How doctors view their health and professional practice: An appraisal analysis of medical discourse

Journal of Pragmatics 42 (2010) 3172–3187

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How doctors view their health and professional practice: An appraisal analysis of medical discourse Susana Gallardo a,*, Laura Ferrari b Centro de Divulgación Científica, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Pabellón II, Ciudad Universitaria, 1428 Buenos Aires, Argentina b Instituto de Filología y Literaturas Hispánicas ‘‘Dr. Amado Alonso’’, Facultad de Filosofía y Letras, Universidad de Buenos Aires, 25 de Mayo 217, 1002 Ciudad de Buenos Aires, Argentina a

A R T I C L E I N F O

A B S T R A C T

Article history: Received 30 August 2007 Received in revised form 18 June 2010 Accepted 4 July 2010

Doctors’ health is a major problem for healthcare systems, and several surveys have been carried out in different countries to assess the situation. Yet information about doctors’ health is limited, especially in Latin America. The problem is that many doctors find it difficult to admit that they are in trouble, that their work is stressful, or that they need help. Thus the aim of this paper is to explore how doctors view their health and the professional practice in relation with their health, through the analysis of the resources of appraisal in informal communication among them. We present a qualitative analysis of a corpus of texts from a discussion forum in which doctors from Spanish-speaking Latin America wrote about their health and profession. We aimed to answer the following questions: (1) How do doctors view and evaluate their professional practice? (2) Do doctors see their working conditions as a risk factor for their own health? (3) To what extent do doctors express positive or negative values in discussions about their work? (4) What do they evaluate in the discussion? (5) Who do they find are responsible for this situation: health systems, their patients or their colleagues? The analysis was conducted using the framework of Appraisal Theory within a Systemic Functional Linguistics (SFL) approach and focused on three main areas: ‘‘appraiser’’, ‘‘appraised’’ and ‘‘goals considered valuable’’. These were examined within the semantic domain of attitude, which includes assessments of human behaviour by reference to social norms (judgment), personal feelings (affect) and assessments of the value of objects, artefacts, happenings and states of affairs (appreciation). In all three areas, attitude was found to be largely negative. Most doctors were acutely aware of risks to their own health as well as of other professional problems, and only a few expressed happiness and satisfaction with their profession. The most interesting findings were the negative judgment of social esteem with regard to neglect of their own health and the judgment of social sanction with regard to the healthcare system, as a whole, and to senior colleagues, in particular. From the point of view of engagement, when doctors valued their work as hard and distressful, they showed a tendency to present the propositions as unproblematic, so they seemed to assume that their audience shared their position. But when they referred to the causes of doctors’ illnesses, which implied judgments of social esteem of themselves and their colleagues, they tended to acknowledge alternative positions and they apparently aimed at persuading their audience to promote a change of situation. ß 2010 Elsevier B.V. All rights reserved.

Keywords: Appraisal Systemic Functional Linguistics Medical discourse Doctors’ health

* Corresponding author at: Honduras 3704 88 ‘‘15’’, 1180 Buenos Aires, Argentina. Tel.: +54 11 4963 2001. E-mail addresses: [email protected] (S. Gallardo), [email protected], [email protected] (L. Ferrari). 0378-2166/$ – see front matter ß 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.pragma.2010.07.008

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1. Introduction Doctors’ health is a major problem for healthcare systems, and several surveys have been carried out in different countries to assess this situation (i.e. Carpenter et al., 1997; Davidson and Schattner, 2003; Kapur et al., 1998). Yet information about doctors’ health is limited (Miller, 2007), especially in Latin America. The problem is that many doctors find it difficult to admit that they are in trouble, that their work is stressful, or that they need help (DH, 2008). In Argentina, a survey was carried out in order to explore risk factors of cardiovascular disease among doctors from different specialties and from different Latin American countries. The survey aimed to determine whether doctors smoked, drank, or were obese or sedentary and it found that doctors’ health is very much at risk. Even though it was also necessary to find out whether they were aware of that problem and what they thought were its causes,1 no information was gathered about how these doctors perceived their own health. However, some of these doctors participated in a discussion forum in which they reflected about different aspects of these topics. Furthermore, in the last two decades, the study of doctor–patient discourse has gained relevance (Cicourel, 1985), but that is not the case with informal communication among doctors, of which there are only few studies. The discussion forum provides an excellent opportunity to explore that kind of communication. Thus the aim of this paper is to explore how doctors view their health and the professional practice in relation with their health, through the analysis of the resources of appraisal in informal communication among them. We report the results of an analysis of texts produced by doctors from different Spanish-speaking countries in Latin America. In these texts, which were part of their participation in the forum, they expressed their thoughts about the medical profession and about their own health. We used a qualitative design derived from text linguistics and discourse analysis to explore doctors’ resources of attitude (affect, judgment and appreciation), engagement and graduation in order to assess how much aware they are of their problems and of the causes of those problems. We aimed to answer the following questions: (1) How do doctors view and evaluate their professional practice? (2) Do doctors see their working conditions as a risk factor for their own health? (3) To what extent do doctors express positive or negative values in discussions about their work? (4) What do they evaluate in those discussions? (5) Who do they find are responsible for this situation: healthcare systems, their patients or their colleagues? From the point of view of engagement, we aim to determine whether doctors recognize alternative positions, which positions they presume as being shared with the audience, and about which positions they consider they need to persuade their colleagues. 2. Theoretical framework 2.1. Appraisal analysis In this paper we used the framework of Systemic Functional Linguistics (SFL). According to this theory, there are three basic functions of language: (1) making sense of our experience: the ideational metafunction; (2) realizing our social relationships: the interpersonal metafunction; and (3) constructing coherent and cohesive texts which relate in appropriate ways to the context of the text’s production and reception: the textual metafunction (Halliday, 1985; Halliday and Matthiessen, 2004). In particular, in this study, we deal with a key aspect of the interpersonal meaning of language: evaluation. In this domain, Appraisal analysis, which is concerned with the linguistic resources that speakers or writers use to express, negotiate and naturalize inter-subjective positions with their audience (Hood and Martin, 2005), identifies three main systems of evaluative meanings: attitude, graduation and engagement (Hood and Martin, 2007; Martin and Rose, 2003; Martin and White, 2005). Briefly, attitude relates to feelings and opinions, graduation refers to the strength with which feelings and opinions are expressed, and engagement refers to the extent to which speakers or writers ‘engage’ with ideas in order to align or distance themselves from their audience. This paper focuses on attitude as a linguistic indicator of relative well-being. 2.2. Attitude Attitude refers basically to the speaker or writer’s feelings and opinions and divides into:  affect, evidenced in emotional responses like happiness, sadness or fear;  judgment, evidenced in moral evaluations of human behaviour (e.g. ‘honest’, ‘untruthful’, ‘brave’), and  appreciation, which refers to the way objects and processes (rather than human behaviour) are evaluated in accordance with aesthetic values (e.g. ‘elegant’, ‘harmonious’) and other non-aesthetic systems of social value (e.g. ‘significant’, ‘harmful’). Attitudes towards people, objects or situations can be either positive or negative and are gradable; in other words, their intensity can be adjusted on a scale, and, while attitude can be inscribed in individual words or groups of words, those inscriptions need to be viewed in the context of the discourse.

1 All these studies were subsidized by IntraMed, a website providing specialized information to health professionals. IntraMed is sponsored by advertisers, the largest of which is the Argentinean pharmaceutical company Roemmers.

