute less thsl ?‘.J of th- .A c nursing forsc. Ho\\:\.-zr, 9s ea:l> as 1951! men wer2 encouraged IO enicr nursing: of iZl_i schz+ls. ther.2 i\ers t-our schools for mr?ie nurxs. r?r.t i23 co- educational schaois [33].

In th2 1950s. for fe:?lais nurses (cl? only 1 i.;lt?lr kind), the symbols of uniform and sap predominated in advertisemen: in ths .-1J.\-. Th2 uniform and can as key nursing s)mbols s22m to hz\2 comt’ from nursing‘s milirxy. and r2hg:ous ie~xics. 5o:h +t which placed high i~aluc on the wear~np of uniiorms [39]. Standardized i;niforms for nursing siuL,-nts UCL’S first adopted in 1376. a!though stud2nis initi~ll) opposed the id2a. Uniforms were commoni! worn b\ servants at that tlmc and g2neraliy signified xrvant status. In fact. th2s2 uniforms included J bib and a:1 apron similar to r:?ose worn b> ‘gentlsircmen b\ hi!2 performing their houiehoid duties. Sinc2 it U.L< considered immodest to show th2 Ltnklcs. dr2i+ ~2:‘: ankle-lengh: ax! :hq I& high co1l.x~ ant shir:- fronts to conceai :hc upper body. The unii’arx; U:TCZ also long-sleeted. v.ith cuCs from t\:is: to 2ibi:~.:. One historical count of nl1rsir.g obserxcs ti?z: “4 nurs:

iiorking on :?n infectious ;ase could not be on duty hdii in hour LQithout settin? her sieeves con- taminated. .Al:haugh the52 sleevss usre carriers of infixri?,n. nurs2s uho roi!2d up their czn”j, or sl22ves ivsrs iol:ndi] rsbuk2d. for such sn aF;2aranc2 sug- g<stcd the u<u;?i demeanor of a laundrsss or scrub- v.omdn” [3Y]. Phc image nurs2s stroL2 [o pressnt to the public ~3s one oi‘ ecntihty: an image of uell- groomed and nsil-bshavsd )aung uonxn.

The first uniforms were dark-colored. or calico. The change in clothing worn by care pro!-idsrs from dark colors to white undoubtedly reflects the chanse in the image of the hospital from a place to die to 2 place to be healed. $Vhite became associated with the institutions of healing. There were at least tao mesn- ings of white in this context: as a sbmboi of iife (as opposed to black. symbolizing death and mourning! and as a symbol of purity. Purity implied innocence and unaroused sexuality, goodness and candor [??I.

Originally, the purpose of the nursing cap \Las TV cover the long hair that was fashionable durin: the late 19th century. The first ones resemble2 duit caps and were relstilely large. Graduail~. ea;h nursing school developed its own Cistinztive cap. ittc: grad- uation, nurses continued to wear their i~hool caps. uniforms and pins. and these cxmc to bc ~ssxi~~l

uith the reputations of the various trair;lng schools. and to xpresent a source of pride.

LI’hcress the period betbtecn lY6O ax? the 19% SLIIV th= aleipi-ilce oi nursing as a distinct. secular profession. the period of the 1950s has ken charac- terized as a declining phase of this epC=Ch. in which more attention \\as paid to outuard t:;ppings and rituals than to the sore of nursing itseif :_‘J]. Nursing in the Is)Ns was ‘-static. rigid. rituaiisri:. and un- challsn$np” [l]. The emphasis on ” c3:;orms and prof:sston;tl bsha:our in the 1950s led IQ the obs<r- l,ation that the jecaisr nurse, ‘viackinp :L:e dignity of the nun‘s coif. is sometimes compellrd :S starch the taqade ot‘ her professionalism e\en m-::e than she starshes her unit;>rm” [j?]. The sours: -of pride in such s> mbols has been likened to ‘resp<::.;.bility’ as a bad%: of‘ m.em.‘nership in the middle C:ZSS !32], Even

NORA J. KRASTZLER

in the 19SOS, thC impO:::irlW fir tb.C j)lT?bOl Ol LhL. uniform is attfstzd to both in adxertijements (jee Fig. 9) and in nurses‘ testimonials [-tl].

