INTRODUCTION

In 2002, the former junior doctor turned writer Jed Mercurio published a novel called Bodies. Written in the first person, the book graphically describes the experiences of a newly qualified doctor. The dominant subtext of the book is the emotional intensity that characterizes hospital life. The book details the gamut of different emotions experienced by the protagonist: fatigue, fear, hurt, guilt, lust, intrigue, disgust, anger, frustration, amusement, elation, sadness, and so on. The world beyond the hospital's interior feels alien to him, and anyone who is not a part of the inner sanctum are referred to as 'civilians'; they cannot possibly comprehend the bizarre world which he inhabits. The book was also serialized in a UK TV production and is one of the huge number of television programmes that have attempted to portray the lives of doctors over the years. From Dr Kildare in 1961 onwards, the popular media in both the UK and the USA has long been replete with such shows: Dr Finley's Casebook, General Hospital, Emergency Ward 10, Causality, Holby City, St. Elsewhere, Peak Practice, ER, Cardiac Arrest, Doctors, Green Wing, House, Grey's Anatomy, Nip/Tuck, and so the list goes on. Among the public then there seems to be an almost endless fascination with the experiences of doctors: their emotional responses and ways of coping with their patients, their colleagues, and their working environments. It is perhaps ironic therefore that, in comparison, medical sociologists have paid rather scant attention to doctor's emotional responses to their work.

Hitherto sociological analyses of the medical profession have tended to portray doctors as relatively unfeeling: an elite who are inclined to make unsubstantiated claims to altruism (Graham, 2006). There is some truth to this. The training of doctors has tended to inculcate a biomedical worldview, which is said to create a professional rationality that eschews feelings, emotions and sentimentality. So, for example, in a paper exploring the 'Hidden values of biomedicine', Kirmayer (1988, p.63) argues that doctors cultivate a rational and objective approach to the care of patients and certainly do not reflect on their own frailties. 'Physicians have exaggerated standards for rationality' he writes, 'based on distancing from bodily feeling and emotion'. Furthermore, he maintains, the 'physicians attention is not focussed on the patient but on the "it" of disease' and they 'expect that giving a biomedical explanation to the patient will reassure, calm and satisfy them'. Nearly two decades on James and Hockey (2007, p.41) comment that the dominance of the medical paradigm often means that practitioners views are likely to be at odds with the more subjective and variable responses to illness of their patients. The alignment of biomedicine with the profession of medicine exacerbates the tendency to portray doctors as relatively lacking in feeling. For example, it has been argued that there is 'an inverse law of status and skill in emotional labour' (James, 1992, p.503) with doctors orchestrating care in a rational way, while nurses and health care auxiliaries carry out the bulk of the emotional mopping up (James, 1989; Hearn, 1987).

So under these interpretations, the role of the doctor is one in which feelings occupy a cognitive position in opposition to rational science; the very notion of feelings potentially involves vulnerability since the whole edifice of biomedical science, and attendant evidence-based practice, presupposes a form of expertise which – to use the terminology of Giddens (1990) – is 'disembedded', from personal relations and local situations so that the abstract system (of biomedicine in this case) is maintained across place and time. Such abstract systems have little room for feelings or emotions. However, there is a tension here, because at the same time some forms of emotion are necessary characteristics of medical work because patients have to feel that they can provide authentic narratives of their 'troubles' to a professional in whom they trust and can invest with 'expertise'. The negotiations of relationships and feelings are dependent on the agency of individuals in the context of particular times and places. These negotiations are circumspect and bound by regulations intended to ensure trust in the abstract system of medicine; however, they are negotiations that can always potentially be undermined by the enactment of feelings such as love, jealousy, desire, hate, indifference, annoyance and so forth, that always enter into human relationships.

Given this essential ambivalence about emotions in professional medical work it is perhaps not surprising that there is a relative 'silence' about feelings when doctors talk to researchers, or indeed when researchers talk to doctors. Feelings are risky in that they may easily be conceived of as 'unprofessional' (as a threat to the abstract system of medicine). Perhaps this is why sociological studies of doctors have tended to foreground the more structural features of the role rather than offering up any sustained treatment of the emotional life of doctors?

