process. In his study of the history of doctors and patients, Edward Shorter
( 1985) identifies the post-World War II era as a pivotal time for modern
medicine. The discovery of sulfa drugs in the 1930s and later penicillin in
the 1940s transformed the practice of medicine. The transformation was,
however, not so much in the prescription of these drugs but in their impact
on medical training. The drug revolution led medicine to the chemistry-ori-
ented sciences of biochemistry, microbiology, pharmacology, immunology,
and genetics and a mainly organic picture of disease to be combated with
drugs. The battlelines were drawn between the doctor and the aberrant
molecules, with the patient often left on the sidelines. Hence the birth of the
biomedical model of disease and medicine's diminished interest in the
patient's experience of illness.

Shorter maintains that the practical fact of this depersonalization of
medicine was the downgrading in importance of taking the patient's history
and giving a physical exam in lieu of more structured data collection and
interpretation of laboratory data. It is not coincidental that the practice of
interviewing patients using a written outline designed around a series of
yes-no questions began during this time. Patient talk was largely curtailed by
these changes; patients were restricted to answering the questions asked. One
important effect of these changes was to recast medical dialogue as wholly
scientific and objective with a goal of keeping patient emotion in check.

In some part, the focus on scientific objectivity reflects a widespread
characterization of medicine as taking place in a context of potential death,
disability, trauma, pain, and uncertainty. Patients are thought to defend
themselves against feelings of overwhelming complexity, demoralization,
and helplessness by recourse to idealization or denigration of the physician.
Physicians, on the other hand, also need to protect themselves from feelings
of grief and helplessness made worse by an overriding sense of their
ever-present potential for making a fatal error ( Hilfiker, 1985). In this context
of heightened emotions and defensive responses, the stereotypic encounter
is characterized as a retreat from rational, logical communication on the part
of the patient, and a retreat to pure rationalism--to the "science" of medi-
cine--on the part of the physician.

A necessary perspective on this quite dramatic portrait is gained by
recognizing that most of the illnesses seen in medical encounters are not the
extreme kind. Clinically urgent and very frightening diseases are in fact the
exception in everyday practice. Moreover, even these most severe illnesses
tend to lead to routine, maintenance-centered encounters over time ( Szasz &
Hollender, 1956; Tuckett, Boulton, Olson, & Williams, 1985). Despite a
reality reflecting a rather undramatic routine, the illusion of drama remains
and subverts the talk that explores everyday matters of concern.

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