Antonio VIRZÌ*, Salvatore DIPASQUALE, Maria S. SIGNORELLI, Oriana BIANCHINI, Giovanni PREVITI, Filippo PALERMO, Eugenio AGUGLIA
University of Catania, Catania, Italy
The objective of the present study was to evaluate how, over the years, the figure of the doctor and the doctor-patient relationship has evolved in cinematic depictions. Two hundred and ninety two films were analysed. The data was evaluated by decade, from 1909 to 2007, using eleven criteria of assessment for quantitative analysis. The results indicated that, in cinematic depictions, the doctor is an American (58.2%) middle-aged (68.8%) man (88.7%), of the traditional (38%) or post-modern type (40.8%), who works as a GP (general practitioner) (36.6%). The most frequent setting is a doctor’s surgery (47.6%), whilst the doctor-patient relationship is frequently based on an activity-passivity paradigm (61.3%). The positive portrayals are 52.1% even though the negative ones are on the increase especially in the last decade (69%). Up to the 1960s, doctors were described in a positive way; between the 1960s and the 1980s negative depictions prevailed, very often with humorous and satirical connotations; from the 1980s to the present day, criticism lost the humorous and satirical connotations, thus becoming tougher and more direct and particularly centred on the doctor-patient relationship. Hence we speculate that cinema seems to suggest the necessity of a new figure of the doctor and of a new relationship with the patient.
Keywords: narrative based medicine, doctor-patient relationship, movies, medical education
Over the years, the motion picture industry has shown a continuous interest towards medicine and, particularly, towards physicians. However, there is still very little literature about these cinematic depictions, even though film portrayals of physicians may easily condition public opinion and, consequently, influence doctor-patient relationship (Flores, 2002). We believe this situation should not be underestimated. In fact, in recent decades, modern medicine, heavily influenced by business and economic needs, has become highly unbalanced in favour of the technical sense and in the detriment of an anthropological orientation. In turn, this has caused doctor-patient relationships to become increasingly impersonal and anonymous, to the point of creating a virtual fracture between physicians on one hand, and patients and the public opinion on the other.
Nevertheless, the crisis of modern medicine and the subsequent spread of “Narrative Based Medicine” have renewed the interest towards the doctor-patient relationship. Recently many scientific works have explored ways to examine and improve this rapport (Charon, 2001). Indeed, some authors have presented cinematic narrations as “The Gold Standard” for the teaching and learning of medical ethics (Blasco, Moreto, Roncoletta, Levites, & Janaudis, 2006). Not only does the cinema, a perfect combination of rhythm, image and sound, represent a valid way of communication and narration, but it also allows for a more in depth study of the complicated problems relative to the doctor-patient relationship (Ber &Alroy, 2001).
Therefore, the aim of this paper is to analyze cinematic depictions of physicians in order to determine the characteristics and the most important themes. We set our focus on the doctor-patient relationship itself in order to evaluate how the cinema has, over the years, represented and influenced it.
Materials and procedure
A research was carried out through the Internet Movie Database (IMDb) and a list of over 615 films was compiled in which a physician was one of the main characters (only medical doctors were taken into consideration for this study). These movies were selected first by excluding TV movies, pilots and episodes of TV series and then the ones in which the doctor portrayal wasn’t inserted into a clinical setting or those in which there wasn’t any reference to the relationship with the patient. Finally, a total amount of 292 films was retrieved. These movies were rated separately by two independent raters, using two kinds of analysis: quantitative and qualitative.