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2.3. Affect Affect is considered as a semantic resource for construing emotions, and it comprises three broad categories depending on whether the feelings and sensations expressed are:  un/happiness: emotions like love, happiness, sadness and rage (e.g. ‘‘the man was happy/sad’’);  in/security: emotions like trust, anxiety and fear (e.g. ‘‘the boy was confident/anxious about the exam’’);  dis/satisfaction: emotions like contentment, weariness and frustration, associated with goal-related behaviour (e.g. ‘‘the woman was bored with/engrossed in her work’’). Expressions of affect can be seen as attempts to position the reader with respect to an individual or a social group (workers, politicians, immigrants, etc.). By attributing emotions to a person or group of people, the writer invokes an emotional response that may bias readers favourably or unfavourably towards that person or group. 2.4. Judgment Judgment refers to the positive or negative evaluation of human behaviour in relation to a set of social norms. Through judgment we praise, criticize or censure the actions, utterances, beliefs or motives of a person or a group. Judgment divides into two types: social esteem and social sanction. Judgments of esteem sub-divide into:  normality: how unusual a person is (e.g. eccentric, traditional, conventional);  capacity: how capable someone is (e.g. brilliant, skilful, stupid); and  tenacity: how resolute someone is (e.g., strong-willed, obstinate, coward, brave). Judgments of sanction sub-divide into:  veracity: how truthful someone is (e.g. honest, credible, deceitful);  propriety: how ethical someone’s behaviour is (e.g. good, unfair, corrupt). Thus, negative judgments of esteem involve minor social offences and entail criticism, whereas negative judgments of sanction are of a moral or legal nature and entail outrage and condemnation (Martin, 2003). Tenacity would seem to occupy an intermediate place between social esteem and social sanction. For example, in time of war ‘‘coward’’ is a judgment of sanction, not simply one of esteem. Appraisal analysis considers tenacity in relation to mental and emotional states rather than external moral regulations (Iedema et al., 1994). Ultimately, however, it is context that determines the judgment system to which a particular appraisal belongs. Finally, judgments – like other forms of appraisal – can be explicit or implicit. For example, we can say ‘‘the government is incompetent’’ or ‘‘the government has no policy for economic growth’’. However, the latter will invoke evaluations of incompetence only in readers who share the same view of the economy and the role of government. It must be emphasized that attitude is ‘invoked’ by the cultural and ideological situation in which it is expressed. 2.5. Appreciation Like judgment, appreciation attributes properties to the evaluated phenomenon rather than to the person making the evaluation. For example, if someone says that a sunset is beautiful, that quality is attributed to the sunset and not to the person observing it. However, unlike judgment, appreciation involves positive or negative valuations of objects, processes and situations rather than people. Thus, although the same linguistic resources are sometimes used in both types of appraisal (e. g. ‘‘John is boring’’ vs. ‘‘the landscape is boring’’), judgments attribute a certain degree of responsibility to the human participant. This is not the case with appreciation, which generally involves valuations of entities which do not bear responsibility, such as objects or processes. 2.6. Graduation Gradability is a defining property of all attitudinal meanings. Values of affect, judgment and appreciation construe greater o lesser degrees of positivity or negativity (Martin and White, 2005). The semantics of graduation is central to the appraisal system. Graduation operates over categories which involve inherent scalar assessments of grading according to intensity or amount, on the one hand, and according to prototypicality and the preciseness by which category boundaries are drawn, on the other hand. The term force references assessments as to degree of intensity and to amount. The term focus expresses graduation according to prototypicality. 2.7. Engagement Here we also consider the dialogistic perspective, and thus we focus on the stance that writers take with respect to other speakers who have previously positioned themselves on the same issue. We consider the degree to which writers acknowledge prior speakers and the ways in which they engage with them. As Martin and White (2005:95) say:

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‘‘(. . .) when speakers/writers announce their own attitudinal positions they not only self-expressly ‘speak their own mind’, but simultaneously invite others to endorse and to share with them the feelings, tastes or normative assessments they are announcing. Thus declarations of attitude are dialogically directed towards aligning the addressee into a community of shared value and belief’’. We aim to determine whether forum participants take it for granted that addressees share their opinion or if, on the other hand, they assume that it is necessary to persuade them to adhere to a particular viewpoint. In agreement with White (2003) and Martin and White (2005), we take as heteroglossic all locutions which recognize that the text’s communicative backdrop is a diverse one. And we take as monoglossic all bare assertions that do not make reference to other voices. Among heteroglossic locutions, we consider the distinction between dialogic expansion and dialogic contraction. The former includes locutions that make allowances for dialogically alternative positions and the latter comprises locutions that challenge or restrict the scope of such positions. 3. Methodology 3.1. Data collection The texts analyzed come from an on-line discussion forum in which Spanish-speaking doctors from different specialties discussed subjects related to doctors’ health. The doctors worked for hospitals in 13 different Latin American countries, namely, Argentina, Bolivia, Chile, Colombia, Ecuador, El Salvador, Guatemala, Honduras, Mexico and Nicaragua. There was also one message from Spain, which was not included in this study. With this exception, all 230 messages posted by 220 different doctors between November 1, 2005 (when the first message was posted) and December 31, 2006 (when the forum was accessed) were analyzed for this study. Original messages in Spanish, selected to be shown as examples in this article, were translated into English by a professional translator. On the following sections we show each example in Spanish and its translated version below. 3.2. Method of data analysis Attitude can be realized explicitly through attitudinal lexis (inscribed), or implicitly, through ideational meanings (invoked), which make reference to cultural attitudinal norms. Ideational meaning can invite attitudinal responses in readers but it can also be used to provoke a response, for example, through lexical metaphor; especially implicit attitude, while instantiated in specific wordings, is expressed in a text in clauses and sentences, and so identifying and classifying attitude using appraisal analysis is context dependent. In order to identify recurring attitudes, the texts were analyzed in two stages. The categories chosen for the initial analysis were:  Appraiser: The appraiser in each text was the doctor, although some doctors included appraisals made by colleagues or patients, or society in general.  Appraised: In each case, attitudes were analyzed in relation to three areas: 1. the doctor’s profession; 2. the doctor’s health; 3. institutional aspects of the medical profession.  Goals considered valuable: These were goals that the doctors considered desirable both for themselves and for the medical community. After a preliminary analysis, the ‘‘appraised’’ category was further sub-divided as follows: 1. The doctor’s profession: a. as a job b. as a vocation 2. The doctor’s health: a. the attitude of the doctor towards his or her health b. the doctor’s lifestyle 3. The institutional aspects of the profession a. the healthcare system b. relationship with patients c. relationship with colleagues d. economic compensation The categories we consider are: Affect: Un/happiness, Dis/satisfaction and In/security