Whatever the reason for this empirical lack, the analytic consequences have been quite profound. Certainly, since the 1960s being attentive to the patient and being 'self aware' are qualities that have been increasingly valued in medical training and practice. Reflecting on such developments Gothill and Armstrong (1999) trace the consequences of such discourses of emotional sensitivity on doctoring. They conclude that these debates have given rise to a 'triad of entities': the 'patient's body', the 'patient's mind', and the 'doctor's mind'. However, a fourth entity, what they describe as 'the anatomy and physiology of the subjective 'doctor's body' is yet to be fully elaborated' (Gothill and Armstrong, 1999, p.10). 'At present the body of the doctor is a sort of proto-space' they continue, 'on to which can be projected the pain of patients or organisational strain'. Although they note the growing number of studies of vulnerability, stress, substance abuse, and suicide, doctors, unlike patients, have no terrain, no physicality upon which these external agents act. Their distress can only be defined in terms of their inability to work; yet accounts of doctors' pathology seem strangely incomplete without an analysis of the effect of this work on their own bodies' (Gothill and Armstrong, 1999, p.10).

The aim of this paper is to provide some small corrective to this situation. We are interested to begin to flesh out the relationship between the 'doctor's mind' and the terrain of the emotions inscribed on the subjective 'doctor's body'. We do this by de-emphasizing the structural roles of medical professionals and explicitly turning our attention to an examination of the 'human side' of the 'occupants' of these roles in order to ask the seemingly very personal question: how do you feel doctor? Seemingly personal but in fact the individual responses must also be socially contingent. In his seminal paper on mundane techniques of the body Mauss (1973, p.70) describes techniques such as walking, sleeping, and swimming – in order to convey the ways in which people 'know how to use their bodies'. We suggest that what we report on here are 'techniques of feeling', which are at once personalized and social responses to a particular set of circumstances. We propose that although doctors vary in terms of their concerns, their persona and of course their gender, age, race, and position in the medical hierarchy, the multiplicity of feelings they describe form the essential features of 'being' and 'doing' doctoring in the early 21st century in the UK National Health Service.

In doing this we are also responding to Graham's (2006) paper recently published in Social Theory and Health, which has called for 'a more compassionate perspective toward medical practice'. Graham argues that such an approach is necessary if we are 'to understand more fully the experiences of doctors and to account more accurately for the role of the medical profession in society' (Graham, 2006, pp.56–57). A compassionate approach, she argues, requires at least three elements, a need: for empathy to gain identification with the viewpoint of the subject; to explore the contribution that personal, emotional, and professional characteristics make to medical practice; and, to locate these findings within broader socio-structural contexts. But surely such studies must exist? There are certainly many studies of the views of doctors. However, they tend to be focussed on quite specific issues such as particular policy initiatives (Berrow et al., 1997; Harrison and Dowswell, 2002), training and socialization (Becker et al., 1961; Atkinson, 1981; Fox, 1989), or dealing with the uncertainty of medical knowledge (Atkinson, 1995; Fox, 1980). Furthermore, in contrast to the massive body of work that attempts to grasp lay people's understandings of and feelings about, their experiences of health and health care (Blaxter, 2004), parallel work on doctors is meagre by comparison (although notable exceptions include Lupton, 1997; Cassell, 1998; Jones and Green, 2006). So our view is that the broad thrust of Graham's (2006) argument is correct. Her analysis of doctors' responses, to what she refers to as the 'corporeally unpalatable' instances of male rape, dental care, and feticide, provides an important empathetic appreciation of certain specialized aspects of medical work. We, however, would like to extend her findings, albeit in a rather modest way, by beginning to describe doctor's emotional responses to their work in a series of more mundane, everyday health care settings.

As noted above, an important vein of medical sociological research is that which understands patients' experiences of illness, much of which benefited from applying symbolic interactionist perspectives (see Charmaz, 2000). Such perspectives presume that our notion of who we are is constantly remade through social interactions and interpersonal relationships. In the light of our attempt to counter the structural analyses of the medical profession, it is salient that we take a perspective that highlights agency; one that reminds us our notions of self are embedded in social networks and relationships and are not simply prescribed.