The perceived need to display an escessi\el> professional demeanor has been related to sociopo!itical and economic features of nursing. The social postu- late that uomen are ic‘ss indepczndzt o? ~~pu‘?ie 01 intt tiatlve than men and. thCiCtOi?. xcG m.irs:ilize ‘i’ guidance. led to the pork ct. IIL:~S~S being de5ne-b as the exercise of functions s;xiti~~lll;. d:!ecated b? t& ph;.sician. Little was dote to e:.p.!x! ;ne n’;rsej j value to the pati~ni-~irti~ui~r~~.. the ex~::onsi vaius. Emotionui support is ~am~~:t::l_::tai~~~d 2s the province of others. su;h ;S seeici worZ?rj. SuCh

support from nurses is \ie\rsd as unnsczssary and almost unprofessionai [3?. 3-t].

Ii nursing rewards arc not alwa>-s forthcoming on a personal Iwe]. nor are they abundant on a mon- etary le~ei. The changing need for nursing ‘man- pouer’ is reflected in rccraitment advertisements in the .&I.\- tTab!e 3). One of the striking things here is the almost four-fold increase in the number of recruitment advertisements in the 1987 compared \\irh the 1952 issue-35 compared bvith 9. JVhile the earlier ads \\sre most likei) to stress salary. benefits and hours. 1932 ads t‘ncus on benefits, care?: oppor- tunities and recreation. .Advcrtising a hosFi:al’s ‘CW

atitc nursing‘ ;?:5i!OjOph, & : is zt na deveiopment: in

Fig. 9tBi

1951 it was n2v2r mentioned-indeed. noi bet cun- ceptualized.

Recruitment advertisements rckct nursing‘s current difficulties in the job market as a ;.sholc. .As Mechanic and Xik2n [-tZ] point out. --NLLrsinS

exemplifies many of the limitations of xomen‘s occupations’ and bvomen’s changing carxr SY- pectations”. Surses are poorI> paid in fom~-irison to those in other occupations rquirin, u sin;i!a.r !2:.els of education. s!<ii! and responsiStlity. Furtkrrr.x:. ex- istmg sslar) jtWCtLIreS do not rzibarii exT_riencsti. career-oriented nurw. -rher?fCU-e. ma n :- ‘I 0 m i‘ n

.

nurses mow from school into the fie!d. There is also a second wave of deparrur~s in nursing after 3-j years of working in the field. The reasons mosi octen cited are lack of autonomy. lack of status and subservient relationships lvith physicians and admin- istrators [-U. p. IO]. In a recent sun+ by R..V. :Waga5nr, 3 out of 4 physicians Here found to regard nurses as nothins more than rhcir assisiants [44. p. lo].

It is of interrst to note that many wirers assume that ‘because 30% of nzn- m2dical students are female and ?9:0 of nurses are now mal2. this situation will changz. This pzrspecti\c assumes a -na!xal inclina- tion by gendsr-i.2. a f2n:a:2 physician ;\i!i ‘be 12s~

likzly to regard nurses in a sexist or subordinate ~ay, and ma12 nurses n-ill ‘be less likely to experience grnder-based prejudice. Cicarly, vizwing physician and nursing ro& as gender-based ~ociai-not biological-idsntiti2s renders the situation much more complcs. Th; physician is still ‘he’ and the nurs2 ‘shr’, in ar::clcs in the mass m2dia [45].

Sursing ad~~r!~~~men~s in the 19YOs stili make use oi t‘2minine gender d~spla>s. such as ritual touching ax! smiiin$. at:? por:~:?~ai~ 0; childr2n as patients. Howcvcr. r:l!hitr than iilUSti:4te xaditional i:urs2-phq sic&n ;el:ltioni:1::<. phlvsicizns arc periph- eral in nursmg xf*~crtis~rne~is-ii, ind:ed. :h2y exist a: all. Nursing .:Ax-T L ~~rtisemc~ts currentI\- .emphasize

