Erving Goffman revisitedBMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7368.817 (Published 12 October 2002) Cite this as: BMJ 2002;325:817
Thirty years ago, when I was a medical student, I read two of Erving Goffman's books. Asylums(1961) examined “total institutions” such as mental hospitals and prisons and showed how inmates can become degraded and dehumanised. The other was Stigma(1963), which I found harder to read, the core of which was about the persona projected by people who carry a feeling of different-ness (or stigma). Compared with the standard texts on psychiatry we were advised to read, these books, written by a Canadian sociologist, were refreshing, particularly to a student who was less interested in psychiatry than in considering the whole human condition.
In thinking now how doctors interact in working teams, I am re-reading another of Goffman's books, The Presentation of Self in Everyday Life(1959). Since the publication of that book, much has been written about group interaction—most of it favourable, so that initiatives taken by individuals seem to be regarded less favourably than those undertaken by groups, and “doing it in groups” seems to be the preferred method for both undergraduate and postgraduate education.
Goffman uses the analogy of actors performing in front of an audience to show how people working together in groups affect a performance. Although he didn't write about this in the context of health care, his generalisations about the methods used to achieve a performance have given me insights into the functioning of a primary care trust executive committee and a primary healthcare team.
He describes the secrets kept by the team in order to be able to cooperate and maintain a performance. He defines three types of secrets—dark secrets, which may never be disclosed to the audience (rest of trust or patients); strategic secrets, which are disclosed when the work is completed; and inside secrets, which define the members of the group but which are neither dark nor strategic.
The concept of secrets leads on to group behaviours that are condoned but not desirable. “Treatment of the absent” is what teams do when away from the “audience.” A primary healthcare team may use derogatory terms to describe patients when talking in a team meeting. Another thing teams can do he calls “team collusion”: teams may give out messages that are misleading so that they can keep up their outward appearances.
Throughout the book he uses examples ranging from Queen Victoria to sales techniques to keep up interest and make difficult ideas easier to grasp. At the end of the book, he tells us to remember that all the world isn't a stage.
Books which help to rewrite our view of reality are worthy of recommendation to others. Revisit Erving Goffman.
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