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The Symbolic and Material Nature of Physician Identity:Implications for Physician–Patient CommunicationKevin Real a , Rachel Bramson b & Marshall Scott Poole ca Department of Communication , University of Kentuckyb Department of Humanities in Medicine, Department of Family and Community Medicine ,Texas A&M University Health Science Centerc Department of Speech Communication , University of Illinois at Urbana-ChampaignPublished online: 11 Nov 2009.

To cite this article: Kevin Real , Rachel Bramson & Marshall Scott Poole (2009) The Symbolic and Material Nature ofPhysician Identity: Implications for Physician–Patient Communication, Health Communication, 24:7, 575-587, DOI:10.1080/10410230903242184

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Health Communication, 24: 575–587, 2009Copyright © Taylor & Francis Group, LLCISSN: 1041-0236 print / 1532-7027 onlineDOI: 10.1080/10410230903242184

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ARTICLES

The Symbolic and Material Nature of Physician Identity: Implications for Physician–Patient

CommunicationCommunication and Physician Identity Kevin Real

Department of Communication University of Kentucky

Rachel BramsonDepartment of Humanities in Medicine

Department of Family and Community Medicine Texas A&M University Health Science Center

Marshall Scott PooleDepartment of Speech Communication

University of Illinois at Urbana-Champaign

This field study considers the implications of the symbolic and material nature of physicianidentity for communication with patients. In-depth interviews of physicians across multipleorganizational contexts reveal that physician identity is a discursive process of situated mean-ing in which particular configurations of beliefs, values, and actions are constructed withinspecific contexts. The content of individual physician identity was related to the generalenvironment of medicine and its local medical context. The identities of physicians workingin private practice were linked to the economic, legal, and social environment of medicine,whereas physicians working as employees had identities related to working in a setting thatbuffered the effects of the environment. Specific implications of the symbolic and materialnature of physician identity for physician–patient communication are examined. Understand-ing physician identity is important to health communication scholarship because of theongoing and central nature of physicians in health-care decision making and delivery.

Whereas traditional sociological studies of the medical pro-fession emphasize autonomy, power, status, specializedforms of knowledge, and medical ideology, less attention isfocused on issues of physician identity and communicationin light of broader environmental forces and local medical con-texts. This study considers physician identity in light of sym-bolic and material forces (Cheney & Ashcraft, 2007; Cloud,1994; McKerrow, 1998) that shape the way physicians

practice and how they communicate with patients. Under-standing the communicative implications of how the sym-bolic and the material shape physician identity is importantbecause individual physicians are challenged by a myriad ofmaterial forces, including economic (third-party payers),legal (malpractice), and organizational (newer forms ofhealth-care delivery), that affect the way they communicatewith patients and how they view themselves as profession-als (Freidson, 2001; Lammers, Barbour, & Duggan, 2003;Pratt, Rockmann, & Kaufmann, 2006; Real & Street, 2009).Despite systemic changes that have altered the role of phy-sicians, examining physician identity is important because

Correspondence should be addressed to Kevin Real, Department ofCommunication, University of Kentucky, 227 Grehan Bldg., Lexington,KY 40506-0042. E-mail: [email protected]

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576 REAL, BRAMSON, AND POOLE

physicians remain the crucial decision makers and commu-nicators in nearly all medical issues affecting patients(Barbour & Lammers, 2007; Cegala, 2006; Pratt et al., 2006).Physicians have critical influence on the flow of patients inhealth-care organizations, affect the extent to which patientsare satisfied, and influence how resources are allocated andutilized (Dukerich, Golden, & Shortell, 2002; Street, 2003).Given the importance of physicians in health care and theshifting contexts in which they work, addressing the com-municative implications of situated physician identity istimely (Cheney & Ashcraft, 2007), consequential (Apker &Eggly, 2004; Harter & Kirby, 2004; Harter & Krone, 2001)and of interest to health communication scholarship.

This study explores how physician identity is related tocommunication with patients in light of the current medicalenvironment (i.e., the general medical, political, legal, andeconomic landscape of American medicine) and local medi-cal context (i.e., the specific organizational setting in whichphysicians work). Given that physician identity is shapedboth by discursive practices (Apker & Eggly, 2004; Harter& Kirby, 2004; Harter & Krone, 2001) and the materialnature of medical work, our goal in this case study is toarticulate the material and symbolic forces that shape physi-cian identity and the communicative implications for physi-cians, patients, and health communication scholarship.Material refers to the actual physical practice of doctoring—treating patients, making and receiving referrals, dealing withthird-party payers—within health-care organizations thatoperate within larger institutional fields (Cheney &Ashcraft, 2007; Cloud, 1994; Lammers & Barbour, 2006).Symbolic refers to the ways in which meaning arisesthrough domains of interaction, discourse, symbols, andartifacts (Cheney & Ashcraft, 2007; McKerrow, 1998). Inthis sense, physician identity is a reflexively organized con-struction shaped by multiple discourses and participation invarious experiences (Giddens, 1991). By studying physicianidentity in situated context, we can delineate the symbolicand material nature of physician identity, illustrate the roleof the material environment in the everyday experiences ofphysicians, and understand the implications for physician–patient communication.

LITERATURE REVIEW

Sociology of Physician Identity

Physicians have traditionally been presented in the sociol-ogy of professions literature as autonomous professionalswho operate independently of hospitals, employers, or otherexternal entities because of their membership in anesteemed profession (Abbot, 1988; Freidson, 1970; Starr,1982). Scholars of the professions assert that the extensivemedical training and socialization process physiciansundergo act to create a strong sense of identification with

the medical profession (Abbot, 1988; Freidson, 1970). Aninfluential perspective that explains how the medicalprofession has traditionally operated in society has beenFreidson’s (1970) professional dominance view, whichmaintains that physicians as a group gained autonomy andcontrol over their professional work through political powerand legal authority. Starr (1982) labeled medicine a “sover-eign” profession in describing the degree of control it devel-oped over its own work. One of the distinctivecharacteristics of these traditional conceptualizations of themedical profession is the emphasis on physician autonomy.

However, the many environmental and contextualchanges in medicine have led scholars to advance alterna-tives to Freidson’s perspective. Some argue that physicianshave become “deprofessionalized” due to the use ofinformation technology by knowledgeable patients (Hafferty,2006), whereas others assert that physicians have experienceddecreased autonomy as a result of increasing corporate controlsover their clinical work (Potter & McKinlay, 2005). Commu-nication scholars have pointed out the erosion of powerexperienced by physicians as a result of managed care andnewer forms of health-care organizations (Barbour &Lammers, 2007; Lammers & Duggan, 2002; Lammers &Geist, 1997; Real & Street, 2009).