Each film was classified by using objective criteria:
- related to movies, such as the original title, the director, the year and the country of release and the genre;
Table 1. Evaluation criteria (objective and subjective)
|Country of release||Objective criterion|
|Main character||Objective criterion|
|Doctor’s nationality||Objective criterion|
|Age||Young (Y): under 30 years of age; Middle-aged (M): from 30 to 60 years of age; Elderly (O): over 60 years of age|
|Post-graduate studiesQualification||Objective criterion|
|Clinical setting||Objective criterion|
|Doctor prototype(according to Shorter’s theory)||Traditional: equipped with inadequate technical-scientific diagnostic and therapeutic tools, but very humane, even though quite often paternalistic.Modern: scientifically more competent, technically more equipped, able to establish a fully professional relationship with the patient.Post-modern: technologically equipped, but more and more confused with regards to the social role of medicine, and more and more unable to establish a mutually satisfactory relationship with the patient.|
|Relationship with the patient (according to Szasz & Hollander’s paradigms)||Activity-Passivity: the doctor, thanks to his unidirectional knowledge and his unambiguous decisions, represents the active subject, while the patient becomes the passive object of his diagnosis and of his therapeutic choices.Guide-Cooperation:from a technical and communicative point of view, the doctor is a guide for the patient who, on the other hand, is asked to cooperate actively for his well-being.Mutual Comprehension: the relationship with the patient assumes the characteristics of a “meeting” (on equal terms as much as possible even though inevitably uneven) between two people or two stories; the doctor and the patient, therefore, learn how to understand one another in their different knowledge, languages, needs, expectations, subjectivity and fears.|
|Personal evaluation of cinematic depictions||Positive (P): the doctor is depicted as a competent figure both from a technical and relational point of view, capable of adequately combining theoretical knowledge with clinical practice, and with a correct management of the doctor-patient relationship.Negative (N): the doctor appears exceedingly inadequate both from a technical and relational point of view. Very often he places other interests before those of the patient: thus, there follows a very bad management of the doctor-patient relationship.From Negative to Positive (NVP): at first the doctor appears to be inadequate both from a technical and relational point of view; notwithstanding, generally, owing to a personal event, he changes attitude, thus acquiring the necessary knowledge and an appropriate behaviour.
From Positive to Negative (PVN): at first the doctor appears very competent from a technical and relational point of view; notwithstanding, generally changes attitude progressively placing other interests before those of the patient, thus there follows a bad management of the doctor-patient relationship.
- related to the depiction of the physician, such as age, nationality, gender, qualification and clinical setting.
In addition, three other subjective criteria were used:
- The physician prototype (traditional, modern and post-modern), based on Edward Shorter’s classification (Shorter, 1985)
- The type of doctor-patient relationship (activity-passivity, guidance-cooperation and mutual participation models), based on Szasz & Hollander’s paradigms (Szasz & Hollander, 1956)
- Personal evaluation of the cinematic physician portrayal as “positive” (P) or “negative” (N), changing from “negative” to “positive” (NVP) or vice versa (PVN)
We decided to use Shorter’s classification and Szasz & Hollander’s paradigms as subjective criteria because these authors were authoritative scholars on the figure of physician and the doctor–patient relationship. Eleven criteria were compiled for quantitative analysis (see Table 1).
The data was evaluated by decade (from 1909 to 2007), collected by using Microsoft Access and then statistically analyzed using SPSS (version 16.0.). In those films where more than one physician was portrayed, only the most significant was taken into consideration for statistical examination. Inter-rater reliability was assessed by the use of the Kappa coefficient. Disagreements between raters were identified and resolved following subsequent discussions with the other authors.
The Kappa coefficient provided a value of .75 (p<.05), which is equivalent of a good degree of agreement (75%). The results of the quantitative analysis are shown in Table 2.
In the cinematic representations analysed, the physician is an American (58.2%) middle-aged (68.8%) man (88.7%), of the traditional (38%) or post-modern type (40.8%), who works as a GP (general practitioner) (36.6%). The most frequent setting is a doctor’s surgery (47.6%), whilst the doctor-patient rapport is frequently based on an activity-passivity paradigm (61.3%). The positive portrayals are 52.1% even though the negative ones are on the increase, especially in the last decade (69%).