cognition and car22r mobilitv. The nursing world is just that: nurses are sho:vn alons, with other nurses or with patients. They are subordinate only to other nurses-as shown by ritual subordination. for instance, in the classroom. with ths instructor looming over the student or teaching at the blackboard. Physicians and nurses are presented as proiessionul equals in the t;‘xt: nurses arz ‘serious about their careers‘. In one adwrrismenr. 2 ELU-ST j:zt2S. -.Ot‘ course. I consult nith :hc doctor. bur it‘s more like we’re uork:ns together. !ike collaboratcrs. \i’here rhr doctor sees my client; occe a mocth. I‘m seeins them at leasi oxs a W?ek. so the docror relics on m) professionn! judgment”. Xotable ;re that tii: nurse

‘consults’ (a mcdizai rituait. that thrrs is no sender pronoun used for rhe physician, and ~i,cii the phlsi- cian’s role is dismissed as virtually iKeievant.

In other. similar. ads, n>rses stand xer patients’ beds with charts in hand, or bend over rbz bedridden patient in a gesture susgesting ‘bedsids manner’ (see Fig. 13). This direct relatiar.ship Hi:? a client. un- mitigated b>, a third party. is rn imporrznr symbol OF

professionallz:ition [S]. Fqin and Diers describe r,nrsina 2’s a metaphor:

for mothering. for c!ass s:rnggic. 7~: qaaliry. for conssicncs ioi the ph>sicianr. :;7r intimx:. and for sex [17]. The>- canc!qG.e: “50 r;.-5 ix tb- xxtaphors of orhers. Far ourxi:es’! \‘G’,- ::-?ink CI .Jurselves as

i

4 5’

,

4.G :

Fig

Florence Nightinga!e-tough, caring. po;wrful. au- tonomous. and heroic” [-I?. p. I1 71. lntsrsstingly, thz caring role of the nurs? in ?Qiphtingle’s time \\a5 restricted to concern tvith the patient’s bodily functions. The role of the nurse \vas not to encourage communication but to ,._? ‘pqr?Sj it [X3]. ;trmstron~ argusr that objectification ai the patixt was the norm until \-zry recenti> [-la] and currzn: trends in adbcrtisino seem to su%g?st a return to this 2s nursing jymbok and behavior mimic ph:.si;iaa<.

1ledia images of physicians and nurses in the United States 951

in achieving good patient outcomes, medical schools and nursing schools have become increasingly iso- fated from one another” [-IL p. 7501. While a team approach is the often-stated ideal model of patient care, these media images indicate that such relationships are clearly not yet institutionalized.

Advertisements in medical and nursing journals depict highly stylized versions of symbols and rituals associated with medical and nursing practice. Changes in advertisements over the past few decades

reflect trends in the self-perception of the professions.

For physicians, the emphasis is increasingly on sci-

ence and technology to the exclusion of social inter-

action with patients: for nurses. the emphasis is on

‘professional’ skills and the trappings thereof-

symbols that were formerly reserved for physicians. Advertisements in these journals further reflect the increasing isolation of medical and nursing traditions from one another.

While advertisements clearly present fictionalized versions of social reality, they draw upon the same ritual idiom that is the resource of all of us who participate in social situations [13]. For this reason, examining the images and symbols in journal adver- tisments can provide a means of self-reflection for medical and nursing professionals.

REFERENCES

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institutions. J. Commrmic. 28, 12, 1978. Lomax A. Appeal for cultural equity. J. C’omnncnic. 27, 125. 1977. ..