Hoff (2001) contends that physicians should be viewedthrough an individualized lens that can reveal distinctionsbetween physicians working in separate contexts. In thisview, physicians construct and understand themselves asphysicians, as members of their practice settings, and asindividuals. This perspective implies that physicians are justas likely to view themselves as employees as autonomousprofessionals and accords physicians more agency in theirresponse to environmental and contextual factors, as well ashow they interact with patients. The evolution of these con-trasting perspectives draws attention to the material forcesthat shape physician identity, particularly changes in thedelivery of medicine (Lammers et al., 2003). Physicianswork in many different organizational contexts, includinghospitals, health maintenance organizations (HMOs), staff-or group-model multispecialty clinics, and large, integrateddelivery systems, as well as traditional private practicegroup or solo settings. These contexts likely influence howphysicians work and how they communicate with patients.

Where physicians work—emergency rooms, operatingrooms, self-employed in private practice, or employees of ahealth-care organization—shapes their relationships withpatients in fundamental ways. For example, health-careorganizations can influence continuity of care, patient load,income, referrals, the degree to which taking medical andsocial history is important, how much time physicians haveto interact with patients, and even the content of their com-munication with patients. These are substantive issues dueto the increase in the number of physician-employees overthe past 2 decades, as approximately 40% of physicianswork as salaried employees (American Medical Association,

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COMMUNICATION AND PHYSICIAN IDENTITY 577

2000). Physician response to this situation has been mixed.Salaried physician–employees in staff-model HMOs reportenjoying the freedom from administrative responsibility(Gross & Budrys, 1991), whereas private practice physi-cians describe the benefits of control and entrepreneurship(Hoff & McCaffrey, 1996).

Although the study of the medical profession has largelybeen the province of the literature on the sociology of the pro-fessions (Abbot, 1988; Larson, 1977), more recently, commu-nication scholars have argued that a communicationperspective can make a contribution to the study of the profes-sions (Cheney & Ashcraft, 2007). An examination of physicianprofessional identity using a communicative lens allows us toexamine the implications of identity in relation to language,medical discourse, and materiality (McKerrow, 1998).

Symbolic and Material Aspects of Physician Identity

Physician identity is symbolic in that it is both influencedby the general discourse of medicine and likely shapeshow physicians communicate with patients; it is materialthrough role institutionalization, professional status, theactual work of doctoring, as well as the legal, political,economic, and institutional forces surrounding medicine.As members of the medical profession and participants inspecific organizational contexts (private practice, employ-ees), physicians construct their identities through both pro-fessional discourse and their actions, such as treatingpatients, making referrals, dealing with third-party payers,and the like. Kuhn and Nelson (2002) argue that collec-tively generated identity types such as “physician,” “attor-ney,” and “professor” exist not only in the cognitions ofindividuals but are properties of social interaction andmaterial reality as well.

The emergence of physician identity has been studied froma communication perspective, and this area remains of vitaland ongoing importance to our understanding of how physi-cians understand themselves and communicate with patients.Apker and Eggly (2004), along with Harter and Kirby (2004),illustrate how physicians discursively develop professionalidentities consistent with the dominant ideology of medicine.Miller (1998) draws attention to the role of the environment inthe social construction of physician identity and reveals howthe osteopathic profession adopted rhetorical strategies to beperceived as mainstream medicine. Harter and Krone (2001)and Zorn and Gregory (2005) highlight the socially constructednature of physician identity. Although identity continues to bedepicted in many ways by communication scholars, this studyengages physician identity from a social constructionist per-spective in which identity is discursively conceptualized inrelation to the symbolic and material environments in whichphysicians work.

This perspective suggests that identity is reflexively con-structed and shaped by interactions with others, exposure tomessages created by institutions (medical schools, hospitals,

mass media), and broadly assembled from language, symbols,experiences, values, and more (Alvesson & Skoldberg, 2000;Giddens, 1991). Identity is constituted through both symbolicand material forces (Cloud, 1994; McKerrow, 1998) and haspragmatic implications for the intersubjective nature of com-munication with patients. Examining physicians’ identityaccounts holds promise for gaining insight into how theyinteract with patients. Accounts, in this sense, are reflectivecommentaries that generate meaning as individuals try tomake sense of their interactions with others and have beenused to gather insights into identity (Tompkins & Cheney,1983).

Physician identity and physician–patient communica-tion arise from a variety of phenomena—institutionalarrangements, roles, professional training, medical spe-cialties, multiple (and perhaps competing) scripts, organi-zational rules, constraints on time allotted for patientexams, and the patients themselves—much of which isoverlooked in research on communication in the medicalencounter (Real & Street, 2009; Street, 2003; Street &Gordon, 2006). Understanding the communicative impli-cations of situated physician identity is important becausephysicians and patients interact in contexts that influencethese relationships. This study examines the symbolic andthe material to understand how physicians make sense oftheir world and how this shapes their communication prac-tices. We seek to articulate the material and symbolicforces that shape physician identity and understand how itis related to communication with patients in light of thecurrent medical environment and local medical context.There is a need for studies that investigate physicians’ sen-semaking about who they are and how their identities con-tribute to and are influenced by social interaction andmaterial reality. We take up one such study of physicians’sensemaking in this study, exploring the followingresearch questions:

RQ1: How do physicians discursively construct theiridentities in light of the symbolic underpinnings of“medicine”?

RQ2: How do physicians discursively construct theiridentities in light of material realities such as thecurrent medical environment and local medicalcontext?

These questions will be explored in light of the implicationsof physician identity for communication with patients.

METHOD

To address these questions empirically requires anapproach that highlights these issues using methods appro-priate to capturing the underlying meanings of identity.We tackled this by conducting interviews with a number

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of practicing physicians from varied organizationalarrangements. Using a grounded theory approach, weexamined physicians’ accounts to understand how theyconstructed their identity through experiences, attitudes,communication, and material constraints to advance inter-pretive themes as intersubjective, coconstructed accom-plishments in light of our research questions (Alvesson &Skoldberg, 2000).

Pilot Study

Pilot interviews were conducted with five physicians fromdistinct organizational contexts (staff-model HMO, grouppractice, solo practice) concerning their experiences andattitudes about physician identity given the current environ-ment of medicine and the local medical context. Theseinterviews were open ended and were conducted primarilyto authenticate the larger study. The five physicians inter-viewed in the pilot study did not participate in the largerstudy.

