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THE REPRODUCTION OF POWER:
MEDICAL AUTHORITY IN A WOMEN'S HEALTH CENTER
presented by

Stacie Marie Gibson

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THE REPRODUCTION OF POWER:
MEDICAL AUTHORITY IN A WOMEN'S HEALTH CENTER

By

Stacie Marie Gibson

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Sociology

1994

ABSTRACT

THE REPRODUCTION OF POWER:
MEDICAL AUTHORITY IN A WOMEN'S HEALTH CENTER

By

Stacie Marie Gibson

The purpose of this thesis is to discuss the ways in which power relations
are maintained and reproduced in a women's health center. A field study,
primarily based on observation, was conducted in the waiting room of such a
health center located in a large midwestern city. The findings of the study show
that patients' time and privacy are accorded less value than medical personnel's
time and privacy. This process of differentially valuing time and privacy
maintains a situation in which patients are powerless to exercise agency in this
medical setting. The data also shows that clinic staff acknowledge "difference"
and by assigning divergent values to people on the basis of social constructs,
reproduce the current power structure. These ﬁndings suggest that to create an
equitable balance of power in the physician-patient relationship, the hierarchy

which exists in medical settings must be dismantled.

ACKNOWLEDGMENTS

I am deeply indebted to Taffy McCoy for her guidance throughout my
study. My thanks goes out to Dr. Rita Gallin for her continued efforts in helping
me to produce a final draft. I also wish to acknowledge my committee members,
Dr. Brendan Muilan and Dr. Jan Bokemeier for their support. Finally, I would
like to express my sincerest gratitude to my family, Joey, Keena, and Joplin for

the many kind words of encouragement.

TABLE OF CONTENTS

INTRODUCTION ............................................................................................................ 1
THEORETICAL FRAMEWORK .................................................................................... 2
REVIEW OF LITERATURE ............................................................................................ 5
SETTING AND METHODS ........................................................................................... 9
REPRODUCTION OF POWER .................................................................................... 10
Time and Power ............................................................................................................. 12
Privacy and Power ......................................................................................................... 18
Hierarchies Within Hierarchies .................................................................................... 22
CONCLUSION ............................................................................................................... 24
NOTES ............................................................................................................................. 27
LIST OF REFERENCES ................................................................................................. 28

iv

INTRODUCTION

As women continue to struggle for equality in all facets of life, health care
has emerged as one of the most dominant issues on the equal rights agenda.
Women make up the majority of health care providers and health care
consumers, yet have almost no power to inﬂuence the medical system (Salk
1984). As an institution of social control, medicine subordinates women in
several ways. Medical professionals increasingly claim expertise over normal
experiences in women's lives. Women are expected to see a physician for birth
control, pregnancy, childbirth, menopause, and a host of other normal bodily
experiences. This medicalization defines women as inherently defective
throughout life.

When a woman makes her "expected" visits to a physician, she is further
subordinated. "The relationship between a woman and her doctor is usually one
of profound inequality on every level, an exaggeration of the power imbalance
inherent in almost all male-female relationships in our society" (Salk 1984, p.
562). Women are often treated as hysterical, unreliable, and unintelligent by
their physicians.

The emergence of numerous women's health centers beginning in the
19605 and continuing through the present, represents both the problems women
face in the health care system and their attempts at resolving those problems.

While some women's health centers provide their patients with an alternative to

the traditional, male-dominated health care system, many others serve to further
subordinate women and medicalize their bodies.

To understand the dynamics of power in such a facility, I carried out a
study in the waiting room of a women's health center in a large midwestern city
in the United States.1 The purpose of this thesis is to discuss the ways in which
social power relations are maintained and reproduced in a women's health
center. To locate my study within a theoretical framework, I begin with a
discussion of how power has traditionally been explained in the field of
Sociology. I then offer a brief review of feminist literature on the physician-
patient relationship and next provide background information about the research
site and a description of my methodology. I then present the findings of my
study. In the conclusion, I discuss the implications of my. findings for the

physician-patient relationship.

THEORETICAL FRAMEWORK

Power is an important aspect of social relationships. Sociologists employ
a number of different theories to explain the nature and distribution of power in
society. The most widely accepted of these theories are functionalism, Marxism,
and conﬂict theory. While I use a feminist analysis of power in my study, it is
important to provide a general overview of these perspectives to locate my work
within traditional sociological thought.

Functionalism assumes that the parts of society are organized into an
integrated whole. It focuses on integration, stability, order, and cooperation

(Shepard 1990). Arguing from a funcitonalist perspective, Talcott Parsons (1937)

regards power as something possessed by society as a whole rather than
something which some individuals hold at the expense of others. There is no
fixed amount of power in society. It can increase or decrease and is measured by
the extent to which collective goals are reached in a society (Haralambos 1985).