Table 3 presents a descriptive view of the main characteristics, separated by physician’s gender.
Table 2. Results
|Cinematographic genre||Drama (54.5%), Comedy (22.6%), Thriller (6.2%), Sci-Fi (3.8%), Crime (3.4%), Horror (2.1%), Others (7.5% )|
|Country of release||USA (63.7%), Italy (11.6%), England (9.2%), France (7.5%), Canada (2.1%), Sweden (1.7%), Others (5.1%)|
|Doctor’s nationality||American (58.2%), Italian (11.0%), British (8.2%), French (7.9%), German, Canadian and Swedish (2.1%), Russian (1.7)|
|Gender||Male (88.7%), Female (11.3%)|
|Age||Middle Aged (68.8%), Young (24.3%), Old (6.8%)|
|Post-Graduate StudiesQualification||General Medicine (36.6%), Psychiatrist (25.3%), General Surgery (16.4%), Gynaecology (3.8%), Dermatology (1.4%), Infectious Diseases (1.7%), Dermatology and Genetics (1.4%)|
|Clinical setting||Doctor’s surgery (47.6%), Hospital (33.6%) Mental Hospital or Psychiatric Home (6.9%), Research Laboratory (5.1%), MASH Unit (2.4)|
|Doctor prototype||Post-modern (40.8%), Traditional (38.0%), Modern (20.9%)|
|Relationship with the patient||Activity-Passivity (61.3%), Guide-cooperation (35.6%) Mutual comprehension (0%)|
|Portrayal||P (52.1%), N (41.8%), NVP (6.2%), PVN (0%)|
Table 3. Differences in gender: most frequent characteristics
|Main character||Yes (76.4%)||Yes (93.9%)|
|Doctor’s nationality||American (64.0%)||American (60.6%)|
|Age||Middle Aged (73.0%)||Young (63.6%),|
|Post-Graduate Studies Qualification||General Medicine (38.3%)||Psychiatry (42.4%),|
|Clinical setting||Doctor’s surgery (48.2%)||Doctor’s surgery (54.5%)|
|Doctor prototype||Traditional (41.1%)||Post-modern (57.6%),|
|Relationship with the patient||Activity-Passivity (68.4%)||Guide-Cooperation (75.8%)|
|Portrayal||Positive (49.8%)||Positive (69.7%)|
Discussion and conclusions
With reference, in particular, to the physician prototype and to the doctor-patient relationship, three periods can be individualized in which these characteristics assume specific connotations: from the beginning of the century to the 60s, from the 60s to the 80s, and from the 80s to the present day.
The heroic physician
Up to the 1960s, the cinema depicted the physician as a male (more than 95%), of traditional type, whose relationship with patients was based on an activity-passivity paradigm. These movie doctors were not only represented in a very positive light but in such a highlighted way that one could talk of a predominant cultural model: the heroic physician. This physician type considered his profession as a mission that could not be negatively influenced neither by money, nor by success due to the fact that idealism, altruism and compassion were at the base of his work. This cinematic stereotype mirrors the outstanding consideration enjoyed by the medical profession in those years. Indeed, the first half of the 20th century was defined as “The Golden Age of Medicine”, a period which was notable for scientific discoveries that allowed a considerable reduction of mortality (Davison, 1955), thus infusing in the public opinion a boundless esteem, respect and trust towards physicians, medicine and the health institutions.
The heroic physician was already present in the first “medical movie”, “The Country Doctor”, 1909, by D.W. Griffith and soon after he was the undisputed protagonist of many films of this period, such as “Dr. Ehrlich’s Magic Bullet”, 1940, by William Dieterle, “And Now Tomorrow”, 1944, by Irving Pichel and “Interns Can’t Take Money”, 1937, by Alfred Santell, a movie which introduced doctor Kildare’s character created by the writer Max Brand. The young and dynamic James Kildare was probably the first movie embodiment of Shorter’s “modern physician”, because of his ability to renew the professional style, thanks to an appropriate diagnostic and therapeutic knowledge, together with an effective management of his relationship with patients (Kalisch & Kalisch, 1985).