Setting and Participants

This study was conducted in central Texas. Using anemergent study design based on research on the localmedical context as well as discussions with physiciansand key informants, there were three salient contexts inwhich physicians worked: (a) a not-for-profit, multispe-cialty staff-model HMO clinic with approximately 90salaried physicians, which is designated “clinic”; (b)group-practice settings, usually single-specialty innature, containing between 3 and 20 physicians; and (c)solo/partnership settings, with 1 or 2 physicians. Using acombination of snowball sampling and direct phonecalls, 43 physicians were interviewed for this study. Ini-tially, the participants were categorized as 14 clinic phy-sicians, 15 group physicians, and 14 solo/partnershipphysicians. However, because there was little substantivedifference between group and solo contexts in terms ofhow they were organized, both groups of self-employedphysicians were identified “private practice” in thefindings. The decision to stop data collection after inter-viewing 43 physicians was based on saturation of catego-ries and redundancy of data (Lincoln & Guba, 1985). Inaddition, 2 physicians and a health-care administrator(who were not interviewed for this study) were consultedas key informants and peer debriefers to verify the valid-ity of our findings. These perspectives were used toguide the interpretive process. In all, 50 physicians wereinvolved in this study.

These physicians were a subset of the 253 practicingphysicians listed as members of the county medical society.We included physicians from 20 medical specialties to gaina broad representation of physicians. There were 35 malephysicians and 8 female physicians, a composition that was

generally representative of the local medical context.1

These physicians had been in medicine, as defined by dateof medical school graduation, from 5 years to 47 years, withan average of 19 years in medicine. On average, privatepractice physicians had been in medicine longer (21 years)than clinic physicians (15 years).

The Interviews

The first author conducted semistructured interviews thatinvited physicians to express their identity and raise issuessalient to their sense of self, given the current environment ofmedicine and the local medical context.2 All interviews wereconducted at the convenience of the physician–respondents,and most were held at the physician’s practice setting. Theaverage length of time for all interviews was 29 min. Allnotes taken during the interviews were transcribed immedi-ately after each interview by the first author, resulting in221 single-spaced pages of data.

Analysis

Grounded theory is a powerful analytical approach tounderstanding physician identity, allowing us to advanceinterpretive themes as intersubjective, coconstructed, reflex-ive constructions of identity in light of our research ques-tions (Alvesson & Skoldberg, 2000; Miles & Huberman,1984; Strauss & Corbin, 1998). After multiple readings ofthe data, an inductive content analysis was conducted by allof the authors, one of whom is a practicing physician, insearch of themes according to the constant comparativemethod as described by Glaser and Strauss (1967) and laterrefined by Lincoln and Guba (1985). We then workedtogether to collectively identify major and minor themesusing a number of specific steps to analyze the interviewresponses.3 After early drafts of the findings were written,

1A check of the county medical society roster indicated that no fewerthan 33 and no more than 54 physicians on the roster were female. This anal-ysis was done by manually examining names on the roster; for 21 names itwas impossible to determine gender. As such, the roster was 13–21% female.Our sample was 19% female and thus generally representative of the localphysician gender composition. Although gender was not the focus of thisstudy, we should note that seven of the female physicians were in privatepractice. We attribute this to the fact that we relied on snowball sampling andthe willingness of physicians to participate in the study.

2The interview opened with “Why did you become a physician?”,followed by “During your medical training, when did you really start tothink of yourself as a physician?” Physicians were asked whether they hadever considered a career change, whether their view of themselves as phy-sicians changed over time, whether they experienced any tensions, andwhether they would recommend that young people enter medicine.

3First, we divided the responses into discrete units of information thatcould stand alone and would later serve as the basis for defining categories.Second, these units were transferred from the full-length transcripts onto5 × 8 cards in order to sort the data into distinct categories based on “feels/like and looks/like” (Lincoln & Guba, 1985). In all, there were 1,305 cards inthe data set. Third, after analyzing 7 interviews, the data was audited multiple

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subsequent analyses that involved multiple iterations wereperformed, which resulted in a general interpretive schemathat helped us understand what these physicians were describ-ing in their interviews. These analyses were then reviewed inprocess by three physicians who were interviewed for thisstudy, as a form of member validation or “member checks”(Lincoln & Guba, 1985; Miles & Huberman, 1984; Strauss &Corbin, 1998) to establish credibility of the findings.

Results

In explaining their professional selves, physicians describedwhat can be read as aspects of their identity in relation tothree key themes—the profession of medicine, the relational-ity of medicine, and the business of medicine—that reflectedboth symbolic underpinnings and material realities. Thesethemes acted as key identity platforms that provide a generalinterpretive schema for understanding physician identity, andeach has a specific connotation for the physicians in thisstudy. They represent common points of orientation and plat-forms for the articulation of identity that serve to constituteand maintain an intersubjective community. Each themearticulates bodies of knowledge, values, beliefs, attitudes,practices, habits, and so on that the physicians use in carryingout their work. The major and minor themes from this inter-pretive scheme are provided in Table 1.

The Profession of Medicine

A number of physicians expressed their self-concept inways that suggest that being a member of the medical pro-fession is central to their identity. Although this themerefers to the medical profession, it carries larger connota-tions that are quite important to identity. The profession ofmedicine is a material practice that physicians engage inand strive to master over their careers. They spend yearsbecoming a member of the profession, learning and honingtheir medical abilities in order to treat patients and fulfilltheir professional obligations in tangible ways. The profes-sion of medicine is symbolic in that it discursively situatesphysicians as members of a high-status profession thatcontains elements of nobility and purity. Many responsesindicated that physicians defined their identities via a directrelationship with the profession of medicine. The characterof this relationship differed but was mostly framed inpositive terms. Physicians discursively constructed theprofession of medicine in relationship to three key sub-themes: medicine as a called profession, a noble profession,and a ministerial profession.

Medicine as a called profession. Some physiciansviewed the profession of medicine as a special vocation towhich they were called and which required certain sacri-fices. Leonard,4 a private-practice primary care physician,described how he knew from a very early age that hewanted to be a physician. “Ever since I was 4 or 5 years old,I knew I wanted to be a physician. Really, it was a calling. . . .I’m one of the minority of people who find their callingearly in life.” Edward, in private-practice primary care,asserted that there was a spiritual aspect to being called.“What I do recall is that from earliest on, the issue for mewas that I believed God had called me to become a physi-cian. I have always looked at this as a calling, not a career.”Edward described the need for meaning and fulfillment inthe profession and went on to decry the lack of this qualityin younger physicians, framing the idea of medicine as acareer in dialectic opposition to a calling. “A lot of youngerphysicians are interested in quality-of-life issues, and manyof them see it as a career. . . . I think that is a grave lossbecause you need to do fulfilling work.” As a calling, theprofession of medicine invites the physician to participate ina special way of life, to experience a transitional event thatchanges one forever. Researchers have long noted that oneof the central characteristics of a profession includes a senseof calling to the field (Freidson, 1970; Starr, 1982).