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Judgment: - Social esteem: Normality (+ normal / - eccentric) Capacity (+ wise / - foolish) Tenacity (+ heroic / - cowardly) - Social Sanction: Veracity (+ trustworthy/ - liar / - dishonest) Propriety (+ supportive / - insensitive) Appreciation: Social Value (+ sufficient / - insufficient; + appropriate / - inappropriate; + healthy / - unhealthy; + valuable / - worthless) 3.3. Audience factors In analyzing the texts we also considered to what extent the doctors intended to persuade the direct addressees of their texts (other doctors) or an indirect addressee (‘‘the authorities’’, ‘‘the healthcare industry’’ or ‘‘patients’’, among others) about the necessity and importance of taking certain measures to solve problems. 4. Analysis We begin the analysis from the perspective of engagement, one of the systems of appraisal that is concerned with resources by which writers adopt a stance towards the other voices or positions being referenced by the text; and we consider the two basic values: heteroglossic and monoglossic (Martin and White, 2005). In the messages to the forum the authors state opinions and make judgments, and account for them with arguments and, in some cases, with anecdotes of personal experiences. From the point of view of engagement, we focus on some features as conjunctions of contrast, concession and refutation (but, although, nevertheless, despite) and negative sentences that contrast what actually happens with what should happen (e.g. ‘‘I don’t get enough sleep’’) in order to determine how authors position themselves in relation to their addressees. Our hypothesis is that judgments on and appreciation of some areas may be presented as unproblematic for them, if they take for granted that the addressee shares their viewpoint. In contrast, judgments on other areas will be expressed on the assumption that the reader may need to be won over to a particular viewpoint (Martin and White, 2005). A recurrent feature of these forum messages is the use of rhetorical questions. These questions can perform at least two functions: (a) they can be used to introduce a proposition presented as one of a number of possible alternatives, or (b) they can represent the proposition as self-evident, so that the reader can supply the required meaning (White, 2003:267). In the first case, writers entertain alternative propositions and locate the one they are expressing in a context of heteroglossic diversity. These propositions are dialogically expansive. Rhetorical questions of the second group, on the other hand, are dialogically contractive because they challenge an alternative viewpoint, as in the following example: Creo que el mensaje es nefasto para el paciente. Con qué autoridad puede un profesional modificar los malos hábitos de un paciente cuando él mismo es un ejemplo de lo que no se debe hacer? Cómo puedo pretender que mi paciente tenga menos de 90 cm de perímetro abdominal cuando la panza me impide abrocharme la chaqueta? Qué fuerza puede tener esta recomendación? [. . .] (22/03/06, Argentina) ?

1.

?

?

I believe that this sends a terrible message to the patient. What authority does a doctor have to modify a patient’s bad habits when he, himself, is an example of what shouldn’t be done? How can I expect a patient to have an abdominal perimeter below 90 cm when my own belly prevents me from doing up my jacket? What force can this recommendation have? [. . .] (22/03/06, Argentina) All three rhetorical questions in (1) introduce propositions presented as obvious or self-evident, and there is a negative answer implied in each of them: ‘‘No authority’’, ‘‘I cannot expect. . .’’, ‘‘The recommendation has no force’’. The textual voice seeks agreement in his/her readers and, at the same time, acknowledges an alternative position, that of doctors who do not care about their image; and this position is rejected. According to White (2003), this dialogically contracting meaning is an instance of one mode of proclamation: concurrence. In the following sections we present an analysis of texts from the perspective of appraisal, through the consideration of some categories that have aroused from the corpus: ‘professional practice’, ‘doctors’ health’, and ‘institutional aspects of the profession’. At the same time we will explore how writers construct their identity through the process of engaging with socially determined value positions. 4.1. Professional practice The doctors appraised their professional practice from two points of view: as a job and as a vocation. As a job, professional practice was appraised through inscribed attitude as risky, strenuous, demanding and stressful. The invoked attitude is expressed through ideational content as unsuitable working hours and long, exhausting shifts. As mentioned earlier,

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negative statements may suggest what is normal or desirable. In the following example we find this rhetorical device used to enumerate the risks inherent to the profession that result from not doing what one should (i.e. eat well, rest, and spend time with the family): 2.

[. . .] como profesionales estamos expuestos a muchos riesgos inherentes a nuestro propio quehacer que pueden ir desde el dejar de comer por correr al trabajo hasta tenés que salir por las madrugadas a exponernos por atender un enfermo. [. . .] (28/11/05, Guatemala) [. . .] as professionals we are exposed to many risks inherent to our job, that range from not eating because we have to rush to work to leaving home in the early hours of the morning and getting exposed to disease for being in close contact with patients. [. . .] (28/11/05, Guatemala)

In (2), by using the noun risks, the writer makes a negative evaluation of the professional practice. Risks are quantified via an isolated term (Martin and White, 2005) which modifies the graduated entity (many risks). A series of actions, such as not eating, rushing to work and leaving home in the early hours of the morning, function as specifications of that noun, and appear under its negative scope. These ideational tokens extend the negative prosodies of the negative appreciation of professional practice as a job and invoke a negative response. From the viewpoint of engagement, (2) is a bare assertion (monoglossic) which presents the proposition as self-evident and unproblematic. The ‘‘sacrifices’’ that doctors have to make were also a recurring theme, illustrated in the following example: 3

[. . .] nuestra profesión evidentemente es muy ardua y de sacrificios [. . .](29/07/06, Ecuador) [. . .] our profession is obviously very strenuous and demands a lot of sacrifices [. . .] (29/07/06, Ecuador)

In (3), the appraised entity is qualified by the adjective strenuous, modified by a quantifier which involves scaling with respect to intensity (very). The noun sacrifice invokes a negative appraisal, with quantification in its force (a lot of). At the same time, the comment adjunct obviously entails that the writer assumes the reader concurs with his/her viewpoint. This is a contractive formulation, because it represents the belief as universally held in the communicative context. In the following example we can see how the negative appraisal of the profession generates an emotional reaction: 4.

Con gran preocupación he notado que mis compañeras colegas doctoras que quedan embarazadas aumentan la cantidad de amenazas de aborto [. . .] patologías que se asocian a estrés [. . .](07/11/05, Colombia) I have noticed with great concern that my colleagues who get pregnant are more likely to suffer a miscarriage [. . .] due to pathologies associated with stress [. . .] (07/11/05, Colombia)

In (4), from the point of view of affect, the emotional reaction of insecurity and uneasiness is expressed with quantification in its force (great concern). The quantified entity (concern) is abstract; and these abstractions are construed as entities, as values which might otherwise have been expressed as qualities or as processes. Another expression of inscribed negative attitude is stress, which is presented as presupposed, i.e. it is assumed by the writer as a problem related to the profession. Thus, from the point of view of engagement, the writer assumes the reader concurs with his/her viewpoint.A frequently mentioned problem in relation to the profession was burnout syndrome2: 5.

Los médicos nos enfermamos, la angustia y la ansiedad ante la progresiva inversión de horas en las que dejamos de lado el esparcimiento y la familia para entregarlas a los paciente y/o al sistema, la capacitación permanente, generalmente con pobres compensaciones materiales y espirituales, debido a una realidad que nos empuja al ‘‘multiempleo’’ para lograr una ‘‘estabilidad’’ socioeconómica cada vez más alejada. Esto lleva a tener médicos insatisfechos, extenuados, desmotivados que reniegan del sistema en el cual se desempeñan (gran porcentaje de ellos ya con un ‘‘burn out’’, mayores tasas de suicidios, divorcios, accidentes, abuso de alcohol o drogas, depresión, enfermedad cardiovascular, menores expectativas de vida. (10/09/06, Argentina) We doctors become ill, the anguish and anxiety of investing an increasing number of hours – time we need to relax and spend with our families and which we devote to patients and/or the [healthcare] system, permanent training, usually with little in the way of material and spiritual rewards, due to a state of affairs that forces us to ‘‘multitask’’ in order to achieve some sort of social and economic ‘‘stability’’ that is more and more unattainable. This produces unsatisfied, exhausted, demotivated doctors who want nothing more to do with the system in which they work (a large percentage of them suffer from burnout syndrome, there are higher rates of suicide, accidents, alcohol or drug abuse, divorce, depression and cardiovascular disease; and life expectancy is falling. (10/09/06, Argentina)

2 First identified in social workers by Freudenberger (1974), burnout syndrome is currently defined as a three dimensional syndrome of Emotional Exhaustion, Depersonalization (often accompanied by cynicism) and Reduced Personal Accomplishment. It is particularly common among individuals working in the helping professions.