In “People Will Talk”, 1952, by Joseph L. Mankiewicz, the humane and compassionate physician, Noah Praetorius, cares for a pregnant unwed student who, upon learning of her condition, tries to commit suicide; at the end of the movie, he decides to marry her in order to save her life. This movie was probably the first to analyze in depth the importance of doctor-patient relationship although it was depicted in paternalistic terms. “The Citadel”, 1931, by King Vidor, tells the story of Dr. Manson whose first medical job was in a Welsh mining community, investigating the problem of a chronic cough in miners. He linked it to tuberculosis and coal dust but suspicious miners, frightened of losing their work, forced him to leave the city. So Dr. Manson moved to London: he opened an opulent Harley Street practice and made a fortune, forgetting his ideals, scientific research and becoming interested only in money and success. But after his friend’s accidental death because of a blunder by an elite unethical Harley Street surgeon, Dr. Manson returned to his idealistic view.
Finally, even the legendary director John Ford has often described many idealized doctors in movies such as “Arrowsmith”, 1932, “The Prisoner Of Shark Island”, 1936 and “The Hurricane”, 1937. Although Ford’s most famous doctor was probably the dentist “Doc Holliday”, the most significant one was undoubtedly Dr. Cartwright featuring in “7 Woman”, 1966, one of the rare cases of a female portrayal of “The Golden Age”, a story about an unconventional heroine that sacrifices her own life to save the women of the mission where she worked.
Up to the 60s, few movies contained negative portrayals of doctors. Some of these can be considered a cinematographic genre, such as the “medical horror” which developed around the 1920s and featured a stereotype character, named the “mad scientist”. This was a physician who, affected by a “God complex”, exceeded the limits of scientific research, as can be seen in the movie “Cabinet Des Dr. Caligari, Das”, 1920, by Robert Wiene; James Whale’s “Frankenstein”, 1931, “Dr. Jekyll And Mr. Hyde”, 1932, by Rouben Mamoulian. Other rare negative portrayals, not connected to the character of “The Mad Scientist”, were depicted in “Night Nurse”, 1931, by William A. Wellman; “Kings Row”, 1942, by Sam Wood; “Knock”, 1950, by Guy Le Franc (one of the first biting satire of the medical profession) and Akira Kurosawa’s “Ikiru”, 1952.
The crisis of a physician’s figure
Across the 60s and the 80s, the movie depictions of physicians substantially changed: even though timidly, female physicians began to appear (they reached 16% towards the 1970s), while the post-modern model (71%) and the paradigm of guide-cooperation (62%) became more frequent but, especially, the negative representations were now predominant (up to 77.4%).
Thus, one could observe the affirmation of a new cultural model, completely antithetical to the physician hero, and that represented a variation of Shorter’s post-modern physician in a critical, humorous and, therefore, satirical way. Movies reflected what was happening in society: “The Golden Age” was going towards a quick decline and, therefore, the figure of the physician appeared more impersonal and open to criticism. The reasons for this were not only due to the major diffusion of chronic diseases which required long-term therapy, thus underlining the physician’s lack of relational and humanistic preparation, but also to the diffusion of hyper-specialized medicine and new technological discoveries that shifted the responsibility of any errors or failures onto the physician (Burnham, 1982).
This new situation can be seen in “The Hospital”, 1971, by Arthur Hiller. This movie tells the vicissitudes of a group of incompetent physicians who, victims of the logistics, managerial and economic demands of the hospital, jeopardize not only the assistance to patients, but also their own existence. The hospital, in fact, doesn’t represent a place of care and scientific progress but a real “metaphor of chaos”. Indeed, the budget available is inadequate, the waiting list lengthy and an insane murderer wanders around the wards killing the patients, not directly, but by causing variations in the normal hospital routine, thus causing the death of the sick. In addition, the chief physician, Dr. Bock is suffering from a mid-life crisis, which leads him to the brink of suicide.