Other physicians noted the sacrifices that come with thisspecial calling. Ben, a private-practice surgeon, who was intraining for 9.5 years after graduating from medical school,suggested that few people outside of medicine understandthis sacrifice: “I don’t think anybody realizes the sacrifices. . . .I don’t think there’s a person in medicine who actually

times by the second author, a practicing physician. This first audit con-sisted of a complete review of the initial analyses of the early interviews. Asecond audit of 1 additional interview occurred after the initial analyses of14 interviews. By auditing the analyses, the physician was able to recog-nize certain meanings in physicians’ responses not previously grasped, andthis added insight into the naming of categories. The fourth step in the anal-ysis was the sorting of responses into larger thematic units or themes. Wenoted earlier that this is an inductive process in search of themes guided bytheory, prior conceptualization, and experience (especially in the case ofthe physician data-auditor). After sorting the responses into broader the-matic units, a third audit was conducted in which the physician-auditorwent over all of the completed analysis to determine if the categoriesbelonged within specific thematic units and if the specific thematic unitwas viable. This work with the auditor was directed toward satisfyingmethodological rigor by establishing trustworthiness (Lincoln & Guba,1985). Any differences in thematic interpretations were resolved amongthe authors during and after the audit process.

TABLE 1Major and Minor Themes of Physician Identity

Major Theme Minor Themes

The profession of medicine Called profession, noble profession, ministerial profession

The relationality of medicine Rewarding relationships, guarded relationships

The business of medicine Salaried or self-employed, disempowering endeavor

4All names are pseudonyms.

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knew of the sacrifices that lay ahead of them when theyentered medical school.” Janet, a clinic primary care physi-cian, discussed the fact that her medical training haddelayed her plans for having a family. “My only regret isthat I had to postpone part of my life—I had my first child at34.” Themes implicit in sacrifice are the losses one musttake in pursuing one’s calling, any changes required, andthe willingness, strength, and persistence inherent in thosewho undertake and survive sacrifices. These physiciansdescribed sacrifice as a given part of their training ratherthan a negative experience, and many articulated it as part ofthe profession of medicine. Shapiro and Driscoll (1979) notethat physicians’ sense of responsibility and commitmentoften develops to the point of sacrifice of other interests.

Medicine as a noble profession. Physicians describedaspects of their identity in relation to the idea that medicineis an honorable and noble profession. A number of doctorstalked about how medicine was “hallowed,” “noble,”“respected,” “honorable”. A private-practice primary carephysician, Ian, talked about the honor and integrity of theprofession. “I still think it’s a very honorable profession andthat you have more freedom to do the right thing or thewrong thing. There’s more personal integrity involved inthis than in any other occupation.” Patrick, a private-practice primary care physician, agreed in describing hismentors. “I saw people who approved of the professional-ism and believed in the nobility of the profession. I stillthink that’s what the profession should be.” In the very bestsense of the word, these physicians described themselves inrelation to a profession that was ennobling. This representsa transformative capacity of the profession of medicine,which challenges incumbents to noble values, attitudes, andbehavior. It imbues them with responsibility to uphold thehonor of the profession.

Medicine as a ministerial profession. Several phy-sicians regarded themselves as ministers to their patients,describing aspects of their identity in relationship to sacredthemes. Harold, a private practice ophthalmologist, assertedthat “Medicine is an extension of my faith—a practicalextension of my Christian faith.” Leonard, also viewedmedicine as a ministry:

Now they’ve done all the studies. If this group is prayed for,they do better than the group who’s not—you know . . . I dopray with patients. . . . The Holy Spirit leads you to patientsat times—not all. . . . People are not offended if you havetheir best interests at heart. If you have a patient who hascancer but has no church, no pastor, no spiritual connection,and now their ultimate disposition is imminent, who is in abetter position to help them but their doctor?

This perspective also influenced how Jake, a clinic special-ist, viewed the clinic’s administration: “My faith is verywell grounded in Jesus Christ, and I’ve had a few ethicaland moral problems with the administration. . . . There was

a real disconnect between what was said and what wasdone.” This physician’s ministerial identity shaped his rela-tionship to his practice setting. Not all physicians believedin taking this approach, however, as Ethan, a private-practice primary care physician, noted his unwillingness:“Some physicians have strong religious beliefs and they reallytry to preach to their patients. I try to go with the flow more.”

Embedded in a ministerial identity frame is the beliefthat the profession of medicine allows them to integratetheir religious beliefs into their professional duties.Although the research on physicians as ministers is limitedand sometimes contradictory, there is some indication thatboundaries between physicians and patients in this matterare less defined than previously thought (Post, Puchalski, &Larson, 2000). Moreover, patients in certain geographicregions may be especially open to the physician–minister.Mansfield, Mitchell, and King (2002) found that “in thesouthern United States . . . most people believe that Godacts through doctors” (p. 399). This study was conducted inthe southern United States, and these physicians may havefelt comfortable in enacting this identity.

Several physicians described working in medicine as asacred trust, the belief that physicians are imbued with ahigher duty in their professional work. This idea overlaps tosome degree with that of a called profession in that sacred-ness can be manifested as a calling. We locate sacred trustwithin ministerial identity to emphasize the spiritual valuessome physicians placed on this aspect of their identity. Forexample, Steve, a private-practice specialist, stated “I viewthe physician–patient relationship as sacred, as a gift fromGod.” Ben, a private-practice surgeon, quoted a mentor indescribing medicine in this way: “this is like a religion,what we do; it is such a gift—a celestial gift—a sacredtrust.” Victor, a private-practice anesthesiologist, recalled amessage that lifted his spirits one dark day:

I was real depressed one day, and this cardiovascular sur-geon . . . said to me, “Let me tell you something: all of thebullshit we put up with, you can’t let it get you down,because what we do, what we were trained to do, is blessedand it’s a sacred trust.” I needed to hear that that day, and ifI live to be 100, I’ll remember what he said to me that day.

These physicians drew on the discourse of medicine to sym-bolically construct themselves as engaged in somethinggreater than the individual self. By connecting action withdiscourse they contributed—materially and symbolically—to the ideology of the physician as member of a sacred pro-fession. In a study of seriously ill outpatients and primarycare physicians from a diverse general practice, Holmes,Rabow, and Dibble (2006) found that a majority of patientsand physicians “considered it important that physiciansattend to patients’ spiritual concerns” (p. 25).

Communicative implications. Across these frames ofidentity linked to the profession of medicine, there werephysicians who described their communication with

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patients and other physicians in terms of both gravity andpractical concerns. For example, Leonard asserted that phy-sicians have to be patient and listen to patients:

You have to find out what their real need is—it’s like thehand-on-the-doorknob thing—they may have a serious issueto discuss, like finding out if they have HIV or cancer andthey want to know if you will listen and if you care enoughabout them to treat them. Only then will they open up.