The Marxist perspective offers a radical alternative to the functional
analysis of power. Marxism maintains that political, legal, and educational
institutions and belief and value systems are primarily determined by economic
factors (Haralambos 1985). In all societies, some social groups are exploited by
others depending upon their relationship to forces of production. Marxism
rejects the idea that power is a societal resource directed by those in power for
the benefit of all. Instead, "power is seen to be held by a particular group in
society at the expense of the rest of society (Haralambos 1985, p. 101). The source
of power lies in the economic infrastructure. The forces of production are owned
by a minority of individuals. This relationship to the forces of production
provides these individuals with power and the ability to exploit others.

The conﬂict perspective emphasizes conﬂict, competition, change, and
constraint within a society (Giddens 1987: Schellenberg 1982). Society
experiences inconsistency and conﬂict on all levels and is continually subject to
change. Those with the most power have the most wealth, prestige, and
privileges. "Segments compete and conﬂict as they attempt to preserve and
promote their own special values and interests" (Shepard 1990, p. 22). The
structure of institutions is such that those at the top of the institutional hierarchy
monopolize power (Mills 1956). The less powerful are often constrained by those

with more power through laws, customs, and institutional regulations. Thus,

competition for social resources is reduced and those with power can more easily
retain it.

This discussion of major sociological theories of power has been
intentionally brief and general. Many other theories and many variations of the
above theories have not been explored. This section is intended merely as a
foundation upon which to develop my analysis.

For the purposes of this thesis, I define power as

the ability of individuals and groups to realize their will in human affairs
even if it involves the resistance of others....Power provides answers to the
questions of whose interests will be served and whose values will reign.
Wherever we look, from families to juvenile gangs to nation states, we
find that some parties disproportionately achieve their way (Vander
Zanden 1990, p. 160).

This definition suggests an analysis of power based solely on the conﬂict
perspective. Nevertheless, my study is also heavily inﬂuenced by a feminist
analysis of power which links gender differences to the ability to both acquire
and maintain power.

While there is no question as to the importance of power in the structuring
of society, just how it is used to create and re-create the social structure is not as
readily apparent. It is this mysteriousness that fosters the maintenance of
society's power relations. If people cannot recognize the power implications of
their daily interactions, they can hardly protest against them. Those with power
can more easily keep it if they make the existing power structure seem natural
and, therefore, not questionable.

In actuality, people negotiate power all of the time, whether or not they
are aware of it. Yet, some people have more to bargain with, such as money or

education, than do others. Moreover, characteristics such as gender, race, class,

and sexual orientation affect people's ability to negotiate power, regardless of the
resources they bring to the process. Most of society's institutions rely heavily on
this skewed negotiation to function properly.

One women's health center does not represent the entire institution of
medicine in the United States. It does, however, offer a glimpse into the power
structure of the health care system. By drawing on traditional sociological
explanations of power as well as current feminist analysis of the physician-
patient relations, insight can be gained into not only the overall structure of the
health care system, but also into how power is maintained and reproduced in the

specific case of a women's health care center.

REVIEW OF LITERATURE

Much work about medical authority focuses on the physician-patient
relationship. There are many explanations of how patients, in particular female
patients, are rendered subordinate in that relationship. For example, Bluestone
(1993) suggests that the power accorded to physicians creates a situation in
which patients are often dehumanized, abused, and manipulated, thereby
rendering them subordinate. They are ordered to reveal their bodies to screening
personnel over and over again just to be emotionally and physically violated and
then sent on to the next test. In Bluestone's View, physicians have lost all respect
for patients' feelings and subjective experiences. Perhaps even more troubling is
that those physicians who do really care about patients are forced to forego all
empathy in the name of efﬁciency. The authority of the medical profession is so

great that, regardless of who the caregiver is, every patient is "trapped

defenseless and inarticulate in a system that doesn't hear a word they say"
(Bluestone 1993, p. 2580). Bluestone cautions that until the medical profession is
restructured to give patients some semblance of agency, the imbalance of power
between medical personnel and patients will continue to grow.

A second explanation of patient subordination focuses on the way
normative definitions of women are replicated in medical settings as a means of
controlling female patients. The work of Foster (1989) exemplifies this approach.
In a study of women seeking health care, she found that women suffer
powerlessness both as patients and as women, and she offers four main critiques
of current health care available to women. First, physicians tend to base their
diagnoses of women's problems on subjective notions about women's natural
drives and roles rather than on scientific or medical facts (p. 338). Second,
women's medical treatment is often inﬂuenced by physicians' perceptions of
women's social roles as those of mother and wife. For example, over-tired
working mothers are advised by their physicians to cut down on paid work
rather than to get extra help around the house (p. 339).