Another chaotic hospital is depicted in Lindsay Anderson’s “Britannia Hospital”, 1982 and, especially, in “Monty Python’s The Meaning Of Life”, 1983, by Terry Jones. This movie describes the brutality of hyper-specialized medicine: in the operating room, a woman, during labour, is completely ignored by doctors and nurses that are waiting for the visit of the administrator of the hospital in order to show him the importance and the technical delicacy of the operation. Meanwhile, the “miracle of birth” takes place without any physicians’ help, since they are busy trying to make a good impression on the administrator while the poor woman in labour is completely forgotten in a corner.
Set in a military camp during the war in Korea, “M.A.S.H”, 1970, by Robert Altman, tells the story of a group of surgeons who are technically competent, but who are completely indifferent towards the patients’ sufferings (treated as slaughterhouse meat) and intolerant of the absurd and rigid military rules. Other humorous and satirical physician figures are depicted in “What’s New Pussycat?”, 1965, by Clive Donner; “Where Does It Hurt?”, 1972, by Rod Amateau; “High Anxiety”, 1977, by Mel Brooks and “House Calls”, 1978, by Howard Zieff.
However, there are also other movies lacking humor: the “medical thriller” genre, an evolution of the “medical horror”, in which the physician, starring as a detective or a guilty person, is involved in complicated investigations. The “detective physician” uses clinical symptoms to investigate and to solve not only clinical cases, but also legal ones. The first “medical thriller” was probably “Panic in the streets”, 1950, by Elia Kazan but this genre developed above all in this period, as we can see in “Blindfold”, 1966, by Philippe Dunne; “Asylum”, 1972, by Roy Ward Baker and “Coma”, 1978, by Michael Crichton.
The patient as a close-up
From the 80s to the present day, movies have maintained a critical vision of medicine and physicians; nevertheless, these criticisms lost humorous and satirical connotations, becoming tougher and more direct, while physicians slowly began to lose their charm and authority. Motion pictures point out the limits of the post-modern physician and his inability to adequately manage the guidance-cooperation relationship with patients. Notwithstanding, on analyzing the relationship with the patient, these movies often offer constructive criticisms, as can be seen in “The Doctor”, 1991, by Randa Haines. This is the true story of a cynical thoracic surgeon, Jack McKee, who learns he has a larynx tumor. The passage to the other end (from doctor to patient) is traumatic: the surgeon will experiment on himself the long hospital waits, the physicians’ indifference, the difficulties encountered to know the diagnosis and the sufferings due to radiotherapy. Anyway, this difficult experience will be very useful to Jack, who will learn the importance of an adequate relationship with patients. “Patch Adams”, 1999, by Tom Shadyac, is based on the true story of Hunter Adams, an unconventional physician who theorized the laugh therapy, looking after patients and struggling not only against the absurd rules of the medical campus, but especially against physicians’ indifference (Sweeney, 1999). Although Adams’s portrayal appears very positive, Shadyac’s movie gives a negative depiction of American health institutions, criticizing the excessive economic power. Unfortunately these important observations were reduced to just a superficial analysis.