A private-practice oncologist, Alex, talked about how fortu-nate he felt in the face of seemingly despairing work. “I feelpretty good. The hardest part is talking to patients aboutdying. People look at you and wonder how can you takecare of people who are dying? But the flip side is we seepatients who we can cure.” Tim, a clinic primary care physi-cian, noted how he learned the importance of communica-tion with patients in medical school:

I was pretty shy and introverted and . . . they had us take aninterviewing course where we would interview mockpatients, and they taped the interviews and showed it to thegroup that I was in. . . . That turned out to be a big eye-opener. I could see how I interacted or how I did not interactwith patients in the interview. I learned that how I commu-nicated with patients was a big part of medicine.

The communication was neither “physician-centered” nor“patient-centered” (Roter & Hall, 1993; Street, 2003) butwas oriented as much toward the physician as the patient.Whereas some physicians described their communicationwith patients as part of their ministerial identity, othersdescribed communication with patients about death as inte-gral to their professional role. In some cases, it was clearthat identity influenced communication with patients.Leonard’s ministerial identity shaped his communicationwith patients in that he often prayed with them. Ethan’sidentity affected his communication with patients in that hewould not preach to his patients. For many of these physi-cians, communication with patients was serious, weighty,with sacred overtones, yet carried a pragmatic side in thatthe physicians described talking to dying patients ordrawing reluctant patients out to discuss life-threateningillnesses.

To summarize, when physicians described aspects oftheir identity in relation to the profession of medicine, theydrew on the discourse of medicine to construct themselvesas working in a calling, doing noble work, or providingministerial services to the sick. These identities are similarto those found in the literature on the sociology of the medi-cal profession (Abbot, 1988; Freidson, 1970), which isreplete with stories of physicians as focused, driven practi-tioners for whom being a physician is the central element oftheir self-concept. This identity is symbolic in that it evokesawe and sacredness as elements of the profession that lend itspecial meaning. The profession of medicine is material inlight of the actual treating of patients for physical illnessesor life-changing events.

The Relationality of Medicine

This theme illustrates how physicians believe that the rela-tionality of medicine, particularly relationships withpatients, is crucial to their identity in important ways. First,the patient is another human being with whom the physicianinteracts in the practice of medicine. In this sense, thepatient is someone to whom physicians can express sympa-thy (and perhaps even identification) and to whom is owedthe physician’s best efforts and greatest care. This relation-ship is symbolic and material in that physicians communi-cate with patients while they physically examine them (andphysically examine them while they communicate withthem). Physicians interact with the patient through givingcare, and that depends on drawing on material practicessuch as their medical knowledge, practices, procedures, andthe like. Second, the physician may also engage in interper-sonal relationships with patients that emphasize the impor-tance of communication and social support. Physiciansconstructed the relationality of medicine as two oppositionalsubthemes: rewarding relationships and guarded relationships.

Rewarding relationships. Several physicians depictedtheir identity in relation to the rewards of helping others and thebenefits they derive as a result of their relations with patients.Michael, a clinic specialist, described the rewards incumbentin helping others, “It is a very rewarding profession. I can’tthink of anything else I could do and feel as good as I doabout my life. I would hope my children would do some-thing they felt good about and could help others.” Gene, aprivate-practice ophthalmologist, discussed the rewards ofhelping others: “It’s a good outlet for those who feel thatservice, as a part of life, is an integral part of who they are.”Several physicians depicted the rewards they receivethrough the gratitude expressed by patients. Ian stated, “Ienjoy what I do, and the icing on the cake is patient gratifi-cation.” Doug, a clinic primary care physician, noted, “Ihonestly do get appreciated . . . the satisfaction of helpingpeople is really nice.” Alex (private practice) related his sat-isfaction with patient gratitude: “I’m sure there are othercareers where you can get well compensated, but the gratifi-cation you get from patients is . . . it’s really a privilege.”For these physicians, the practice of medicine involves rela-tionships that were both symbolic and material. Service toothers and the gratification received are mutually materialand symbolic and are central aspects of a helping identity.Scholars of the professions have noted that the medical pro-fession traditionally has more of a service orientation than aprofit orientation (Freidson, 1970; Starr, 1982).

Guarded relationships. A second view of the rela-tionality of medicine was one that viewed the patient as anopponent, someone in a position to challenge and poten-tially harm the physician and undermine trust between thephysician and the patient. For example, Peg, a private-practice primary care physician, described how a patient

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died when she was a new resident and she was by herselfand could not reach any of the upper-level residents. “Nowthat I’m an attending physician, when I have special cases, Iask for help from specialists. You never go down by your-self.” In this theme an external institution, the legal system,also plays a role as an agent of the dangerous patient. Zach,a private-practice primary care physician, called malprac-tice an “assault on doctors” and Ethan (private practice)declared, “I definitely would not strongly encourage peopleto enter the medical field right now. It’s a tough profession. . . .If a patient gets mad, you get sued. It’s not justified and it’sa horrible experience.” These are important issues, as thequality of physician–patient relationships has been shown toinfluence patient decisions to pursue malpractice litigation(Levinson, Roter, Mullooly, Dull, & Frankel, 1997). More-over, organizational context played a role in this matter.Although many private-practice physicians expressed cautionand restraint when it came to dealing with patients, few clinicphysicians described this phenomena, indicating less expo-sure to malpractice than private-practice physicians. Indeed,interviews with clinic leaders indicated that the clinic assistedits physicians with malpractice protection.

Communicative implications. Physicians linked tothe relationality of medicine indicated that their communi-cation with patients was based on respect, empathy, andthe value the physicians themselves placed on relation-ships and communication with patients. Janet (clinic)talked about the importance of communication withpatients as a result of her experience with physicians whenher mother died.

It was the way we were not being kept informed by the physi-cians who took care of her. I can still remember thinking thatthese doctors are all a bunch of assholes—they were avoidingus. Now, I make a conscious effort to let people know—if Isay I’ll let you know on Tuesday, you can be damn sure I’lllet you know on Tuesday. . . . That really made me aware ofthe need to communicate well with patients.

A clinic emergency room physician, Nathan, expressed hiscommunication style thusly: “We’re in the people business,and if I see 30 patients a day, then I’m a diplomat 30 times aday as well.” There were also examples of communication-related misfortune for patients, as Gene recounted an expe-rience from his residency, what he described as a bad rolemodel’s interaction with a terminal patient whom the rolemodel, the attending physician, did not like:

The patient was this hard-driving businessman who wasalways trying to get the best care and his favorite saying was“we need to keep the ball rolling.” Well, we got the diagno-sis and we were right there in his room, and it was inopera-ble lung cancer and this attending just said in an off-the-cuffway, “Well, I guess we need to keep the ball rolling.” Thepatient looked up from the bed and said, “Doctor, you’relaughing at me because I wanted to live.”

