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Remember, Appearances Can Be Deceiving

In histology, we are taught that ‘structure dictates function.’ It is a simply stated phrase that tells medical students to think about how the structure of a tissue determines what its role is in the human body. Does it secrete substances? Is it involved in mechanical abrasive stress? Does it have a large layer of muscle? Of collagen? Many ducts? Extensive folding of the epithelium? These questions, answered entirely by staring at a slide of tissue under a microscope, can tell you where in the body the sample is likely from and what it does, essentially using visual clues to determine properties. In anatomy, an identical idea is behind identifying and understanding the function of the various muscles in the body. The shape of the muscle, its length or thickness, the breadth of its tendon, and where it originates and inserts can tell you exactly what it does, and what it would not be able to do if it were injured. Once again, this momentous determination of the all-important medical correlation to the subjects we study in medical school can be almost entirely understood not on the basis of memorization, but on the basis of visual examination.

Even after medical school itself, a large component of medicine is seeing the patient physically and examining visually. This is the reason why a patient must be seen in an office visit before a medication is prescribed, instead of being able to obtain a prescription based on symptoms alone. It is not an issue of trusting the patient about what symptoms they have experienced, it is simply because how visually sick a person appears can oftentimes tell the physician a significant amount about the current severity of the condition or what may be involved.

Unlike this underlying principle of medicine, we are taught that in life, we should generally avoid determining properties of something from visual examination alone. “Don’t judge a book by its cover” literally summarizes this idea: that one can never know the depth or meaning of an object simply from its outward appearance. A book with a plain or ugly cover may be absolutely riveting, while one with a beautiful and intricate cover may be an uneventful and unenjoyable read. When applied to human beings, this practice is known as making judgments. It is a behavior that we all do to various degrees, but recognize as generally frowned upon. When we see someone who is dressed a certain way, many of us may automatically make an assumption, or possibly even just a thought or comment about the person: what they do, what their morals or values are, or what they may be like. What these comments ultimately address is a natural tendency for humans to be concerned with and curious about the why behind other people’s lives: their decision making, decency, actions, and behavior, among other things.

Social behavior and motives are highly complicated factors that devour the entirety of the field of sociology, from birth and cultural ties to life experiences and individuality. Understanding the ‘recipe’ that comprises each individual and how it determines their behavior is a task that fascinates some, and yet is undoubtedly apparent in every single person.

We judge. We as human beings are judgmental. Sometimes, being judgmental can lead us to make inappropriate and disrespectful assumptions, but other times it can contribute to us making decisions rooted in intuition and internal cohesiveness to one’s own values — the latter of which may be very important to many people. We judge whether we want to stop in a city to get gas or continue on to a more comfortable and less worrisome area. We judge whether we want to proceed with treatment in the course of a patient’s diagnosis, a decision which sometimes cannot be entirely based upon lab values, data, figures and statistics. We judge risk versus reward in considering taking a medication: whether to try a novel drug with unknown long-term side effects or stick with a safe but possibly less effective older drug. But most shockingly and silently, we judge each other. We may judge each other’s behavior for ‘right’ or ‘wrong’ against our own morals and values. We may judge each other’s appearance for appropriateness, or deem it as a reflection of one’s personality, thereby assuming a person’s likely behaviors. These judgments can be made unknowingly, and may well result in unintended consequences for those involved.

In medicine, judgments in the social interaction context primarily originate from those of appearance: what a physician looks like, and what a patient looks like. It is these judgments that worry me, as their extensive effects could be detrimental to the health care of a person, or a society at large. When I thought about histology and the importance of visually labeling structures, I wondered if this same technique — which comes naturally to most students once we are told the names and characteristics of structures to look for — also comes naturally to people in other applications, such as social and professional interactions. Judging a tissue based on appearance is one thing, but judging a physician based on appearance and determining his or her likely behavior is another.

I wondered if a physician’s hairstyle would effect how new patients would think about him or her. Would patients judge a physician who had a mowhawk as less competent than one with a more traditional haircut? If so, why? Does a physician’s personal decision and taste reflect his or her ability to interpret and analyze medical issues? Obviously, if I change my own hair color or cut, or obtain a piercing, I know no more or less than I did before; it doesn’t change the way I study, or how much I study, or how well I know medical material. So why then would the same behavior change the way a patient views me, if it in fact does? And if it does, does it imply that physicians must refrain from changing their physical appearance in ways that might disagree with the personal tastes and views of their patients, so as to avoid negative judgments of their abilities and barriers to effective treatment?

A physician is undoubtedly thought of as a very respected and professional figure throughout the world. The white coat has historically been worn as a symbol of trust, respect, and professionalism. Is it this archetype that causes the development of a link between physical appearance and personal decision making? Between personal decisions and professional decisions? Would a very obese physician be trusted less by patients? Would a physician with tattoos down his or her arms showing from under that symbolic white coat be judged as any less competent than the physician without them? What about one with streaks of hot pink and purple in his or her hair? Is it an issue of professionalism and how a physician should appear, or is it one of being concerned or bothered by the personal tastes and decisions of one’s physician as a reflection of their ability to make sound health care decisions in practice? If these judgments are made, the question is whether we as humans acknowledge that we are making them, and whether we view them as situationally-appropriate, or admit them as unknowingly done and in need of modifying their frequency.

To examine these questions I developed a simple survey consisting of just three questions, and asked 50 individuals for their responses. Most of these individuals were undergraduates at the university I attend, while some were adults approximately 30 to 50 years of age. When asked whether learning of an event in the personal life of your doctor that was not congruent with your own morals would negatively affect how you viewed him or her — such as an affair — 12 out of 50 said ‘yes,’ 31 said ‘no,’ and seven were ‘not sure’. When asked whether they believe that the moral reasoning of a physician as seen in his or her personal choices and private behavior would extend and be similar to that which the physician applies to his or her profession: 26 said ‘yes,’ 10 said ‘no,’ and 14 were ‘not sure’. And finally, when asked if seeing a facial piercing on your physician would negatively impact your view of him or her in respect to professionalism and their ability to care for you, nine said ‘yes,’ 30 said ‘no,’ and 11 said ‘not sure’.

These results, while only grazing the surface of social judgments in health care, were valuable to me in discovering what a small section of young adults believe regarding these questions. It is eye-opening to think that approximately 50 percent of this small sampling does indeed think that the decisions I make in my personal and private lives directly link to the same reasoning I would use in my professional practice of medicine. I myself am not sure if I feel my professional reasoning is separate from my private decision-making, or how the two would parallel if they were linked, but it certainly presents to me as a topic that warrants further research. Is it acceptable that 20 to 40 percent of this group might negatively judge a physician for a facial piercing? Would that percentage change for a group of individuals 50 years and older, who may have more conservative or traditional views of respectful appearance and personal tastes? Would a physician feel uncomfortable knowing that a significant number of his or her patients judge his or her skill in care giving by a facial piercing? To me, these questions are pertinent in medicine, where mutual respect is very important to effective care, and where inappropriate or negative judgments may well hinder that care.

Jennifer Evan Jennifer Evan (6 Posts)

Contributing Writer Emeritus

Indiana University School of Medicine

Jennifer Evan is a 2011 graduate of Purdue University with a degree in liberal studies and a minor in chemistry. Having interests in a range of subjects, she enjoys participating in a variety of fields and experiences, from art and music, to writing and research. Her professional interests include international medicine and culture, while her academic passion is neurological studies. She is a member of the Indiana University School of Medicine Class of 2016.