Third, Foster argues that physicians often try to further objectives which
they believe are for the good of society, even if they are not for the good of the
patient. A case in point is a physician who "pushes" or forces sterilization on
women who are poor and perceived to have too many children, or who, for some
other reason, the physician feels should not have more children. Finally, Foster
contends, medical professionals have developed strong defense mechanisms to
protect themselves from patient demands. In so doing, physicians force patients
into overly passive roles rather than encourage them to be active participants in

their health care plan (p. 340).

Gold (1983) offers a third, and related explanation for the subordination of
patients. In her view, sexism based on essentialist notions of women affects the
way gynecologists interact with their female patients.2 According to Gold,
medical professionals use sociobiologic ideas to support notions that women
have genes that are different from and inferior to men's, and that these notions
affect women as both gynecologic patients and as health care workers.
Specifically, Gold suggests that in gynecologic practices women are treated as
unintelligent, hysterical beings who are unable to give a good medical history (p.
134). Like Foster (1989), she also finds that women are treated as though they are
interested only in pregnancy and giving birth and if they are not, that they are
considered to be rejecting their femininity (p. 135). Moreover, Gold claims that
women who seek gynecologic care are often treated as though they do not have
"real" illnesses (p. 135).

These behaviors, Gold argues, are based on sexist notions that are
delivered by and to medical workers. For example, often a gynecologist will
parade a troop of interns into an exam, showing no respect for the patient's
privacy and instilling in the interns that very same lack of respect (p. 137). Gold
also cites sexist pharmaceutical advertisements which portray women as weak,
anxious, and in need of sedation (p. 136). The result of all this sexism, Gold
claims, is a gynecological setting in which women are not accorded agency as
patients and, ultimately, do not have control over their own health care.

Yet another, and fourth explanation of women's subordination as patients
is offered by Notman and Nadelson (1989) who argue that medical tradition
maintains the omnipotence of physicians. They suggest that the medical

profession has posed patients as child-like and physicians as parent-like. This

characterization, they claim, is compounded because patients tend to regress
when ill and physicians yearn for omnipotent power (p. 894). The result is a
physician-patient relationship in which physicians have excessive authority,
thereby preventing patients from objectively assessing the dangers, beneﬁts, or
alternatives to recommended treatment (p. 896). Gold (1983) and Foster (1989)
would suggest that women are even less able to make these assessments because
the medical profession subordinates them on the basis of their sex as well as on
the basis of their status as patients.

Echoing Foster (1989), Notman and Nadelson argue that physicians must
differentiate their roles as agents of patients from their roles as agents of society
(p. 899), forgoing the use of their medical authority to further what they believe
is for the good of society rather than what is for the good of the patient.

Finally, Schwartz (1973) provides a ﬁfth explanation for patients'
subordination to physicians by maintaining that processes operative prior to the
physician-patient interaction itself set the stage for the hierarchy inherent in the
relationship. In his view, power can be exercised well before an interaction, such
as one between a physician and a patient, takes place. In support of this
contention, he analyzed "waiting" to show some of the more subtle ways in
which those with power can inﬂuence an interaction with those without power.

His analysis reveals that waiting is stratified so that an individual's
position in the social system is characterized by the extent to which he or she
waits for and is waited for by others. "In general, the more powerful and
important a person is, the more others' access to him must be regulated"
(Schwartz 1973, p. 218). Subordinates, for example, may even be called on to

wait while an engagement is in process, while more powerful clients are immune

from waiting because they have the resources to refuse to wait and can afford to
go elsewhere for faster service (p. 219).

Schwartz notes that waiting is also affected by the availability of
alternatives. When there are not alternatives, waiting is sure to be extended. For
example, in courtrooms, where parties are often instructed to arrive before the
judge does, they may have to wait all day to gain access to the judge's time. In
this situation, clients have no alternative but to wait, and wait they do (p. 220).
Alternatively, waiting can be imposed by those who wish to protest against
authority. Subordinates may deliberately act sluggish to dramatize their
autonomy to their superiors
(p. 223). In these many ways, the dynamics of waiting serve to create, maintain,
and resist social differentiation.

In summary, sexism, notions of physician omnipotence, and waiting all
serve to make the physician-patient relationship one in which women as patients
are rendered subordinate. One might assume that a health center designed
speciﬁcally for women would make a special effort to eliminate the
powerlessness of women as patients. Unfortunately, my study reveals that this is
not the case. The power of medicine is alive and well and, even in a women's

health center, patients continue to exercise little agency.