Within medical sociology there is also considerable literature on the management of emotions in the health care settings – although saliently not much in relation to doctors – however, here we are less concerned with 'emotional labour' as such and more interested to try and identify doctors emotional responses or more particularly their feelings in relation to their day-to-day encounters and experiences. Nevertheless, Hochschild's classic book on the topic is useful here because she includes an attempt to classify different emotional states in an appendix titled 'Naming Feeling' (Hochschild, 1983, pp.233-239). In this she provides a table which comprises a list of 'emotions' and how they might be operationalized – which in turn relates to a person's aspirations, achievements, and positioning of self in relation to events. Her list of named feelings includes – among others – anger, contempt, frustration, guilt, nostalgia, sadness, and shame. 'To name a feeling' she suggests, 'is to name our way of seeing something, to label our perception' (Hochschild, 1983, p.233). What we want to do here is describe some of the feelings expressed by doctors when talking about their work in order to begin to flesh out the terrain of the proto-space of their bodies described above.

THE STUDY

The data reported on here derives from in-depth, semi-structured qualitative interviews carried out by the lead author between mid-2005 and mid-2006 with 52 doctors (32 men and 20 women) working in hospital and primary care settings in the North of England. In-depth interviews enable participants to reflect on their practices, histories, and identities, allowing people to 'account for themselves' (Gilbert and Abell, 1983) and are therefore a valuable resource for eliciting people's reflexive identities (Bourdieu, 1999). Our aim is to explore the doctor's recollections of their day-to-day working experiences and, as such, we are not necessarily tapping into any realities about what they do and how they actually go about their work, but rather their interpretations of it. All of the doctors talked candidly and in a highly engaged manner. Saliently, a number of them talked about how much they enjoyed the interview and that they welcomed the opportunity to reflect upon their work, with some claiming that it helped them to clarify how they felt about their current circumstances and aspirations for the future.

The sample was selected purposively in order to capture a diverse range of perspectives; we sought to recruit doctors from a number of different health care settings and to ensure suitable variability in terms of: age, gender, seniority, and ethnicity. Twenty of the 52 worked in a large teaching hospital serving an ethnically heterogeneous and predominantly socially disadvantaged area (identified as A1–A20) and 27 worked in a smaller (formally district) hospital serving a more affluent predominately white population (identified as Z1–Z29). Five worked in General Practice with both urban and rural locations being represented (GP 1–5). Thirty-nine were consultants and eight were training grade doctors (ranging from Senior House Officer (SHO) through to Specialist Registrar (SR) grades). In the whole sample five had trained overseas and six were from minority ethnic groups. The age range of the sample spanned from 25 to 65 years, with the youngest consultant being 35.

The interviews covered four broad areas. First, their education and career thus far, second, their current work, third their views on the current state of the medical profession, and finally, what they thought the role of doctors – as individuals and as a profession – should be in the 21st century. The interviews lasted a minimum of 1 hour, but with the majority lasting 2 hours or more. All of the interviews were recorded, transcribed, and entered into Atlas.ti (a qualitative data computer package) for analysis. The data were coded both descriptively and analytically.

HOW DOES IT FEEL DOCTOR?

So what are doctor's responses to various aspects of their work and how do they feel about their encounters with patients, relatives, colleagues, and their place of work? A recurrent theme was that working with people, seeing them get better, supporting them throughout difficult times, doing something for the benefit of humankind was gratifying. I do perceive my job as useful, whereas I watch the news and there'll be something about bankers, and I'll think that's a complete waste of time, we could kick them all out and it would make no difference at all. Whereas if you got rid of all the dustmen, typists or doctors it would make a big difference. So I do perceive myself as socially useful and I do derive some satisfaction from that. I have a lot of patients I enjoy talking to because they are interesting and the core bit about medicine is the interest you have in the human condition. And I think I am perfectly adequately paid, I have no gripes at all about my payment (Z009, Consultant Male, 40s).

Similarly, a younger SHO enthuses: I love it, there are frustrations, but there are frustrations in every job. Every job has boring bits. My job is so special; you can make a difference. Every day is different, so you meet some amazing people, some nasty people. I absolutely love my job and I wouldn't change it for the world (A019, SHO, Female, 20s).