These are substantive issues. Physicians whose identitieswere oriented toward the relationality of medicine weremore likely to value communication with patients and basetheir relationships on empathy and respect. For some physi-cians, their identity shaped their communication withpatients. Alex recounted gratitude-imbued interactions, andGene described the importance of good and bad role modelsfor developing rewarding relationships. Conversely, Pegmade it clear that her interactions with patients were strate-gically guarded as a result of her past experiences. Anumber of studies have found that patients tend to ask morequestions and more openly discuss their concerns when cli-nicians use patient-centered approaches (Roter & Hall,1993; Street, 2001; 2003). Symbolic and material factorsplay a role in physician–patient communication as well. Forexample, the extent to which a physician can employ strate-gies for patient participation (Cegala, 2006) and engage indetailed information sharing may be a result of both sym-bolic (individual communication styles of the physician)and material (organizational and environmental forces)aspects of the encounter. Context played a role in physi-cian–patient relations in this study, as physicians from pri-vate-practice contexts were more likely to have guardedrelationships than clinic physicians.

In summary, the relationality of medicine was veryimportant to many physicians for a number of reasons, andthis is echoed in the literature as well. Physician–patientrelationships can influence a number of factors (for reviews,see Roter & Hall, 1993; Stewart, 1995; Street, 2001),including health outcomes (Kaplan, Greenfield, & Ware,1989), patient satisfaction (Stewart, 1995), and physiciansatisfaction (Gallagher & Levinson, 2004). This relation-ship is both symbolic and material in that, although thepatient is a physical being, the relationship with the patientis a rhetorical construction (often idealized by practitionersand scholars alike) with material consequences. Treating,consulting, healing, interviewing, and more involve thematerial (actual treatment, medical training/experience) aswell as the symbolic (responsive communication, emotionalbonds), which leads to symbolic outcomes (therapeutic rela-tionships, guarded relationships) and material consequences(sickness/recovery, malpractice lawsuits).

The Business of Medicine

Several physicians, particularly those in private practice,portrayed themselves in relation to the current market-basedenvironment of medicine. The business of medicine wascentral to many physicians because of its major role in theireveryday experiences. The business of medicine was amaterial practice that physicians strove to successfullyengage in order to meet their individual goals, whether thatwas understanding (and keeping up with) third-party-payeraccounting language or deciding to work as an employee onsalary in order to focus primarily on clinical practice. It is

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symbolic in that it discursively situates these physicians ineconomic frames of identity wherein they are part of a mar-ket-based model of medicine and can thereby succeed or failbased to some degree on the vicissitudes of the American med-ical marketplace. Physicians constructed the business ofmedicine in relationship to two subthemes: salary/self-employed status and medicine as a disempoweringendeavor.

Salaried or self-employed. Physicians here describedtheir identity in one of two distinctly separate ways: as anemployee on salary or as a self-employed entrepreneur. Thebusiness of medicine was relevant for both groups. Allclinic physicians were salaried employees, and the majorityexpressed positive sentiments about the situation. Many ofthem believed the reduced administrative and business-related work allowed them to focus more on practicingmedicine. Urban, a clinic surgeon, asserted that the clinicwas a unique organization because it was run by a group ofphysician administrators. “I think the beauty of the modelhere, which is a unique model for most of the United States,is that physicians decide what is being done.” Othersclaimed identification with the clinic because of the patient-oriented nature of the organization and the clinical auton-omy physicians have to practice medicine. William, a clinicanesthesiologist asserted, “You read about physicians beingtold not to do this because it costs too much money. Neverhave I heard that here.” Satisfaction among physician–employees is supported in health services research. Grossand Budrys (1991) and Hoff and McCaffrey (1996) foundthat salaried physicians working in staff-model HMOs weresatisfied because of their ability to focus primarily onclinical aspects of their professional work.

Alternatively, private-practice physicians felt that attend-ing to the business of medicine was crucial to their survival,as exemplified by Edward’s change of perspective frommedical school to practice: “When I was in medical school . . .I looked with disdain at colleagues who would read aboutthe business side of medicine. I thought I was above all that,but now I can’t afford to think that way.” In this perspective,the profession of medicine is mitigated by the business of med-icine. There were also a small number of physicians whoexpressed entrepreneurship in a positive frame. For example,Gene, whose office employed more than 10 employees,described the pride that he feels in his solo practice. “I have thatfeeling that I created this; I know I had a lot of help from thepeople that work here. I have a sense of pride when I walk inthe door in the morning and I walk out the door at night.” Thisresponse indicated that the profession of medicine could bemediated by the business of medicine. In this view, the busi-ness aspects of a given physician’s identity could generatebehavior and values that promoted the profession of medicinein the best sense of the term.

Context was a significant matter for many physicians.Whether one worked in private practice or the clinic was a

point of contention for a number of physicians related tohow they symbolically constructed oppositional views ofmaterial context. For example, Adam (private practice)noted that “managed care has insinuated itself between practi-tioners; it is not the collegial relationship it used to be. . . . Wemay run across a clinic doctor somewhere and acknowledgethem, but we are not particularly collegial or willing to helpthem out.” This was reinforced by Ben (private practice):“In private practice, we have a bond with the patient, but if Iam on salary, my bond is with the insurance company. Youcannot be in an adversarial relationship with the people whoprovide you care.” On the other hand, Michael (clinic)asserted the opposite: “When I was in private practice . . .many of these doctors were interested in making moremoney and doing less work and they were not interested intaking care of their patients or how well their patients weredoing. Here at the clinic everything is geared toward takingcare of the patient.”

A disempowering endeavor. Many private-practicephysicians and a few clinic physicians described their feel-ings of disempowerment, such that the individual physiciancould not be an adequate practitioner in the current environ-ment of medicine. This stemmed primarily from the percep-tion of interference by third-party payers but also included asense of nostalgia for a past in which physicians wereempowered. Many private-practice physicians discursivelyconstructed third parties as a material source of frustration.Steve, a private-practice specialist, indicated his frustrationwith managed care and the process of seeking authorization.“I have to have the person in my office, who is not a trainedphysician, call an insurance company employee, who is nota trained physician, and if that’s not absurd, I don’t knowwhat is.” Ben contended that third-party payers havetargeted physicians for cost savings. “All this crap that’sgoing on with [third parties] who all think that . . . you arethe last thing they can squeeze.”