SETTING AND METHODS

Located in a large medical complex, Women's Health Center (WHC) is a
clinic which offers a variety of medical services for women including obstetrics,

gynecology, fertility counseling, menopause information, ultrasound,

10

mammography, laser surgery, urinary incontinence treatment, lifestyle and pre-
conception counseling, and hysteroscopes. The center was founded in the 19605
and is now a partnership owned and operated by two male physicians. The
clientele are mostly white, middle-class women who range in age from young
women in their teens to women in their seventies and eighties (February 5,
1993)3. The staff at the center includes both male and female doctors and nurses,
and receptionists who are all women (April 5, 1993).

I performed my observations in eight two-hour weekly sessions beginning
on February 5, 1993. I spent the two hours sitting in the waiting room of WHC as
if I was a patient waiting for an appointment. While I was there, I took notes in a
folder and usually had a book open beside me so as to appear to be doing
homework. I was able to record direct transcriptions of conversations and events
as they happened since no one ever sat close enough to me to see what I was
writing. It is important to note, however, that all names I recorded have been
altered for the purpose of this paper. In addition to these observations, I
conducted two interviews which were tape-recorded, one with the ofﬁce
manager lasting seventy minutes and the other with a patient last forty minutes.
For the purpose of this paper, I refer to the patient as "Janis" and to the ofﬁce

manager as "Mary".

REPRODUCTION OF POWER

Power relations are continually reproduced at WHC. This process relies
heavily on the use of commodities, to the extent that a commodity is, "something

that is of use of is valuable" (Kellerman 1985, p. 203). To engage in a negotiation

11

for something like power, people must have something to bargain with. Not just
any old thing has enough value to exchange for a signiﬁcant amount of power.
Money is an obvious and visible commodity and it is often used in negotiations
for power. Other bargaining tools are not so recognizable and thus have equal if
not more value for precisely that reason. In the case of WHC, these commodities
are time and privacy.

The importance of identifying these commodities is not readily apparent
because time and privacy are not always equally valued by people. For example,
if you do not consider your time valuable, you may be willing to give up a lot of
it in order to gain access to someone else's time which you regard as more
valuable. Further, if you do not recognize time's connection to power, you may
willingly spend it and not object to the conditions under which you do so. It is

by subtly exploiting your time that those in power stay in power.

Time, like money, is valuable because it is necessary for the
achievement of productive purposes; ends cannot be reached
unless an appropriate amount of it is "spent" or "invested" on their
behalf. On the other hand, the power that a time surplus makes
possible may be protected and / or expanded by depriving others of
their time (Schwartz 1973, p. 217).

The same kind of value, and connection to power, can be attributed to
privacy. Those with power have more privacy, more valuable privacy, and more
control over other people's privacy than those without power. Power structures,
in short, are maintained by differentially allocating value to time and privacy.
The skewed negotiation of these two commodities represents the process by

which WHC reproduces existing power structures.

12

Iimeandﬁmm

It is important to acknowledge that in medical settings, situations arise in
which the control over time is governed by external forces. There are
emergencies, some situations necessitate the use of more time than do others, and
there are no doubt other happenings over which the clinic staff has no control.
Nevertheless, these circumstances are not always present and some other
explanation for how time is "spent" must be available. My study speaks to the
spending of this internally controlled time at the Women's Health Center.

The conditions at WHC are such that a patient's time is given less value
than a staff member's time. The first indication of this occurs when a patient
enters WHC and signs in on a "sign in sheet" that is located at the receptionist's
window. The patient rarely interacts with the receptionist and the receptionist
seldom makes an effort to acknowledge that the patient is even there. She does

not "waste" her time greeting or signing in patients.

[The receptionist's] greeting to patients who come in the clinic is
much different than the greeting she gives on the phone. When a
patient comes in the clinic she rarely acknowledges her and if she
does, it is usually just with a "hi" (March 24, 1993)

Once a patient signs in, she sits down in the waiting room. This is
significant for several reasons. First, the very fact that there is a room especially
designated for waiting suggests that patients are expected to wait. Second, the
room is designed in such a way that maximum compliance is derived from

patients, as my ﬁrst impression of it indicates.

There are 28 pink cushioned chairs....The chairs are very
comfortable. The room is soft....There are three tables located
around the room with magazines and pamphlets on them....They
have created a very soft, comfortable space in here, there is no

13

metal or chrome furniture and few sharp or shiny images.
(February 5, 1993)

By making the room comfortable and giving patients magazines, WHC
maximizes the amount of time a patient will wait without protesting. This
design also says to the patient, "You should expect to wait." Indeed, the patients
expect to and accept the wait. They read magazines or bring newspapers or

books and when they do not have to wait long they are surprised.

A large woman in black pants and a grey coat comes in....She signs in and
sits down. She barely sits down and a [nurse] comes out from the door on
the left and says, "Karen." The woman...who just walked in gets up. She
kind of laughs and says, "Oh that was quick," and walks back into the
office. (February 17, 1993)

Karen was surprised that she gained access to the nurse's time and space so
quickly. Indeed, most of the patients expect to wait and they behave

accordingly.