Many said that they felt that they were in a privileged position; they were given access to people's private and personal lives, and on occasions influenced them. Participants often appeared diffident when expressing these views noting that it sounded rather trite – 'it sounds a bit pathetic doesn't it' – they would say, even though for some these feelings had motivated them to enter medicine. Living in a context where media culture is saturated with emotional crises, the expression of such positive feelings can appear hackneyed and distanced from authentic emotion, thus making the reporting of such feelings difficult. Nevertheless, overwhelmingly throughout the data working with patients appeared to give rise to the main source of fulfilment and sense of achievement.

Feelings in relation to patients

Fostering 'good' relationships, learning about people's lives, their families, and their illness trajectories were repeatedly reported to be a source of satisfaction and pride. Such responses are perhaps hardly surprising as these accounts invariably draw upon a range of discourses, not least prevailing societal and professional expectations of 'good doctoring' (GMC, 2006). Even so the emotionally charged nature of exchanges with patients – the 'human' side of their work – was reflected upon during the interviews, as we hear from a radiologist who was reflecting on his career choice. I like the patients, I like the emotion that goes with it; you know, the tears and the happiness. Compared to a lot of the other parts of radiology it's significantly more emotionally charged. There's a good proportion of tears in that clinic and they're not all nasty tears, you know, some of them are tears of joy. But I mean it's, it's a good tiring hard work session. But I mean that wakes me up and sort of gets me started, you know it's a 'nice' tired. It's, you know, it's like climbing to the top of a mountain and sat there and thinking Christ I've done that; it's an 'achievement' sort of tired (A007, Consultant, Male, 30s).

Most doctors recalled particular patients who they felt had touched their sensibilities. Recollections of their patients were not simply of passive objects – as bodily containers of disease – as the biomedical paradigm might imply. On the contrary, they had enduring memories of their patient's lives, their families, their circumstances and how some of their patients had coped with their illness experiences. Yet, retaining their 'rational self' at the same time as feeling such emotions was viewed as an important aspect of being an effective doctor. You move the bar up in terms of what upsets you, because an upset doctor doesn't do anyone any good. Only a small group of patients make it over that bar to upset you and I think that's still important otherwise you feel as though you're completely dehumanised. But I can remember people, I can remember what their scans look like, what they were like, what their son was called, how they were. A group of patients and it's probably growing all the time, who've got to me. They kind of live with you really and you think by knowing them, and by getting to know them, by trying to help them it's made me better and I guess it's a kind of selfish approach isn't it? (A011, SR, Male, 30s).

Doctors reported that the majority of patients are grateful and on occasion expressions of gratitude could be humbling. In some specialities, for example, oncology, paediatrics, and renal medicine, cards and letters were displayed which contained moving expressions of appreciation. Gratitude, or being remembered by their patients, was evident even when contact was episodic. In the following quotation, a consultant talks about a patient she sees only once a year for an annual review, but who had been admitted to hospital after a fall. This is worth a million pounds or more. I got a referral from the surgical ward for one of my ladies who is almost 91 and I see her once a year. But she fell and so was brought in. The orthopaedic surgeon had said 'transfer her to geriatrics and get her a nursing home.' This is a lady who is independent! I went to see her and she was lying in bed, which is always a bad start, and when she saw me, she said 'my doctor' and she put her arms out and gave me a hug and I could have cried (Z013, Consultant, Female, 40s).

Saliently, in instances such as these doctors could recall their patient's circumstances with impressive detail and clarity – even those they had not seen for many years.

Wallace and Lemaire (2007) in a study of North American physicians found that while the emotional aspects of working with patients was a major source of well being it was also, concurrently, one of the main factors that eroded it. Certainly 'demanding', 'rude', 'difficult', and 'ungrateful' patients generated feelings of 'anger', 'bitterness', and 'annoyance'. Feelings of 'hurt', 'frustration', and 'resentment' were said to be engendered by such interactions with patients, as is illustrated in the following quotation. A bad day that really gets under my skin will be one where someone walks in and says 'I don't want to see you' just outrageously rude to me, sometimes I'll try and win them over. People that are unnecessarily rude (Z020, SR, Female, 30s).