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In example (5), nouns (anguish, anxiety) and adjectives (unsatisfied, exhausted, demotivated) show inscribed negative values of affect. The ideational content (investing hours and unattainable goals) invoke negative feelings. In this example, intensification is realized through the verb increasing, and the comparative. The combination of these features (negatively loaded lexis) interacts with inscribed attitude and increases its ‘‘volume’’ as an evaluative prosody across the text. In this particular case, the up-scaling of attitude acts to align the reader into that value position. In the same way, positive meanings (rewards) are down-scaled. From the point of view of engagement, this formulation is a bare assertion, so the proposition is presented as unproblematic. The use of the first person plural presents the addresser as including the addressee, whose agreement is taken for granted. When the doctors evaluate their profession as a vocation rather than a job, we find two radically different points of view. Some emphasize the vocational character of the profession as a public service and emphasize the fact that the choice of profession was a personal decision. Others, however, claim that depicting the profession as a vocation favours exploitation of doctors at the hands of healthcare systems and justifies excessive demands from patients. Those who valued the vocational side of the profession usually expressed positive affect in the subcategories of happiness and satisfaction. Thus, some claimed to feel ‘‘happy’’ with their careers, or to ‘‘enjoy’’ them. They also expressed positive appreciation, considering their careers to be ‘‘valuable’’. Generally, positive appraisals of the profession as a vocation were contrasted with negative aspects by the conjunction but, as can be observed in the following example: 6.

[. . .] No se duerme, se come muy poco, pero todo vale la pena. [. . .] (10/08/06, Ecuador) [. . .] you don’t get much sleep, or eat much, but it is all worthwhile [. . .] (10/08/06, Ecuador)

In (6), from the perspective of engagement, it can be observed that, in the first part of the sentence, ideational tokens invoke negative appreciation of profession, which is later relativized by the main argument (the positive appreciation), stated in the second part of the sentence. In the first part, the adverb much conveys to the verbal processes eat and sleep a sense of downscaling (through the negative), adding negative value, for they are below what is considered normal. In the second part of the utterance, the assessment of amount applies to professional practice. This fragment is dialogically contractive, for the textual voice counters an alternative negative position on profession. The same is true in the next extract: 7.

Estamos en contacto con enfermedades, corremos riesgo de contagio, dedicamos más horas que el común de la gente a nuestro trabajo, nos estresamos, postergarnos nuestra familia. . . pero es maravilloso, vale la pena el esfuerzo. (21/10/05, Buenos Aires, Argentina) We come into contact with disease, we run the risk of infection, we devote more hours to work than most people do, we are stressed, we neglect our families. . . but it is wonderful, it is worth all the effort. (21/10/05, Buenos Aires, Argentina)

In the first part of (7), the addresser seems to agree with negative appreciation of profession, which can be seen in the accumulation of negatively valued items such as disease, risk of infection, stress and neglect. But in the second part of the utterance, he/she ‘‘replaces’’ the proposition that would have been expected in its place. In this part, the adjective wonderful, located at the upper end of the scale of intensification, counters the negative position about profession (contractive formulation). In general, when positively appraising the profession as a vocation, doctors pointed out that it had been their own choice to become doctors. Nevertheless, some of them expressed scepticism: Nos creímos aquello que la medicina es un sacerdocio y ahora nos convertimos en mártires. Pero vale la pena? [. . .] (04/ 11/05, Buenos Aires, Argentina) ?

8.

We believed all that stuff about medicine being like priesthood and now we have become martyrs. But is it worth it? [. . .] (04/11/05, Buenos Aires, Argentina) In this extract, the author questions the sacrifice involved in the profession. In Spanish, the word sacerdocio means ‘‘priesthood’’, but it can also refer figuratively to ‘‘active and zealous devotion to a profession or a high and noble ministry’’. But a martyr goes even further and ‘‘dies or suffers greatly to defend beliefs or convictions’’. It is interesting to note that when the author says: ‘‘we believed’’ he takes it for granted that the proposition is false. At the same time, the implication is that there is an external appraiser – perhaps society as a whole – that sees the profession as ‘‘priesthood’’ and has deliberately misled doctors into believing it is so. However, the author does not deny the value of the profession categorically, but rather expresses his appraisal by means of a rhetorical question, leaving the response to the reader (in this case, his colleagues). This is an open-ended question, and the answer may be negative or positive. The first utterance is a bare assertion, it presents as unproblematic the fact that, at the beginning of their career, doctors believe in something false. The second utterance is dialogically contractive, since it counters the first; but it is expansive if we consider that the open-ended question entertains two different alternative positions.

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The following examples also offer invoked negative appraisal of the profession as a vocation through the use of the term utopia. The lexical items fault and blame belonging to legal domain, contribute to the negative appraisal of professional life. 9.

Pero también es culpa nuestra [. . .] en los inicios obrar en la utopía de ‘‘ser médico’’ ‘‘qué vocación’’ [sic] y comprender de entrada que lo que vale se debe cobrar y sin chistar [. . .](02/02/06, Corrientes, Argentina) But it is also our fault [. . .] behaving at the beginning as if ‘‘being a doctor’’ was some sort of utopia: ‘‘what a vocation’’ [sic] and understanding right from the start that what is valuable must be paid for without a word of complaint [. . .] (02/02/06, Corrientes, Argentina)

10.

La culpa del maltrato y descalificación es sólo nuestra y de nuestros representantes, nos convertimos en la mano de obra ma´s barata, bajo el lema que lo tenemos que hacer por vocación o porque es un sacerdocio. (04/01/06, Buenos Aires, Argentina) The only ones to blame for the ill-treatment we get are ourselves and those who represent us. We turn ourselves into the cheapest labour on the belief that we have to do so out of vocation or because this is a sort of priesthood. (04/01/06, Buenos Aires, Argentina)

In (9), the textual voice, in first person plural, admits a fault: considering profession through the metaphoric term utopia (an imaginary place considered to be perfect or ideal). The wrong appreciation of vocation entails that if the doctor does not earn money, it does not matter, for he/she is following his/her vocation. Both fragments (9 and 10) present doctors as responsible for the ill-treatment that they receive. The propositions in both are dialogically contractive: in (9) the textual voice counters an alternative position, that of society, not of the audience, i.e. the colleagues; in (10) the formulation is a pronouncement, for the adverb only adds authorial emphasis. Some participants in the forum, on the other hand, expressed other people’s appraisal of the profession (that of society, or the health care institutions). 11.

Lamentablemente está todo tan desvalorizado que uno deja de lado toda la vocación que aprendió en la facultad por tratar de subsistir, Argentina es un país que todos amamos pero vivir aquí es cada vez mas difícil siendo medico. . . (22/10/05, Santa Fe, Argentina) Unfortunately, everything is so devalued that one leaves aside all the vocation one learned in medical school to try and make ends meet, Argentina is a country we all love but doctors’ lives here are getting more and more difficult. . . (22/10/05, Santa Fe, Argentina)

In this extract, the author expresses his unhappiness with the situation mainly through affect (the sentence adverb unfortunately). Although the expression that follows (‘‘everything is so devalued’’) is somewhat vague, it is clear that it refers to the profession. Here, institutional aspects are implied. We will go into these more deeply in a moment. In (11), relative scaling with respect to intensification is realized via comparatives and applies to doctors’ quality of life. The sentence adverb unfortunately expresses unhappiness, on the one hand, but it presents the proposition as a fact, as monoglossic, as taken for granted on the other hand. The next writer makes this devaluation of the profession more explicit by means of a comparison between the past and the present, of quantification (very low salaries) and of a metaphorical expression (working day never ends). 12

Es terrible pero por lo que veo así es en todo el mundo yo soy mexicana y actualmente la profesión médica ya ‘‘NO ES’’ lo que era antes, ahora no valoran a los médicos, los sueldos son muy bajos las jornadas de trabajo no tienen límite [. . .] (21/09/06, México) It is terrible but as far as I can see it is the same all over the world, I am Mexican and nowadays the medical profession ‘‘IS NOT’’ any longer what it used to be, doctors are not valued any more, salaries are very low and the working day never ends [. . .] (21/09/06, Mexico)

In (12), the writer begins his message with a negative evaluation (an expression of insecurity) of the doctors’ situation. The formulation refers to the fact that the devaluation of the profession is the same everywhere, and it is dialogistically expansive, for it comprises the expression ‘‘as far as I can see’’, which opens to alternative positions. Yet, the devaluation of the profession is presented as a fact. This brings us to a related issue: the fact that the different medical specialties are valued differently by the medical community, as shown in the following examples: 13.