A woman in a long black trench coat and grey pants comes in. She
has long dark hair. She signs in, then hangs her purse on the arm of
a chair located near the reception window, walks over to a table in
the corner with lots of magazines on it, selects one, and then returns
to her seat and starts ﬂipping through it.

This woman seems familiar with the waiting routine here. She
knew that she would be waiting. She expects to wait, so she goes to
get a magazine before she even gets tired of sitting there. (March 3,
1993)

By expecting and accepting the waiting period, patients are agreeing that access
to a physician is "worth the wait." In essence, this means that the physician's

time is perceived as more valuable than their own.

14

The staff tries to foster this image as much as possible. If they perceive

that a patient may be beginning to get anxious, they attempt to pacify her.

There is an older woman sitting near the door wearing a pink sweat
suit....She is ﬂipping through a magazine....Later I hear a nurse in
the back yell out, "Jayne, I'll be right with you." The woman in pink
says, "sure"....

[The nurse] for some reason seems to feel that Jayne has been
waiting too long or for longer than she expected to wait....The nurse
has some sense that she needs to pacify her. (March 24, 1993)

If all of the patients are paciﬁed or believe that they are not "spending" an
extraordinary amount of time, then the staff does not have to worry about
protests or resistance.

The staff and the patients both have an idea of how much time is
appropriate to spend waiting for the physician after the scheduled time. Mary,
the ofﬁce manager, in response to my query reported that, "I don't like to see
patients wait any more than twenty minutes. Ya know that might be an
unrealistic goal [laughs] but um probably twenty to thirty minutes" (April 5,
1993). Janis, the patient interviewed, had much the same estimation of how
much of her time she thinks she should spend waiting. "I think over a half hour
is too long to wait. I think actually after twenty-ﬁve minutes is too long to wait"
(April 6, 1993).

One strategy the staff uses to pacify patients who have spent more time
than expected waiting is to remind the patient how valuable a physician's time is.

Mary explains what usually happens at WHC in this situation.

[MJy nurses go in and inform the patients, especially if they have already
brought them back to a room. Say the doctor got called out ya know to go
to the hOSpital or...maybe...the ultrasound test results have come back and

15

the doctor wants to look at ultrasounds while he had the patient sitting
right there. The patients tend not to get so upset about it if they are just
explained ya know, if you go in and say the doctor had this happen and so
forth. (April 5, 1993)

The WHC nurses, in sum, are sent to exalt the physician's time if the patient
begins to feel that she is being "overcharged" for it.

WHC even has scheduling procedures that reinforce the notion that the
physician's time is more valuable than the patients'. Mary readily admits that,
"we book in advance, but we do book two people at one time, like at nine o'clock
we'll put two people in one slot....That way the doctor is in seeing one and when
he comes out of the room there will be another patient ready..." (April 5, 1993).
By booking two people at one time, personnel at WHC ensure that patients will
have to wait. Their overestimation of the value of a physician's time makes them
willing to deliberately deprive the clients of their time so that the physician can
have another patient ready at the same time he or she is. WHC knows that the
patient will not be seen at her scheduled time and does not accord any value to
the time that the client is taking out of her day to come and sit in the waiting
room.

Patients do not seem to have the sense that their waiting is part of a
deliberate policy on the part of WHC. Rather, as Janis revealed when I asked her
why she thought she had to wait, they View an extended waiting time as the fault

of other patients, not a strategy of WHC.

Who the hell knows, they are just slow. Well. sometimes, ya know you get
people in there like me who see the doctor and the doctor says you have
this and I say okay give me a prescription and I am out the door.
Otherwise he gets patients in there like my grandma and she'll tell him
every little ache and pain...and ask him a lot of questions that are

16

unnecessary. And if he gets a lot of those in there then obviously it takes
me longer to get in. Just depends on who he sees. (April 6, 1993)

If patients are unaware that they are deliberately being forced to wait because of
a power structure that says that their time is not valuable, then they are in no
position to challenge that hierarchy. By assigning a higher value to the
physician's time rather than to a patient's, WHC thus maintains the power
structure that says physicians are more important/ valuable / powerful than
patients.

But this process is structured such that patients do not really recognize its
significance. It is because the commodity is so invisible that people do not
connect it to power. Thus, although both staff members and patients may readily
admit a physician has power, they cannot always understand its roots. Even
Mary has trouble identifying the source of a physician's power. Her only
explanation is, "a lot of people put physicians up on this pedestal" (April 5, 1993).
Because people are relatively ignorant about the process by which a physician's
power is created and maintained, they often blindly participate in the very
system that keeps them powerless. One of the easiest ways to stay in power is to
construct a situation in which the powerless continually legitimize, accept, and
perpetuate your authority. This is exactly what happens at WHC.