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American Medical Association. Pamphlet distributed bv the Amencan Medical .Association’s Ofice of Adver- t&e Evaluation. 198-t. Colgzzi J. L. Drug product selection. In Perspectus on Medicine in S0cier.v (Edited by Wertheimer A. 1. and Bush P. J.), p. 113. Drug Intelltgence Publications, Inc.. Hamilton, Ill., 19i7. Webster’s Third .V~LL. International Dictionary of‘ rhe English Language. G. & C. %lerriam Co.. 1976. Hahn R. and Kleinman A. Biomedical practice and anthropological theory: frameworks and directions. ,-I. Rer. dnrhrop. 12, 305. 1983. Johnson T. M. Medical education and practice on the periphery: Consultation psychiatry and the psychosocial tradition in American medicine. Sot. Sci. Med. 22, 963-971, 1986. Balint M. The Docror. his Parirm. and the Illness. International Universities Press. Xew York, 1957. Bush P. Psychosocial aspects of medicine use. In Per- speclices on .Uediicine in Sociei~ (Edited by W’ertheimer A. I. and Bush P. J.). p. 92. Drug Intelligence Publica- tions, Hamilton. III.. 1977. Blumhagen D. The doctor’s white coat. .inn. inlern. Med. 91, Ill. 1979. Dimond E. G. Women in medicine: two points of view--I. The future of women physicians. J. .-lm. mecf. Ass. 249, 207, 1983. Mauksch H. Personal communication. Kriss J. P. On white coats and other matters. .Veir Engf. J. Med. 292, 102-I. 1975. Shryock R. H. Medicine in America: Historical Essays. The Johns Hopkins Press, Baltimore. 1966. Singer C. and Underwood E. A. .-L Sliort History of Medicine. Oxford University Press. New York, 1962. Foucault M. T/ir Birrh of‘tlie Clinic. Tavistock. London, 1973. Stedman’s Medical Diclionary, 24th edn. Williams & Wilkins. Baltimore. 1982. Stimson G. V. The message of psychotropic drug ads. J. Communic. 25, 153, 1975. Crawshaw R. Technical zeal or therapeutic purpose- how to decide? J. Am. med. Ass. 250, 1857, 1983; Grouse L. Has the machine become the physician? J. .-Im. med. Ass. 250, 1891. 1983. Devereux G. and Weiner F. The occupational status of nurses. Am. social. Rtw. 15, 628. 1950. Warren D. Commercial liberation. J. Communic. 28, 169, 1978. Krantzler N. J. Treatment for cancer: nurses and the sociocultural context of medical care. Doctoral dis- sertation, University of California, Berkeley, De- partment of Anthropology, 1982. Slack W. S. Fifty years of Journal advertising. rim. J. Nurs. 50, 635, 1950. See, for example. .-im. J. lVurs. August, 1983. Groff B. The trouble with male nursing. .dm. J. ,Vurs 84, 62, 1984. As described by Devereux G. Institutionalized homo- sexuality of the Mohave Indians. Hum. Bioi. 9, 498. 1937. This idea was suggested by Hans Mauksch. , personal communication. Kalisch P. A. and Kalisch B. J. The Adcance of Amer.

. ican ‘Vursing. Little, Brown, Boston, 1978. Levine E. Nurse manpower-yesterday, today, and tomorrow. Am. J. Nurs. 69, 190, 1969. Janowski M. J. My love affair with uniforms. Am. J. Nurse. 83, 1241. 1983. Mechanic D. and Aiken L. A cooperative agenda for medicine and nursing. ‘Vetr Engl. J. .Med. 307, 717, 1982. Interestingly, a 1981 advertisement for Army medicine showed a physician with his family, with a text urging that military medicine offers the physician a chance to spend more time at non-clinical activities.

92 NORA J. KRA%;TZLER

U. SchrJm M. L. P. The bamshlng nurse. Cali,/omiu Living .Ilagu:ine. Sun Francisco Sunday Exummer & Chronicle. 9 January. p. S. 1983.

-15. See. for example. Ref. [A-t] as an example. 16. Searle M. (The professionalization of anesthesioiogy-

again. SOC. Sci. ,Iled. 81, 323. 1984) describes the process of professionalization in anesthesiology, a mar- ginal biomedical tradition wth some parallels to nursmg. She suggests that the relationship between profes-

sional status and technological etTec~i\eness ma> be curvilinear: when levels of dlfficuity and nsk are tngh. its use requires the special ability of a highly-tralned professional. As the technology becomes easier to oper- ate. it can be handed over to lesser tmined persons.

47. Fagin C. and Diers D. Nursing as metaphor. .Vr\r Engi. J. .l/ed. 309, 116, 1983.

18. Armstrong D. The fabrication of nurse-patient re- lationsinps. Sot. Sci. Med. 17, 457. 1953.

Documents

Media images of physicians and nurses in the United States