Soy médica generalista del oeste formoseño, [. . .] somos considerados todos mediocres, a pesar de la continua información que recibimos y los cursos que realizamos. (01/01/06, Formosa, Argentina) I am a GP in the west of Formosa [. . .] we are all considered mediocre in spite of the constant information we receive and the courses we take. (01/01/06, Formosa, Argentina)

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El médico general es visto como el eslabón menos importante en la medicina y no es así [. . .]. (07/02/06, Panamá) The general practitioner is seen as the least important link in medicine and that’s not so [. . .]. (07/02/06, Panama)

In the last two extracts, general practitioners refer implicitly (through the use of the passive voice) to the medical community by expressing that their colleagues from other areas of medicine do not value their specialty. They feel that their colleagues are prejudiced against them and so they counter the unnamed appraiser. 4.2. Doctors’ health This section analyzes doctors’ attitudes towards their own health and life style. 4.2.1. Doctors’ attitudes towards their own health In their messages to the forum, the doctors express inscribed and invoked attitude in describing health as a prized commodity (mental health important, cannot be traded on the currency markets, most valuable commodity). In particular, the importance of mental health – which seemed to be most at risk – was frequently emphasized. On the other hand, the doctors’ attitude towards their own health was expressed mostly through negative judgments of social esteem within the sub-category of tenacity. The doctors blamed themselves for being inconsistent and for lacking determination, using terms like ‘‘careless’’ and ‘‘carefree’’. This attitude ties in with their invoked appraisals of the profession as an activity and vocation: they do not give priority to their own health because they have other priorities, as shown in the following extracts: 15.

[. . .] pero creo que la causa principal de nuestras enfermedades es porque nosotros no damos la prioridad a nuestra propia salud [. . .] (22/09/06, Ecuador) [. . .] but I believe the main reason why we become ill is that we do not give priority to our own health [. . .] (22/ 09/06, Ecuador)

16.

[. . .] sucede que muchas veces las pasamos trabajando, otras nos las aguantamos y cuando los síntomas son muy fuertes, por fin acudimos a la consulta. (27/12/05, Guatemala) [. . .] what happens [when we are ill] is that we often continue working, sometimes we just put up with it, and we finally seek medical attention when the symptoms are really bad. (27/12/05, Guatemala)

In the examples above, doctors give their opinion about the causes of doctors’ illnesses. They express negative judgments of social esteem on themselves, and use the first person plural to include addresser and addressee. They say that doctors’ behaviour is not what it should be. Utterances are dialogically expansive. In (15), the proposition is presented as a belief, so it entertains alternative positions on the reasons why doctors become ill. In (16), through adverbs of frequency (often, sometimes), the addresser entertains alternative positions, but through the expression what happens is, the textual voice is contracting dialogicity. Some doctors, however, refer to their experience of personal neglect in the first person singular. 17.

Me preocupa que he pospuesto mi revisión ginecológica ‘‘para después’’. (30/08/06, México) It worries me that I have postponed my gynaecological check-up ‘‘till later’’. (30/08/06, Mexico)

In this example, the doctor does not express a judgment of esteem about the way doctors in general neglect their health, but rather her uneasiness (affect: in/security) about her own health and the fact she has missed a necessary medical examination. In this case the ideational content (invoked) expands the negative expression of affect. In many texts the idea of ‘‘neglect’’ is invoked by means of directive speech acts, that is, recommendations about what should or needs to be done. Some of these are general suggestions: we must look after ourselves; let’s take care of ourselves; let’s be our own doctors; others are more specific: we should leave an hour free for exercise, eat fruit and vegetables and not neglect our mental health. The doctors, then, admit that they neglect themselves. Some go further, adding a judgment of social esteem about the irrational ways in which doctors refuse to face the fact that they are only human: 18.

Hay una realidad: el médico descuida su salud, y declina pensar en la posibilidad de enfermarse porque, al saber factores de riesgo, por el mismo estilo de vida es mejor desentenderse por considerarse infalible. He sabido de casos que gastroenterólogos han fallecido de cáncer gástrico. (30/08/06, México) It is a fact: doctors neglect their own health and refuse to think about the possibility of becoming ill because, being aware the risk factors, because of their life style [they think] it is better to ignore them, since they consider themselves infallible. I have heard about cases of gastroenterologists who have died of gastric cancer. (30/08/06, Mexico)

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No será que muchas veces por cuestión de orgullo no queremos consultar a otros colegas para no dar signos de flaqueza o ignorancia??? (27/11/05, Panamá) Couldn’t it be that many times, for a matter of pride, we do not want to consult other colleagues so as not to show signs of weakness or ignorance??? (27/11/05, Panama)

In these fragments, neglect is attributed to the fact that doctors consider themselves to be infallible or are too proud to seek help. This is no longer a negative judgment about tenacity, but about capacity (to behave sensibly), because they have a wrong image of themselves. In (18), through the dialogically contractive formulation ‘‘It is a fact’’, the textual voice rules out alternative positions. On the contrary, in (19), the writer presents the proposition as an open-ended rhetorical question, expanding alternative positions. 20.

Creo que nos enfermamos porque siempre pensamos que el enfermo es el otro y que a nosotros, superpoderosos, nunca nos va a tocar [. . .] (07/09/06 Saladillo, Argentina) I believe we become ill because we always think of the ill person as someone else, other than us, and we think that it is never going to happen to us, the super powerful [. . .] (07/09/06 Saladillo, Argentina)

In this example, the addresser expresses irony through the expression ‘‘super powerful’’ and censures doctors for their incapacity to think straight – because they fail to recognize the obvious. This is a case of relative scaling with respect to intensity. This item conveys strong writer investment in the utterance. From the point of view of engagement, the formulation is expansive. The addresser entertains alternative positions by explicitly presenting the proposition as grounded in its own individual subjectivity (I believe). 4.2.2. Doctors’ lifestyle Appraisals of doctors’ lifestyle are, of course, related to health. Their lifestyle is considered detrimental to their health and is appraised from the perspective of negative appreciation. Many doctors used the resources of affect, in the category of in/ security, reacting with concern, surprise or curiosity at the fact that bad habits are so widespread among their colleagues. 21

[. . .] Es increíble ver las tasas de consumo de tabaco, alcohol y hasta drogas por colegas nuestros, algo que riñe con la mas trivial de las lógicas. . . consultaría ud. a un dentista sin dientes??? tendría peso la opinión de un nutriólogo de mucho peso??? cosas individuales para meditar y modificar cuando se pueda. Amén de los condicionantes sociales que ésos si se han comentado mucho. . . (28/11/05, Guatemala) [. . .] It is incredible to see how much tobacco, alcohol and even drugs are consumed by our colleagues; something that goes against the most basic common sense. . . Would you consult a dentist without teeth??? Would the opinion of an overweight nutritionist carry much weight??? A few things to reflect on and change as soon as possible. Together with the social conditionings, which have already been commented upon. . . (28/11/05, Guatemala)

22.

