Review

Return of a classic case

THE CEREMONIAL ORDER OF THE CLINIC
PM Strong (edited by Robert Dingwall)
Ashgate Publishing Ltd, 2001, £45

Erving Goffman’s works made a strong impression on Phil Strong, and on me. Goffman’s sociological analysis was powerful but anarchic. His analysis of medical phenomena, particularly Asylums and Stigma were illuminating, sophisticated and often funny. Strong’s study of paediatric outpatient clinics, first published in 1979 and now reissued, is a classic work in which he attempts to apply Goffman’s approach in a systematic fashion.

Unlike Goffman’s often rather wild theorising this study is based on detailed analysis of 1120 consultations, mostly in children’s neurology clinics. It is a fascinating account of the way in which such events are structured as rituals. As Dingwall remarks: ‘medicine may be life and death to the rest of us but is also legitimately a routine job of work to its practitioners.’

Strong’s interest in power in health systems gives his analysis considerably more political bite than the title might indicate. The experience of power as exercised by doctors in their clinics is very important in the way in which patients and their families understand their place in the world.

For the doctors this was clearly a moral exercise and they were in a position to impose their view of the situation. Doctors have to manage mothers and fathers, social workers, medical students and foster mothers. Strong demonstrates very clearly the different ways in which they are treated.

He also shows how the degree of education or sophistication of the parents made little difference – even where the mother was a doctor.

Interestingly, in this study the children who were the patients played little active part. My anecdotal experience is that doctors now are more inclined to talk to the child itself.

Some of the unhappiness now exhibited by doctors may be due to the degree to which they are no longer in absolute control of everything which happens in their clinic. Certainly in these clinics patients very rarely made any explicit criticism of their doctor, even in a setting which delivers much less by way of diagnosis or cure than most clinics.

Parents got little explanation even where the doctors made a diagnosis of profound handicap, and Strong makes interesting observations on how doctors managed the unfolding of dreadful news. He also shows how the bureaucratic constraints of the clinic setting appeared to inhibit emotion.

I thoroughly recommend this book to anyone who is interested in the study of health care or is going to an outpatient clinic for the first time. I hope its republication will provoke further studies in this area.