Not all patients at WHC are completely compliant, however. There are
occasions when a person decides to complain about the amount of time she is
being required to wait. After waiting for quite some time one woman tries to
speed things up:

The woman in the blue sweatshirt goes up to the reception window and
asks Kim, "Do you know how long it is going to be?" Kim replies, "Well

17

they should be taking you back anytime." The woman says, "Okay, cuz
last time I didn't get in till 9:30."
(March 24, 1993)

By asking the receptionist about the wait, this woman assumes that the
receptionist has the power to do something to shorten it. While she appears to be
resisting, she is doing so in a way that reinforces the existing power structure.
That is, she relies on the receptionist to do something, thereby acknowledging
her agency - or at least assuming that the receptionist has agency and she does
not. WHC has organized the waiting process in a manner that allows patients no
other form of protest than appeals option to the receptionist. They cannot even
protest without surrendering authority to a staff member.

Moreover, staff have the authority to deprive patients of their time as

women attempt to gain access to a physician. For example,

The nurse who made Mindy ﬁll out those forms comes out of the door on
the right [into the waiting room] and walks over to the woman holding
the baby. She says in a long high voice, "Hiii...oh my god he is so tiny."
...The older lady hands the baby to the nurse and the nurse grabs him and,
smiling, looks at him.

(February 9, 1993)

The nurse does not have to, nor expect to , wait to see the patient or her baby.
She has immediate access. She simply walks out and begins talking to her
without waiting or filling out forms or having to be called back by someone else.
Thus, it is apparent that those with power are waited for and those without

power simply wait at WHC.

18

W

Like time, privacy is linked to power. Those with power have more
valuable privacy, more authority over others' privacy, and more ability to
regulate others' access to their own privacy. At WHC, privacy issues are
magniﬁed due to the nature of the health care services provided. Gynecological
procedures involve, what US. society has labeled, the "private parts" of the
female body. Because of this, there is a heightened awareness of privacy at WHC
on the part of the patients. Patients have their bodily privacy invaded in the
examining room, and one might assume that because WHC is a women's health
clinic, special precautions are taken to maintain some semblance of privacy for
patients in the waiting room. The opposite, however, proves to be true at WHC.
The privacy of the staff is given much more value than that of the patients.
Indeed, many barriers to protect the staff's privacy have been constructed. The
most obvious of these is physical. The waiting room is separated from the offices
by a large wall with one closable reception window and two closable doors.

The nurses at WHC carefully regulate who goes in and out of those doors
-- in essence, who obtains access to the staff's privacy. They are the gatekeepers.
A patient cannot go back into the office unless her name is called by a nurse.
Patients are very aware of their restricted access to the ofﬁce and the gatekeeping
function of the nurses, as Janis indicated when I asked how she knew that it was
time for her to go back into the ofﬁce. "Well, the receptionist, nurse, or head
nurse, comes out and calls your name" (April 6, 1993). Janis knows that she must
wait for the nurse to "open the gate" by calling her name.

The patients' space in the waiting room is not similarly regulated. Anyone

can walk off the street into their space. Even the chairs are arranged around the

19

room in a manner that gives patients the minimum amount of privacy. By
having the chairs all face the center of the room, WHC forces patients to sit in full
view of each other.

As with time, patients have no power to regulate access to their privacy.

The staff has immediate access whenever they need or want it.

A nurse in white pants and a black sweater comes out from the back with
some papers and a little packet and sits next to Candy. She says, "Okay
Candy, here is your packet, you just need to sign here." She hands Candy
a pen and a form and she signs it....The nurse smiles and walks back into
the ofﬁces. (February 17, 1993)

The nurse is able to walk right into the waiting room and gain access to Candy's
time and privacy. She does not have to wait to fill out a form, or to be
summoned by a gatekeeper. Candy has no power over the situation.

The behavior of the staff serves to further demarcate the space at WHC.
When a nurse comes out from back ofﬁces to call a patient, she rarely walks all
the way out into the waiting room, but rather stands in the doorway holding the

knob to the office door.

[A] nurse comes out of the door on the other side of the room, holds the
door knob, and says, "Sandra." The older woman reading [a magazine]
gets up, sets her magazine in her chair and walks back....(March 3, 1993)

Holding the door knob symbolizes the opening of the gate to the office by the
nurse, which she also does by calling the patient's name. It is also symbolic of
power. Nurses hold the door knob even when the door is already open. It is as if
the knob is a tether to valued space. It signals a nurse's power to open and close

the gate and restrict access to the office. She negotiates who is able to come in

20

and when. It also defines her own space, by signaling a border to the ofﬁce,
which belongs to her.