In “Wit”, 1999, by Mike Nichols, a literature teacher, Vivian Bearing, owing to a diagnosis of a cancer at an advanced stage, decides to undergo a very aggressive experimental chemotherapy characterized by severe side effects. During her period in the hospital, she experiences the indifference of the medical staff, the humiliation of not being considered any more as a person, but only as a “guinea pig” and the continuous suffering because of the side effects of the therapy. “Wit” also underlines the problems connected to the medical language, which is often very complicated and incomprehensible to patients, thus highlighting the limits of the “Anglo-Saxon model” in the communication of a diagnosis. This is evident in the first scene of this movie when Dr. Kelekian communicates the diagnosis to Vivian in only four minutes, asking her to join the experimental clinical trial without informing her of the side effects and the uselessness of the treatment. Also, “Terms Of Endearment”, 1983, by James L. Brooks and “Awakenings”, 1991, by Penny Marshall are concerned with the problem of an adequate rapport with patients. Other movies represent the physicians “sinking” in the burn-out syndrome, often as a consequence of a lack in relational and humanistic preparation because of their excessive interest in science, success or in money. “Dead Ringers”, 1989, by David Cronenberg, is the story of a pair of twins, Elliot and Beverly Mantle, well-known gynecologists that share everything: residence, women, pleasures and professional honours. Their perfect symbiosis is interrupted abruptly after the appearance of Claire, a television actress, affected by fertility problems. The obsession for Claire and her illness will push Beverly towards drug addiction, soon followed by his brother Elliot in this destructive spiral. “Riget”, 1994, by Lars Von Trier; “Eyes wide shut”, 1999 by Stanley Kubrick and “Bringing out the dead”, 1999, by Martin Scorsese, are also concerned with burn-out sunk physicians.
Medical horror and thriller, instead, are more focused on bioethical themes such as euthanasia, transplants, cloning, abortion, artificial insemination and many others. Consequently, the figures of the “mad scientist” and the “detective physician” appear less characterized, less eccentric and interesting as compared to past years. Finally, some movies have recently shifted the attention from physicians to patients, thus introducing the new figure of the “self-caring patient”, considered by Herzlich and Pierret (1984) as the most meaningful novelty in medical field in these recent years. Alone or inside self-help groups, the “self-caring patient” manages the illness on his own, in a relationship sometimes based on conflict but, in any case, actively negotiable with physicians and health institutions. Movies, such as, “Lorenzo’s Oil”, 1992, by George Miller; “Son Frere”, 2003, by Patrice Chereau and “Les Invasions Barbares”, 2003 by Denys Arcand, feature this character.
Despite the limitations due to the small group that has selected, viewed and evaluated the movies, and the necessity to discard many interesting but not available titles, it was possible to reach some interesting conclusions.
Over the years, the motion picture industry has faithfully represented the changes that have interested medicine, the physician’s figure and the doctor-patient rapport. Undoubtedly, the negative portrayals of physicians and of the health institutions are on the increase: from 10.3% in the 1940s to 69% at present. The criticism of the medical post-modern prototype and the guidance-cooperation paradigm, along with the contemporary consolidation (social and cinematic) of the “self-caring patient”, would suggest the need for a new figure of the physician and, especially, for a new approach of the patient. In this sense, narrative based medicine and cinema could constitute useful tools for educational and training purposes.
Another interesting consideration concerns the figure of the female doctor, who is on the rise, evolving from 4.0% in the 1930s to the current 24.1%. Woman doctors are predominantly portrayed in a positive way (69.7% versus 49.8% of men): it seems that movies give greater esteem and confidence to female doctors.
Finally, this work has confirmed the validity of cinema that, on one hand represents a “mirror of life” (Beccastrini, 2006), and on the other, influences the expectations and the attitudes of doctors and patients and therefore, the doctor-patient relationship itself. This confirms the possibility of using cinematographic works for education of psychosocial aspects of medical care (Alexander, Hall, & Pettice, 1994), training and perhaps in the future, for therapeutic aims, as has already been suggested by many authors (Solomon, 1995; Miller, Mangano, Park, Goel, Plotnick, & Vogel, 2006).
We believe it is important to pursue this area of investigation in future studies. First of all, it would be relevant to consider the figure of the woman doctor. Secondly one could look for objective criteria for the assessment and identification of the most useful titles for didactic purposes, taking also into consideration the increasing interest that is developing around narrative medicine, the problem of doctor-patient relationship and, especially, the need to re-humanize medicine.
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