Patient's relatives too represent a particular 'headache'; when talking about them, the verb 'demanding' was used repeatedly. There appears to be something of a consensus that the expectations of patients and their relatives are changing, they are said to be 'better informed' and make use of resources such as the Internet that can be time-consuming in consultations (a point we return to in our discussion).

Feelings in relation to criticism from patients

When talking about formal complaints lodged by patients terms such as 'vulnerable', 'angry' and 'bitter' were common (see also Allsop and Mulcahy, 1998). Doctors felt that they were invariably 'trying to do their best' and so found it upsetting when they were then subject to criticism, which in turn could jeopardize their careers. Being in receipt of a complaint could result in loss of sleep, strained relations with family, insecurity, and sometimes, when an error had been made, deep feelings of shame and regret. You don't sleep, well two things, I mean you know you've got it wrong, you have a death and you know it's technically wrong. Fortunately it's only about once every two or three years but it still knocks the shit out of you, cos you're ashamed inside (Z019, Consultant, Male, 60s).

Even in those instances where doctors felt that the complaints were not necessarily justified this could lead to a questioning of themselves. As one put it 'it makes you question if you're a good doctor or not' (A015, SR, Female, 30s). Maintaining sufficient confidence to carry out complex procedures and make decisions in the face of the clinical uncertainties, however, was something that one had to learn to live with in medical practice – 'one just has to get on with it'. As we noted in the previous section there is sensitivity to the need to balance ones rational and emotional responses to everyday practice.

Feelings in relation to clinical work

Modern bio-medical work rests on the clinical method – the search for the correct diagnosis and its subsequent management and treatment. Many of the doctors reported that they still found this exciting. Doctors talked about 'getting a buzz', 'deriving pleasure', and the enduring 'satisfaction' that was derived from solving a diagnostic conundrum or finding that an initial hunch about a diagnosis was later found to be accurate. The process of piecing together the data – listening to the patient's presentation of their symptoms and clinical history, requesting appropriate investigations, assessing test results and so on was intriguing and stimulating. Cases, which were not what as they first seemed, present cerebral challenges. The opportunity to share such challenges with colleagues could make the intellectual endeavour rewarding. Similarly, the technical procedure successfully carried out and the complex surgical intervention effectively conceived and executed could be gratifying (for a good fictional representation of this, see Ian McEwan's (2005) novel, Saturday).

But of course there is always scope for error and human frailty – and most were sensitive to the precariousness of their work. Alongside the intellectual stimulation, pride and achievement sit feelings of shame and regret. One consultant recollected idly reading – for historical interest – a now dated medical book when he happened upon the details of a rare disease. He realized that a patient he had treated some years earlier, who had since died, may well have been suffering from that particular condition. 'Perhaps I got it wrong', he reflected, 'when I read it, it was like being kicked in the stomach.' Could it be that if he had made a 'correct diagnosis' the patient might still be alive? Facing the possibility that one might not have done the 'right thing' is something that doctors' feel they encounter early on in their careers. As this one recalls: It was a great shock when I saw a patient who was very sick who was admitted to the ward and I was treating them as I thought best and they died. Nobody else had seen the patient and I thought afterwards: How, how do I know? Was I right? Or had I completely missed the diagnosis? Cos nobody had been there, there wasn't the time for somebody else to come and look and check (A005, Consultant, Male, 50s).

Working with supportive colleagues can provide a buffer to these precarious aspects of medical work, the quality of relationships with other doctors provides comfort and security for some. There is something you get from being at the coalface that you don't get from being formally taught; I often say that my worst mistakes have been my best experiences. That's true not only of the techniques of learning to do things better, but it's when it goes wrong, because it does go wrong for all of us sometimes. If you put a hole in someone's gullet, unless you've made a hole in someone's gullet as a specialist registrar, you don't know what to do. Sadly I had a perforation a month ago, I'd done that once as a SR under the supervision of my consultant and therefore I knew as soon as I'd done it what I'd done, what I needed to do next. It's not just knowing the steps, it's knowing how to cope with it on an emotional and psychological level. Unless you've got someone senior to guide you through the hoops I don't know that people will know what to do. This is one of the important things, people will just fall to pieces if they've never seen it before, and that to some extent can happen. To me that's an argument for making the consultant structure more hierarchical. I've got a lot of support, I think we are very lucky as a group of [named specialists] because we are a nice group of human beings and that is not a universal truth in medicine (A006, Consultant, Male, 30s).