Lo curioso en todo esto estimados colegas es que tenemos bien identificados todos nuestros factores de riesgo y pocas y pocas veces hacemos algo para mejorarlos. Creo que tenemos una cruel adicción al trabajo, a no comer bien, a no descansar y por supuesto a no pasar tiempo con nuestra familia. (02/04/06, México) The odd thing about all this, dear colleagues, is that we can perfectly identify all the risk factors inherent to our profession and we very, very rarely do anything to improve the situation. I believe that we have a cruel addiction to work, to bad eating habits, to not resting and of course to not spending time with our families. (02/04/06, Mexico)

In these extracts, the writers express their surprise (with the adjectives incredible and odd referring to everything that follows) before going on to enumerate the habits they identify as detrimental to their health. In (21) and (22), the terms ‘‘incredible’’ and ‘‘odd’’ express a negative reaction (appreciation). Furthermore, the ideational tokens invoke negative attitude because, on the one hand, they extend the negative prosodies of negative affect, and, on the other, they are intensified through quantification (how much), and the adverb even (which indicates that something is unexpected). In (22), the writer employs the adjective cruel to judge doctors’ addiction to work, which entails a judgment of social sanction. It is a metonymy through which the speaker attributes to the abstract noun a human quality. In (21), rhetorical questions present the proposition as self-evident; the writer is talking about a third person, neither about him/herself nor the audience. In (22), the writer employs the first person plural referring to him/herself and to the audience, and the formulation is dialogically expansive (I believe). It should be emphasized that when the attitude of doctors towards their own health is judged and detrimental habits are negatively appraised, there is usually a judgment of social sanction in terms of lack of propriety. Doctors’ lives should be models for their patients to copy. A doctor whose own life style is unhealthy is behaving improperly and cannot be trusted.

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4.3. Institutional aspects of the profession Our analysis of institutional factors included appraisals of the health care system, of relationships between junior and senior doctors and of doctors’ pay, on the one hand, and of the doctor–patient relationship, on the other. With regard to the health system, negative judgments of social sanction were clearly predominant. The system was condemned as ‘‘abusive’’ from an ethical standpoint, and was accused of exploiting and mistreating doctors. 23.

En cambio se produjo la felpudización de los médicos, salvo los anestesistas, somos explotados, como si no tuviésemos derecho a tener un buen nivel de vida, incluso muchas veces castigados por hacer un break o ir a tomar un café. (04/01/ 06, Buenos Aires, Argentina) However a ‘‘doormatting’’ of doctors has taken place; with the exception of anaesthetists, we are exploited, as if we had no right to a good living standard, often even punished for taking a break or going for a cup of coffee. (04/ 01/06, Buenos Aires, Argentina)

24.

Cómo proteger la salud del médico si es explotado institucionalmente en hospitales, prepagas y obras sociales. Los pacientes creen que debemos estar siempre listos para resolver, cómo se modificaría nuestra calidad de vida si los honorarios fueran dignos en relación con nuestra capacitación y experiencia demostrable. (12/01/06, Buenos Aires, Argentina) How can we protect doctors’ health if doctors are exploited by medical institutions: hospitals, healthcare companies and health insurance companies. Patients think we must always be there to provide solutions. The quality of our lives would be quite different if fees were in keeping with our qualifications and proven experience. (12/01/06, Buenos Aires, Argentina)

These examples clearly reveal a negative judgment of the exploitation suffered by doctors at the hands of the healthcare system. In (23), the metaphor ‘doormatting’ (fepuldización), implies a premeditated strategy on the part of the institutions, thus invokes a judgment of social sanction on the institutions (rather than on the doctors) as well as doctors’ own dissatisfaction. The formulation is dialogically contractive: the idea that doctors are exploited institutionally is contractive in that it presents the shared value or belief as universally held in the communicative context. A related institutional phenomenon described in these texts is that of bullying or harassment. 25.

Lamentablemente el mobbing en la Argentina es parte de la cultura del país, agravado por la no vigencia de las leyes y el desafuero de las autoridades. (08/10/06 Buenos Aires, Argentina) Unfortunately, bullying is part of the culture in Argentina, made worse by failure to enforce the law and the impunity with which the authorities are able to act. (08/10/06 Buenos Aires, Argentina)

26.

Quienes trabajamos en salud, independientemente del cargo que ocupamos, nos afecta a diario el mobbing. (19/10/06, Buenos Aires, Argentina) All of us who work in the health services, no matter what position we hold, are affected by bullying on a daily basis. (19/10/06, Buenos Aires, Argentina)

27.

Los patológicos que lo ejercen (mobbing) deberían ser identificados y corregidos [. . .]. (21/02/06, Buenos Aires, Argentina) The pathological [cases] that do this (bullying) should be identified and corrected [. . .]. (21/02/06, Buenos Aires, Argentina)

In (25)–(27) the addressers make inscribed judgments of social sanction on authorities and health system: in (25), through the nominalization impunity. In (26), the writer, through employment of the passive voice, does not mention the actor. Example (27) is particularly interesting because, in the original Spanish, the adjective pathological is nominalized – the same process that takes place in English when talking of ‘‘the injured’’ or ‘‘the sick’’. This replacement of the person by an attribute (known as ‘‘metonymy’’) reflects here the dehumanizing nature of the doctors’ relationship with institutions. From the perspective of engagement, in (25)–(27), the formulation is monoglossic, there is no recognition of dialogistic alternatives, and it is taken for granted that the addressee shares the position. In (25), the adjunct unfortunately contributes to presenting the proposition as a fact. When appraising relationships with colleagues, judgments of negative esteem and social sanction were directed to those in positions of authority within health institutions. 28.

Lamentablemente al tener que justificar una licencia por enfermedad, un colega (es) el que nos tiene que evaluar y es lastimoso ver que aparte de no contemplarnos como tales, hasta se llega a dudar de la veracidad de nuestro relato y estudios. Somos nosotros mismos los que no nos respetamos. (05/11/06, Buenos Aires, Argentina)

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Unfortunately, when we have to justify a period of sick leave, (it is) a colleague who has to evaluate our case and it is pathetic to see that, apart from not considering us as such [i.e. as colleagues], they even doubt the truthfulness of what we tell them and [the results of] our [clinical] tests. It is us who have no respect for ourselves or each other. (05/11/06, Buenos Aires, Argentina) 29.

No sólo no nos cuidamos la salud, tampoco nos respetamos. Es vergonzoso. (12/11/06, Buenos Aires, Argentina) We not only don’t take care of our own health, we have no respect for each other either. It is shameful. (12/11/06, Buenos Aires, Argentina)

In these extracts the adverb unfortunately, and the adjectives pathetic and shameful express a subjective inscribed attitude on the part of the writers, revealing an emotional reaction of dissatisfaction and displeasure. The adjective shameful, in addition, adds a negative judgment of social sanction. The colleagues are condemned for their connivance at the exploitation of their fellow doctors by the health system. At the same time, these adverbs and adjectives present the proposition as a fact, as taken for granted, making the formulation monoglossic. As for economic rewards, most doctors from both public and private healthcare institutions considered their pay to be inadequate. In some cases, this appraisal in terms of negative appreciation was accompanied by a judgment of social sanction because inadequate pay was perceived as part of a more general system of exploitation. In either case, the doctors’ implicit reaction was one of negative affect – more specifically, dissatisfaction. On the other hand, doctors in private practice showed less agreement about what they should charge. Some applied judgments of sanction to patients who failed to pay while others complained that doctors’ fees were inadequate for the work they did – an appreciation in the category of Social Value. As far as the doctor–patient relationship is concerned, some participants in the forum expressed a sort of negative judgment of social sanction with regard to patients who were reluctant to pay, were aggressive or expected the doctor to be permanently available, condemning such behaviour as unethical. This led to dissatisfaction and uneasiness, as can be observed in the following example: 30.