In addition to having power to regulate access to valued privacy, nurses
also have authority over patients' private health information. Protecting that

information is a priority at WHC, as the office manager indicated to me.

[Patient confidentiality] is stressed, it's VERY important. And you are
seeing a lot more lawsuits pop up because of breach of patient
conﬁdentiality, you have to be very careful. (Mary, April 5, 1993)

Yet, the reason patient information is considered private at WHC is for the
protection of the clinic, not for any value assigned to patient privacy.

Further, the staff at WHC do not make any special effort to protect patient
privacy.

A woman in a white winter coat and black pants comes in....She glanced
around the room and starts to walk toward the [reception] window. The
receptionist says, "Oh, you must be looking for Jennifer." "Yes." The
receptionist points her hand out the window and says, "She is down
around the corner in the lab, you know, where she used to go all the time
for ultrasounds and mammograms....(February 5, 1993)

The receptionist is quick to tell not only where Jennifer is, but also to reveal
personal information about past health tests she has had performed. Perhaps
even more revealing, she does so in a voice that I, and everyone else in the
waiting room, can hear. Patients are hardly able to regulate their own privacy
when nurses can approach them at any time and receptionists can blurt out
personal health information into the waiting room. Clearly, the privacy of

patients is not given much value at WHC.

21

The result of this systematic violation of privacy is that patients are left
with only symbolic ways by which to regulate their privacy. One way in which
patients symbolically protect themselves is through their posture.

There is [a] woman sitting next to the receptionist's window...she has her
legs crossed and her coat in her lap. (February 5, 1993)

There is a woman sitting across from me and to the right....She has her
legs crossed and is reading a novel. (February 9, 1993)

There is a woman in a long red coat and black skirt sitting on the other
side of the room....Her legs are crossed....(February 17, 1993)

Patients almost always sit with their legs crossed and often have a purse or coat
in their lap. This covering or protecting of the pelvic area allows them to
symbolically maintain a feeling of privacy in a situation in which they do not
actually have it.

A second way in which patients attempt to symbolically maintain their

privacy is through the tone of their speech.

The receptionist calls out the window, "Yvonne." The African-American
woman replies, "Yes." "You have an ultrasound scheduled, do you have
any other tests?" Yvonne stands up and starts to walk toward the
receptionist, "Well...I have..." Her voice is quiet and hesitant, as if she
does not want to discuss this in front of the whole waiting room.
(February 9, 1993)

By lowering her voice, Yvonne tries to keep information about her health private.
But this strategy is only symbolic because, despite her efforts, the fact that she is
going to have an ultrasound is broadcast throughout the room before she can do
anything about it.

Yet a third way patients attempt to symbolically maintain their privacy is

through the content of their language. For example, I observed one woman

22

change the words she used to talk about what would happen to her. The woman
rose, walked up to the counter, and asked the receptionist, "How long will the
annual exam last?" (March 10, 1993) By calling her exam an "annual" rather than

H H

a "pelvic, gynecological," or "vaginal" she neutralizes the term. Nevertheless,
her neutralizing tactic remains only a symbol because it does not change what
will physically happen to her in the examining room. And indeed, everyone who
heard her still knows what kind of exam she is to have, even though she changed
the word.

Thus, while patients attempt to negotiate privacy, the message that they
receive from the staff is that theirs is not very valuable while the staff's is. This
situation leaves them with little power to regulate their own privacy or to gain

access to the staff's. Their efforts to do so are merely symbolic and, ultimately,

patients are subject to the will of staff members.

11' 1' 151° 1' 11' 1'
Thus far I have argued that the differential allocation of value to time and
privacy maintains a power imbalance between staff and patients. This process
however, often is mediated by gender, sexual orientation, and class. That is,
patients are not viewed as a homogeneous group but rather are dealt with on the
basis of categories that are assigned differential value.
For example, WHC gives more value to men's time and privacy than to

women's time and privacy.

A large African-American man walks in. He walks up to the reception
window and says, "I would like to make an appointment with Dr.
Schultz..." The receptionist says, "Would you like me to see if he is
available now?" "Yeah, could you?" (March 3, 1993)

23

This man simply asks for an appointment to talk to the physician, but the
receptionist tries to get him immediate access to the physician's time and
privacy. The women sitting in the waiting room, however, already have
appointments but they are still forced to wait. The receptionist automatically
accords more value to this man's time based on his gender. He, therefore, has
more power and quicker access to the doctor than do women.

WHC also attaches more value to heterosexual unions than to homosexual

ones, as the following excerpt from my notes indicates.

A nurse calls out of the left door, "Rita." Both the large young women and
the older woman get up, and the older woman in the dress follows the
younger one into the door. The nurse asks, "Which one's Rita?" The
younger woman raises her hand a little bit and says, "I am." (March 16,
1993)

The nurse is quick to question two women walking in together. Though she only
appears to be clarifying who the patient is, she does so in a rather demeaning
way. She refers to Rita as "one," presumable meaning "one of something,"
thereby according Rita little dignity.