Feelings in relation to transformations of medical training

As well as describing the experience of making and coping with a mistake this doctor is also alluding to organizational changes that have been taking place to the context of medical work (see also Nettleton et al., 2008). He alludes to the demise of traditional hierarchal structures and to the reforms in medical training which, in concert with the reduction of working hours, means that doctors may have less 'hands on' experience prior to becoming consultants. There was a view that there is a growing gap between doctor's formal knowledge and their practical experience. Training grade doctors no longer work the on-call rotas, which require them to be on duty on consecutive days and nights, but instead work shifts. While acknowledging that this is much more humane there is also a worry that the trainees lose out on clinical experience, continuity of care for patients, and the support and camaraderie that was said to be found among doctors working in such physically and emotionally demanding conditions. Recalling her experiences of doing a 'one in three' rota this consultant suspects that the current juniors are not gaining sufficient experience. In terms of getting your clinical experience up to speed they just don't get it now and they don't get the continuity either...The junior doctors aren't getting the experience they used to do, they'll probably see as much in three weeks as I used to see in one. And the problem is they're doing shift systems so they don't have ownership of the patients...If you're admitting someone at nine at night and you're clocking off ten hours later or whatever, then the day after you're just doing the same and admitting another load, you don't get the continuity, you don't see how people are managed and you don't learn (Z004, Consultant, Female, 30s).

Endurance, fortitude, and staying power had served these doctors well and this, they feel, distinguishes them from the newer generation. As this consultant recalls, not only did they work long hours but they also worked independently. I remember the first few sections that I did being completely drenched in sweat. Then picking yourself up and getting on with it; you were in a system where you didn't call a consultant unless it was absolutely appalling, you managed and you got your experience that way. I don't think I did anyone a disservice by doing that, but you learned very fast. Whereas now I'll get called for all manner of things that I would never have called for help for (Z020, Consultant, Female, 50s).

Consultants, when recounting their early careers, thus invoke feelings of nostalgia and these memories of becoming a doctor seem to be critical to their identity. McDonald et al. (2006) found that doctors present nostalgic accounts in order to rebuff political discourses of 'modernization', but we suggest that they can also be interpreted as an emotional response and indeed nostalgia is one of the feelings 'named' by Hochschild (1983). Such remembrances of working long hours, extreme fatigue, and carrying out new procedures without guidance in the middle of the night were often described in affectionate terms. For example, one consultant reflecting upon his time doing his post-registration surgery described it as 'great fun'. He recalled one stint as a house officer when he apparently did '60 appendectomies' with pride. This was a time when junior doctors lived, worked, and played together. When they cooked together, watched 'Neighbours' (a TV soap opera) together, slept together, drank together, and when they whinged together. When they 'worked and played hard'. We had a mess and we all lived in. We used to just cook food and you would sit and whinge or play bridge, because we were a group, there were always people around. It's not social, it's the support aspect; you need support because it's hard. You're a junior house officer, you haven't got that much life experience and someone comes into casualty arrests and dies in front of you, they might not be any older than you, especially if they are a road accident, and you need someone to go and say you've had a really crap day (Z21, Consultant, Female, 50s).