Por supuesto que los médicos nos enfermamos, también somos humanos y no como algunos pacientes creen, que somos máquinas creadas para atenderlos sin derecho a parar. (14/10/05, México) Of course we doctors become ill, we are human too and not, as some patients think, machines created to take care of them without the right to stop. (14/10/05, Mexico)

In (30) the formulation counters an alternative position, that of patients. The lexical metaphor indicates an appreciation of doctors, supposedly made by patients. This metaphor invokes a negative judgment of patients’ capacity: they make wrong appreciations. Indefinite quantification of patients who are wrong (some) presents the assertion as dialogically expansive. On the other hand, in certain cases the negative judgment of social sanction was directed at colleagues who did not understand or did not respect their patients: 31.

Error el que no entiende a sus pacientes. A mí, mis pacientes como me ven lo mucho que trabajo, y como no marco una superioridad con mi actitud hacia ellos, cuando estoy enferma me llaman para que me cuide[. . .] A veces, deberíamos hacer un mea culpa antes de decir que la gente enferma está agresiva, revisemos nuestra relación médico-paciente y seamos objetivos y reales, el mal humor se lo gana el médico que no los respeta [. . .] (01/11/05, Argentina) [The] Mistake is not understanding one’s patients. My patients see how hard I work, and how I don’t try to come across as superior in my attitude towards them and when I am ill they call and tell me to take care [. . .] Sometimes, we should ask ourselves how responsible we are before saying that sick people are aggressive. Let’s review our doctor–patient relationships and be objective and real. Doctors who show no respect for their patients are just asking to be treated badly [. . .] (01/11/05, Argentina)

In this extract the writer’s inscribed negative judgment is clearly directed at colleagues who do not respect their patients, and not at the patients themselves, who are judged in terms of positive social esteem. Utterances in the first paragraph are bare assertions, whereas in the second one, the author makes two commands, the first one is dialogical due to the presence of an adjunct of frequency, and to the use of a modal (should). Yet, the second directive clause is imperative (monoglossic) and the last utterance is also monoglossic, for it is a bare assertion. 4.4. Goals considered valuable In order to identify the goals that doctors consider valuable, we have taken into account the formulation of directive speech acts. It can be observed that doctors may conclude their texts with some advice or recommendation as a logical outcome of the argument (Gallardo, 2005). From the point of view of engagement, we distinguish monoglossic advice (imperative) from heteroglossic advice, expressed through deontic modality.

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Table 1 Recommendations for doctors. Lexico-grammatical expression Imperative (monoglossic)

Number of utterances 1st. person 2nd person

20 (34.5%) 5 (8.6%)

Deontic expression (must, should, etc.) (heteroglossic)

33 (56.9%)

Total

58 (100%)

From a total of 230 messages to the forum, 65 of them (28%) contain directives. In 58 of these messages, writers express directives addressed to their colleagues; 39 of them are related to health care, and 19, to doctors’ habits, i.e. to preaching by the example and being respectful with patients. Only 7 of the messages include recommendations to an indirect addressee: society in general or authorities in particular (in relation with legislation, rights and economic rewards). Even then, texts do not clearly and specifically state who should carry out their proposals. In Table 1 we show the frequency of directives to colleagues expressed in the imperative or in modalised forms, i.e. through modal verbs (must, should), expressions like it is necessary, and conditional clauses that can be interpreted as directives (if . . . then). As we can see in Table 1, around 40% of recommendations were expressed in the imperative mood (monoglossic). Yet, writers tend to employ the first person plural (let’s look after ourselves; let’s try to support each other). Only 8.6% of texts gave the reader a direct command in the second person (colleague, learn how to live). When writers used modal verbs, they also employed first person (we must fight against sedentary life). However, some writers used more distanced forms, such as the third person (doctors must look neat and tidy) or impersonal forms (the most important thing is to start . . .). By including themselves among those who were supposed to carry out their proposals, writers managed to sound less imposing and the relationship between sender and receiver was clearly symmetrical. From the content of these directive speech acts, or proposals for action, it is possible to infer the goals that the writers considered to be valuable. These goals relate to three areas: the practice of the medical profession, doctors’ own health and institutional factors, and can be summarized as follows:  Goals related to professional practice o Considering the profession as a form of public service o Enjoying the profession o Behaving in accordance with the values of the profession o Protecting the doctor’s image  Goals related to professional practice o Giving priority to one’s own health o Changing one’s life style o Spending more time with the family o Having regular check-ups o Recognizing one’s own limitations  Goals related to institutional factors o Uniting to defend doctors’ rights o Bringing about changes in the health care systems o Fighting for respect and to stop being exploited o Obtaining fair economic rewards o Avoiding mistreatment by patients and improving doctor–patient relationships.

5. Conclusion In order to determine how doctors view their health and professional practice, in this work we have used appraisal analysis in an attempt to tease out the multiple evaluative meanings encoded in the doctors’ texts published in the discussion forum, particularly with respect to the doctors’ own health and to factors detrimental to their professional and private lives. We have seen how different aspects of the topics explored in this study tend to give rise to different emotional responses in terms of the three sub-systems of attitude: affect, judgment and appreciation, and how the topics explored are graduated to indicate increased or decreased investment in the value position. We began by analyzing appraisals of the doctors’ professional practice. We saw that when the doctors considered medicine as a job, they generally resorted to appreciation to express a view of the profession as risky, arduous and stressful (see Table 2). From the point of view of affect, this generates a feeling of insecurity and uneasiness. On the other hand, when they appraised the profession as a vocation, two different approaches were found. Some emphasized a vocation of service to the community and remarked the fact that they had chosen the profession. Others, however, suggested that the view of the

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Table 2 Evaluation of professional practice. Lexico-grammatical items Negative Nouns

Negations Adjectives

Work description

Consequences for doctors’ life quality

Doctors feelings about work

Risks, risks of infection, sacrifices, little rewards, cheap labour, multitask Not eating, not sleeping, don’t get much sleep Hard (work)

Stress, suicide, accidents, alcohol and drug abuse, depression, cardiovascular disease, miscarriage, pathologies associated with stress

Anguish, anxiety, great concern

Verbs Positive Adjectives

Worthwhile, wonderful, worth all the effort

Neglect family rush to work, leave home early

Exhausted, demotivated, burned out Suffer

–

–

Table 3 Evaluation of health care system. Lexico-grammatical items Negative Nouns

Evaluation of senior colleagues

Evaluation of patients

Impunity (to act) Doormatting and bullying (of younger doctors)

Negations

Do not respect colleagues

Adjectives

Pathological (their personalities) Shameful, pathetic (their actions)

Verbs

Doubt truthfullness of what doctors tell Exploit (doctors) Punish (doctors)