These frustrations were not limited solely to private prac-tice, as Urban, a clinic surgeon, asserted that the quality ofhealth care has eroded because of interference in clinicalmedicine. “I think autonomy has been significantly reduced,and the result has been the gradual erosion in the quality ofhealth care. Most of this stems from nonphysicians makingdecisions over what should occur.” Barry, a clinic specialist,contended that “managed care has made medicine a lotmore industrialized—it’s like an assembly line where theparts are all interchangeable . . . the relationship betweenphysicians and patients is gone.”

In general, however, the perception of third-party inter-ference was held primarily by private-practice physicians.Evelyn, a private-practice primary care physician, con-tended that “We made a big mistake all those years agowhen we agreed to accept third-party payers.” Ian, (privatepractice) described his frustration with third parties in medi-cine. “I have lots of frustrations at times, primarily with

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interference from third-party payers and the government.It’s frustrating for me as a young physician.” Edward(private practice) talked about the hassles of having to dealwith all that is going on in medicine, including having onefull-time staff member for each physician to deal with insur-ance companies “just to ensure that we get paid for ourwork—they do all the paperwork, make all the telephonecalls, do the appealing.” Adam (private practice) describedhis frustration with the economics of maintaining a practicein the economic environment of medicine. “They’vesqueezed all the blood out of the turnip. . . . The frustrationlevel of taking care of patients in the current economic situ-ation is burdensome. . . . I experience frustration with hospi-tals, third-party payers, and loss of autonomy in dealingwith patients.”

Scholars have observed the impact of third-party payerson American physicians. Potter and McKinlay (2005)contend that third-party payers monitor and challenge phy-sicians’ clinical decisions, the amount of time they spendwith patients, and reimbursements for professional work.Others note how third-party involvement has createdconflicting loyalties, mistrust, and disruption of continuityin physician–patient relationships (Mechanic, 2003). In gen-eral, these issues were confined to private-practice physi-cians because the clinic shielded its physicians from havingto deal with business-related problems.

A small but passionate set of private-practice physiciansdescribed a nostalgia for a past in which physicians had ahigher quality of professional life. These identities aresituated within the business of medicine because this nostal-gia was presented as a contrast to the current business envi-ronment of medicine. This longing for a simpler past ledsome of them to evoke memories of the past as a way ofcomparing it to the present. For example, Steve brought uphis father, a physician who practiced in the 1940s, whenthere was no insurance.

He wasn’t a millionaire but he made a good living. Hedidn’t drive a Mercedes, but people paid him—some paidhim a little more, some paid less, sometimes he got paidwith chickens, maybe somebody came and cut down a treelimb, but his patients loved him. We need to find that again.

Adam described how he saw older physicians leave medi-cine due to material changes. “I have seen senior physicianswalk away from medicine. It isn’t as professionally satisfy-ing as it once was, especially for those senior physicianswho experienced life before managed care and the Medicareintrusion. They saw the heyday of medicine.” Gene talkedabout how physicians used to be respected and how that hasaffected the physician–patient relationship: “There was anage that existed where physicians were revered. . . . Butwhat’s going on in medicine is a detriment to physicians,and patients don’t get the same degree of care or empathybecause physicians feel put upon.” James, a private–practiceprimary care physician for more than 40 years, described

how changes in the business of medicine have changed rela-tionships with patients:

This is the most frustrating part of being a physician now.When I started there was no insurance. When you saw apatient, you expected them to pay or to give them credit ornot to charge them. But all of that has changed. Along camethe HMOs and the insurance, and instead of having a rela-tionship with the person, we have relationships with insur-ance companies.

These physicians, all in private practice, compared thepresent with a better past. These findings echo what othershave found: that physicians involved in managed care con-tracts experienced reduced satisfaction, reduced clinicalautonomy, and reduced power (Lammers & Duggan, 2002;Lammers & Geist, 1997; Potter and McKinlay, 2005). Ofinterest, there were no clinic physicians who yearned for aonce-golden past. In fact, Peter, a younger clinic physician,noted how this affected his communication with some of hisolder colleagues:

There is definitely a lack of communication between me andsome physician who’s 64 years old and has been practicingmedicine for 30 to 40 years. There is a chasm between themand me—I’ve grown up in the HMO/PPO [preferred pro-vider organization] world . . . and you feel it when you arein the same room with some of these guys. . . . Some of theolder guys think we rolled over and accepted managed care,but it wouldn’t have come to this if some of them hadn’tabused the system the way they did. At least, I feel that mostof the older guys don’t want managed care. But I don’tknow anything different from the managed care world.

Receiving their training in a managed care era, youngerphysicians may view the business of medicine differentlythan do older colleagues. Scholars have noted just such achange, with younger physicians no longer aiming to estab-lish a practice as much as trying to get a job (Shortell,Gillies, Anderson, Erickson, & Mitchell, 2000). This is inline with the increasing number of physicians working asemployees (American Medical Association, 2000).

Communicative implications. Physicians (primarilyin private practice) who described their identities in relationto the business of medicine were more likely to view theircommunication with patients through a prism of autonomy.On the one hand, some private-practice physiciansdescribed perceived interference, whereas others describedthe freedom to treat patients in their own ways. Ben (privatepractice) asserted,

What any real doctor wants is to interact with the patientwithout anyone or anything coming between them—it’s justme and the patient all the time without other entities such asthe government, hospital corporation, HMOs getting inbetween.

On the other hand, Xavier, a private-practice specialist,described the satisfaction he gets from interacting with the

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same patients over time. “I love seeing patients, investigat-ing problems, the interplay with patients, I get to know mypatients pretty well—I’ve seen some of them for more than25 years.” Gene (private practice) described an interactionhe had with a patient with no health insurance who neededmultiple operations (that he performed as a service), whotold him how valuable he was to her. “For the first time inmy life I could see why I’m doing what I’m doing.” Thissecond group of private-practice physicians had the auton-omy to treat patients and the business of medicine helpedmake the practice of medicine a gratifying experience. Formany private-practice physicians, there was an autonomy-versus-interference dynamic at work. Some felt that thirdparties interfered with their relationships with patientswhereas others enjoyed their autonomy.

Communication with patients by clinic physiciansevinced mixed feelings related to continuity of care andrespect for patients. Frank, a clinic specialist, wonderedhow the increasing number of specialists affected continuityof care. “That is better as far as taking care of medical prob-lems, but it has eroded the physician–patient relationship tosome degree—it’s not like having ‘old Dr. Jones’ treat youyour whole life.” William declared his respect for patients,based on his own experience as a patient, when interactingwith patients in very practical ways. “I try to spend timetalking to the patient because this helps them understandwhat we do so when they see the bill, and see how much itcosts . . . they’ll know what it is for.”