In contrast, when a woman and a man walk into the ofﬁce they are not

treated the same way, as another excerpt from my notes indicates.

A different nurse comes to the door and says, "Gina." Gina and the man
she is with both walk back into the office. (March 30, 1993)

Gina and the man are not questioned. While the nurse obviously can ﬁgure out
who Gina is, the fact that she says nothing to them when they both walk back
into the ofﬁce is telling. She assumes that nothing needs to be questioned -- that
it is "normal" for men and women to be together. The heterosexual couple is

faced with fewer barriers to the physician and the two women (whether

24

homosexual or not) are more heavily regulated as they try to gain access to the
physician. This treatment reinforces the idea that heterosexual couples are
"normal" and homosexual couples are not.

Finally, staff at WHC use distinctions of class to assign value, thereby
reproducing existing inequality. While class relationships are not as visibly
reproduced as others, WHC's differential policy concerning class became
obviously apparent when I asked Mary if the clinic accepted Medicaid or

Medicare as payment for services rendered.

We don't accept new Medicaid patients....If like a patient was already
established here and maybe went through a divorce and lost her insurance
and stuff and then had to be on Medicaid, well, then, ...we would go

ahead and accept that....But no, we don't take any new patients. (April, 5,
1993)

By refusing to take patients who cannot afford insurance other than Medicaid,
WHC is differentially assigning value to time on the basis of class. A Medicaid
recipient's time has no value at WHC. No matter how long she is willing to wait,
she will be unable to gain access to the physician's time - even though Medicaid
would probably pay for the services. WHC does not "waste" their time with such

women.

CONCLUSION

The reproduction of power in a women's health center has been the focus
of this thesis. A field study was carried out in the waiting room of such a health
center over the course of several weeks. In addition, interviews were conducted

with both a patient and a staff member at the Center. Analysis of the data

25

revealed that the differential allocation of value to time and privacy by clinic
personnel function to maintain the power that the medical staff holds over
patients. Moreover, the data showed that this process is mediated and reinforced
by social constructs (gender, sexual orientation, and class) that maintain
inequality.

My study contained a number of limitations. First, it was relatively short.
I spent only eight weeks in the field and conducted only two interviews. The
brief nature of my study renders my observations highly tentative. Second, my
observations were limited to the waiting room. I was unable to observe what
happened when patients actually entered the physicians' offices. Finally, my
study was conducted at only one women's health center. I was unable to develop
a comparative analysis.

This study might be expanded by taking these limitations into account. A
more involved study would certainly require more time in the field and
additional interviews with both patients and physicians. While access to
physicians' ofﬁces would be difficult to obtain, it would greatly improve the
quality of data by providing more comprehensive observations and a better
understanding of the external constraints placed on clinic staff. Finally,
observing at multiple sites would provide data for a comparative analysis and
reveal what is unique about WHC and what is common to most women's health
centers.

While the power of physicians and the powerlessness of patients,
especially female patients, have been well documented, my findings on waiting
room interactions illuminate the process by which the hierarchy in their

relationship is maintained. Interactions in the waiting room set the stage for the

26

physician-patient interaction. It is in the waiting room that a woman is ﬁrst
assigned her subordinate role as patient. She is rendered powerless before she
even engages in an interaction with a physician. Patients may attempt to
negotiate for agency, but these attempts remain symbolic because of the
imbalance of power that is perpetuated by staff.

For patients to exercise agency, change must occur in this pre-interaction
stage as well as in the actual physician-patient relationship. Perhaps the ﬁrst step
in effecting such change is to help patients understand the process by which
medical personnel maintain and reproduce the powerlessness of patients. If a
physician's power is no longer mystified and, therefore, no longer considered
"natural," a patient may be in a better position to ﬁrst identify the process by
which it is maintained and then to resist it.

The existing power structure clearly serves the interests of medical
personnel. The staff at WHC are able to retain power, gain patient compliance,
and pacify patient resistance because of a hierarchy which allows physicians to
exercise authority over patients. Were this hierarchy dismantled, greater
autonomy would be accorded to patients in medical settings and the physician-
patient relationship would ultimately reﬂect a more equitable balance of power

than that which currently exists.

27

NOTES

1. The study was originally conducted as a course project for Sociology
985, "Qualitative Field Methods," at Michigan State University, Spring,
1993.

2. A general practitioner, Gold contends that her many years working
closely with gynecologists have given her insight into how sexism
affects their relationship with patients.

3. The dates used in this paper refer to the time when either observations
were made and recorded in my field notes or when interviews were
conducted.

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