Think doctors are machines and have no right to stop

Positive

–

Call doctor and tell to look after himself

profession as a vocation favours the exploitation of doctors by the various health care systems and justifies the excessive demands of patients. As regards their own health, the doctors evaluated it from the perspective of appreciation as a very valuable commodity. Special emphasis was placed on mental health, which seemed to be most at risk. When expressing their attitude to the ways in which they neglected their health, the doctors generally applied negative judgments of social esteem (see Table 3). Bad habits were appraised negatively from the perspective of appreciation as detrimental to health. This also carried a judgment of social sanction in terms of lack of propriety. Doctors saw themselves as a bad example for their patients. In analyzing institutional factors, we considered the healthcare system, the relationships with colleagues and economic rewards, on the one hand, and the relationship with patients, on the other (Table 4). Doctors were found to appraise the health care system mostly in terms of negative judgments of social sanction while relationships with senior colleagues in institutions were characterized by negative judgments of esteem and social sanction. Appraisals of economic rewards were more complex. In terms of affect, the doctors expressed dissatisfaction. This was often done indirectly through an appreciation of rewards as ‘insufficient’. But in some cases this appraisal is accompanied by a negative judgment of social sanction because the inadequate rewards are seen as part of a more general system of exploitation. As far as relationships with patients were concerned, some doctors expressed negative judgments of social sanction, condemning the behaviour of some of their patients, from an ethical point of view. These judgments were accompanied by an affective reaction of dissatisfaction and uneasiness. A total of 28% of the texts contained directive speech acts from which we can infer the goals that the writers considered to be valuable: taking care of one’s health, knowing one’s own limits (recognizing that doctors are only human) and receiving greater social recognition for the profession. Writers expressed directives through monoglossic as well as heteroglossic forms. Yet monoglossic directives comprised advice to take care of their own health, and they were expressed in first person plural, including the addresser and thus mitigating imposition. In short, appraisal analysis allowed us to show that these Latin American doctors were very much aware of the problems and risks involved in practicing their profession. However, they expressed different attitudes, ranging from more subjective reactions of affect to more objective positions where there is clear moral condemnation of the health systems and the working environment. If we place the different systems of attitude on a scale of subjectivity, affect is the most subjective (or least objective) and appreciation is the least subjective (or most objective) with judgment occupying an intermediate position.

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Table 4 Judgments about doctors’ attitudes towards their own health. Lexico-grammatical items Negative Nouns

Addiction to work Pride

Negations

Don’t want to consult colleagues Don’t take care of own health Do not give priority to own health Don’t seek medical attention not eating properly Not resting Not spending time with family Have no respect for themselves

Adjectives

Incredible, odd (doctors’ attitude towards health) Cruel (addiction to work) Mistaken

Verbs

Continue working (when ill) Put up with it Consider themselves infallible Postpone check-up Neglect own health

Positive

–

Nevertheless, in all three systems negative values predominated. Only rarely did the doctors express happiness and satisfaction with the profession. Doctors made negative judgment of social esteem towards neglect of their own health, and negative judgment of social sanction in condemning, from an ethical point of view, the health care system, in general, and senior colleagues, in particular. These negative judgments, especially social sanction, observed in doctors’ discourse makes us wonder if this is something specific to the medical profession, or if it is also present in other professions; so it would be interesting, in future research, to examine to what extent different professions associate with different domains of attitude in their evaluations of self and profession. From the point of view of engagement, we can say that when doctors regarded their work as hard and distressful, they showed a tendency to present the propositions as unproblematic, the content was treated as given, assuming that addressees shared this value position. But when they referred to the causes of doctors’ illness, which implied judgments of social esteem about themselves and their colleagues, they tended to acknowledge alternative positions. In other words, when doctors referred to the risks of their profession, they showed an assumption of solidarity at work, and the colleague reader was construed as standing with the addresser. But when the causes of the problem were at stake, and social esteem was involved, addressers, assuming the existence of alternative positions, seemed to try to persuade their audiences to promote a change in the situation. Finally, this study also shows that appraisal analysis can be a useful tool for determining how certain professional groups perceive aspects of their profession and their health based on linguistic evidence of social valuations. Acknowledgements We would like to thank Mercedes Rego Perlas for her translation of part of the article and for her assistance in improving the style of the English version of the text. We are also grateful for the valuable contribution of anonymous referees. References Carpenter, Lucy M., Swerdlow, Anthony J., Fear, Nicola T., 1997. Mortality of doctors in different specialties: findings from a cohort of 20,000 NHS consultants. Occupational Environment Medicine 54, 388–395. Cicourel, Aaron V., 1985. Doctor–patient discourse. Discourse Analysis in Society, vol. 4. Academic Press, London, pp. 193–202. Davidson, Sandra, Schattner, Peter, 2003. Doctors’ health-seeking behaviour: a questionnaire survey. Medical Journal of Australia 179, 302–305. Department of Health, 2008. Mental health and ill health in doctors. Available in: www.dh.gov.uk/publications (accessed 25.03.08). Freudenberger, Herbert J., 1974. Staff burnout. The Journal of Social Issues 30 (1), 159–166. Gallardo, Susana, 2005. Pragmatic support of medical recommendations in popularization texts. Journal of Pragmatics 37/6, 813–835. Halliday, Michael A.K., 1985. An Introduction to Functional Grammar. Edward Arnold, London. Halliday, Michael A.K., Matthiessen, Christian, 2004. An Introduction to Functional Grammar, third edition. Edward Arnold, London. Hood, Susan, Martin, James, 2005. Invocación de actitudes: El juego de la gradación de la valoración en el discurso. Revista Signos 38 (58), 195–220. Hood, Susan, Martin, James, 2007. Invoking attitude: the play of graduation in appraising discourse. In: Hasan, R., Matthiessen, C.M.I.M., Webster, J. (Eds.), Continuing Discourse on Language. Equinox, London. Iedema, Rick, Feez, Susan, White, Peter, 1994. Media Literacy. Disadvantaged Schools Program, NSW Department of School Education, Sydney. Kapur, Navneet, Borrill, Carol, Stride, Chris, 1998. Psychological morbidity and job satisfaction in hospital consultants and junior house officers: multicentre cross sectional survey. British Medical Journal 317, 511–512. Martin, James, 2003. Beyond exchange: appraisal systems in English. In: Hunston, S., Thompson, G. (Eds.), Evaluation in Text. OUP, Oxford, UK, pp. 142–175.

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Martin, James R., Rose, David., 2003. Working with Discourse: Meaning Beyond the Clause. Continuum, London. Martin, James R., White, Peter, 2005. The Language of Evaluation. Appraisal in English. Palgrave Macmillan, New York. Miller, Liz, 2007. Doctors, their mental health and capacity for work. In: http://occmed.oxfordjournals.org/cgi/content/abstract/kqn111v1 (accessed 30.03.09). White, Peter, 2003. Beyond modality and hedging: a dialogic view of the language of intersubjective stance. Text 23 (2), 259–284. Susana Gallardo holds a PhD in Letters from the University of Buenos Aires (UBA), where she directs the Centre for Public Communication of Science and lectures in the Faculty of Exact and Natural Sciences. She teaches courses on scientific writing for both specialized and non-specialized audiences and is a member of the Termtex group, which researches specialized texts. She is the author of the book Los médicos recomiendan. Un estudio de las notas periodísticas sobre salud (What doctors recommend. A study of newspaper articles on health), and has published numerous journal articles. Laura Ferrari holds a BA in Letters from the Faculty of Philosophy and Letters of the UBA, where she is currently an associate professor of Grammar and Lexical Theory. She is a joint director of a UBA Institute of Science and Technology research project on academic communication and is a member of the Termtex group, which researches specialized texts. She has published numerous articles in books and journals.