Although many studies have examined physician–patientcommunication, only recently have researchers investigatedhow the clinical context influences these interactions (see,e.g., Street & Gordon, 2006). Yet, as Street (2003) hasnoted, physicians are situated within and affected by a vari-ety of social contexts, including interpersonal, organiza-tional, media, political, legal, and cultural contexts. Atelling example of contextual influence on physician–patient communication involves possible constraints ontime allotted for patient exams. Shorter visits are character-ized by an increase in controlling communication behaviorsby physicians (more directives, interruptions, less tolerancefor questions), whereas longer visits allow patients moretime to raise their concerns as well as more time for physi-cian responses to these issues (Bensing, Roter, & Hulsman,2003; Street, 2003). Although an individual physician maywant to develop rapport and allow patients time to talk morein visits, if the organizational context is restrictive, theremay simply not be enough time and resources for this tooccur regularly. Those physicians predisposed to engage inpartnership-building, empathy, and encouragement will bemore likely to do this in contexts in which this is part of theorganizational culture.

To summarize, the business of medicine is material andsymbolic, as physicians discursively constructed an environ-ment that included “interfering” third-party payers, “powerful”government regulations, “threatening” malpractice lawsuits,

and “burdensome” paperwork. Many of these themes car-ried a negative cast, particularly for private-practice physi-cians and represent devalued elements of physician identity,particularly reduced autonomy (Lammers & Geist, 1997;Potter & McKinlay, 2005). Many private-practice physi-cians saw themselves as embattled businesspersons, disem-powered by third parties, inexperienced at business, andyearning for a golden past. Conversely, many clinic physi-cians echoed Hoff and McCaffrey’s (1996) findings thatphysicians can enjoy working as employees. Each of thesematerial and symbolic identities were relevant to communi-cation in the medical encounter.

IMPLICATIONS

It is important to study the situated nature of physician iden-tity, as we have done, in part because of the need to betterunderstand the contextual nature of physician identity(Hoff, 2001) and its relevance to physician–patient commu-nication (Street, 2003). We found three key identityplatforms that provide a general interpretive schema forunderstanding physicians’ identities and their communica-tion with patients in light of the symbolic underpinnings andmaterial realities of medicine. These themes act as a set ofdiscursive constructs that physicians can draw on to consti-tute their identities in particular ways that vary across physi-cians. Private-practice physicians drew on facets of identityrelated to the economic, legal, and social environment ofmedicine, whereas clinic physicians described identitiesmore closely linked to an organizational context that buff-ered the effects of the environment.

Understanding the communicative implications of thesymbolic and material nature of physician identity is impor-tant for a number of reasons. First, physicians whodescribed aspects of their identity as primarily orientedtoward the profession of medicine were likely to view com-munication with patients as serious, sacred, or a gift fromGod that entailed listening and being available for patients.Physicians who described aspects of their identity asoriented toward the relationality of medicine were likely tobring respect and empathy to the encounter and value theirpatient relationships. Private-practice physicians whodescribed their identity in terms of the business of medicinewere more likely to view communication with patientsthrough a prism of autonomy, whereas clinic physician–employees were more likely to view physician–patientcommunication in terms of continuity of care and respectfor patients.

Second, it is important to consider the capacity of com-munication to constitute identities and mediate the contex-tual and environmental forces that influence physicians andthose with whom they interact. Because physician identitiesare negotiated within social institutions, broad external dis-courses about particular identities (e.g., those that suggest

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what it means to be a “real” doctor) enable and constrain theconstruction of identity. Physicians’ identities are shapedthrough discourse about what it means to be a physician(Apker & Eggly, 2004; Harter & Kirby, 2004; Harter &Krone, 2001), and through what they do (interacting withpatients, treating the sick, running a small business) andwhere they practice medicine. As members of the medicalprofession and specific organizational arrangements (hospi-tals, HMOs, private-practice settings), physicians constructidentities through professional and organizational discourse.Physician identities are socially constructed and discur-sively enacted in light of broader institutional and organiza-tional contexts (Cheney & Ashcraft, 2007). Physicianidentity is symbolic and material in that it is constructed outof local talk in social interaction, the general discourse sur-rounding the medical profession, and the material realitiesof environmental and organizational contexts.

What implications do environment and context have forphysicians and their patients? Physicians are pressured bymany “countervailing powers” (Light, 1993) surroundingthe corporate practice of medicine (Robinson, 1999; Starr,1982), which is increasingly organized and controlled byfor-profit corporations that operate with market-based stan-dards of “managed care” rather than traditional principles ofmedicine (Rodwin, 1993). This has implications for patientsas well, with shorter visits (Mechanic & Schlesinger, 1996),increased distrust of physicians (Lammers & Geist, 1997),and reduced physician autonomy to treat them (Freidson,2001). As Street (2003) notes, physicians are situated withinand affected by a variety of social contexts, including inter-personal, organizational, political, legal, and culturalcontexts. Although many studies have examined physicianand patient communication within medical encounters, onlyrecently have researchers investigated how the clinicalcontext influences these interactions (see, e.g., Street &Gordon, 2006). Less attention has been paid to the impact ofhealth-care organizations—which are the sites where muchinterpersonal health communication takes place—on thecommunication that occurs in these encounters.

The limitations of this study include the relatively smallnumber of participants, the location of participants in aspecific geographical location, and the possibility that par-ticipants may have had special characteristics that led themto participate in the study. The clinic itself was not a stereo-typical HMO but instead was a not-for-profit organizationwith physician leadership. We recognize that more general-izable conclusions would require conducting the study withadditional physicians in other locations, but we believe thisstudy represents a small step toward understanding the sym-bolic and material nature of physician identity. Futureresearch could explore, perhaps through other researchmethods, the ways in which specific aspects of physiciancommunication are shaped by particular contexts. The gen-eral underrepresentation of women physicians is a limita-tion that future research should address as well.

The current environment of medicine and its localmedical context are substantive matters in shaping physi-cian identity and communication with patients. We foundphysician identity to be related to three key identityplatforms that reflected the symbolic underpinnings andmaterial realities of practicing medicine. This interpretiveschema has implications for physician–patient communica-tion, which is complex and shaped by symbolic, contextual,and material forces. This study contributes to our under-standing of physician–patient communication and profes-sional identity by illustrating the capacity of communicationto constitute identities and mediate the contextual andenvironmental forces that shape the medical encounter.Because physicians remain central to health-care decisionmaking and delivery, health communication research isenriched by attention to the situated institutional contexts ofpatient–physician interactions.

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the symbolic and material nature of physician identity: implications for physician–patient...

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