Feelings of nostalgia, however, were not universal. Lost opportunities and memories of exhaustion for some were tinged with regret. For example, one consultant who despite expanding upon the fulfilment he derived from his work reflected: I feel I lost my twenties and early thirties slaving away and in hindsight I could have done other things with my life and that is one of the biggest bits that gets me (Z9, Consultant, Male, 40s)

Nevertheless, one gains a sense in the data of a lost era in medicine, with regret expressed that the current cohorts will have very different experiences and are likely to have lower levels of competence, commitment and are likely to be less 'colourful' characters – who for good or ill – were to be found in medicine. One aspect of the nostalgic discourses was talk about the mavericks and larger than life characters that were to be found in medicine. Outrageous and scurrilous behaviour was recalled with affection but thought to be a thing of the past. Very likely it was ever thus. However, it may also be that relative shifts in power between managers and professionals and transformations of regulatory practices and accountability serves to alter the psyche of doctors (Power, 1997). Relatedly many of the older doctors in our cohort will have seen shifts in norms and values pertaining to socially acceptable behaviour with overt sexism, racism, and homophobia and so on now being officially unacceptable.

Three repertoires or scripts used by doctors can be identified from the reflexive accounts of doctoring we have gathered. First, there is the traditional ideal of the hard working, committed, experienced, colourful but caring doctor who survived the gruelling years of medical training. Then there is the modern professional who appreciates the need for a work/life balance, who is dedicated and well organized but appreciates the value of being a more rounded individual. Finally, there are those (often younger) doctors – who although we did not meet any in the flesh, figure large as a rhetorical foil, or plot bolt, in the accounts of the doctors in the sample – with only partial 'hands on' experiences, whose commitment appears to be questionable and who seem to take an instrumental approach to their training.

Feelings in relation to colleagues

Within hospital settings the scope for informal support and the opportunities for dissoluteness were thought to be on the wane. Some doctors lamented the demise of the hierarchical 'firm' structure – in spite of the scope for patronage and opportunities for consultants to humiliate their juniors. Relationships between consultants and juniors are now more prescribed as the former have to carry out more 'objective' assessments of their trainee's competences. Relationships may be becoming formalized and impersonal. The relationship with juniors and ourselves has changed because we much more explicitly assess their competencies. You know, they rely on a more objective sense of how they're doing in order to move on in their careers. So that relationship has changed not hugely but it's changed a bit. It's not just you [the consultant] any more; it's a broader group of people who will collectively make the final decision. It doesn't rely on one relationship. So their behaviour, the junior doctors' behaviour has changed as a consequence. There is much less kow-towing now than there used to be, which is more comfortable. Though there's still a bit of it to be honest (A001, Consultant, Male, 40s).

The informal spaces where doctors could meet are disappearing; the consultant's dining room, the doctor's mess, and the (in)formal social events. There are few 'backstage' settings in hospitals with only some consultants having their own offices (others share with other consultants and/or their secretaries) and non-consultants having very few places into which they might retreat from the public gaze. This is in marked contrast to doctors working in general practice who reported having ample meetings and discussions with their colleagues and who are only 'front stage' for clearly demarcated periods.

While doctors were witnessing a demise of opportunities for informal social contact and support, the policy agenda has included a number of initiatives to enhance formal contact by establishing team meetings and programmes for professional development – which aim to bring practitioners together. Such opportunities to formalize the exchanges with colleagues were generally valued and when they worked well could be a source of enjoyment and support. This overcomes the old style mode of communication about clinical matters such as ringing a 'friend' or chance meetings in the corridor. Feeling supported in ones working environment, however, still seemed to be something of a haphazard affair. All the doctors who felt supported in their working environment described themselves as 'lucky' – because they all had experiences of isolation and in some cases bullying and discrimination.

Some doctors had witnessed overt discrimination and bullying at some point in their careers, however, many are dismissive about it. Cassell (1998) also found resistance to the idea of overt sexism in her ethnography of women surgeons and she suggests it is because the notion is too disembodied. The processes of 'doing gender' and negotiating difference are altogether subtler and so participants in these social processes cannot recognize them. Furthermore, in relatively closed institutional settings it can easily become normalized, as this woman who did experience and observe overt sexism explains. I don't think it's just the blokes that do the bullying, the women are just as bad, and they just do it in a different way. Blanking your colleagues, undermining them, the amount of personal criticism I've heard in conversations I've had with individuals who've been talking about other individuals, completely unprofessional, it goes on all the time as if it's normal (Z016, Consultant, Female, 40s).

Cassell argues that women in surgery are in effect 'matter out of place' (cf Douglas, 1966) and so negotiating and maintaining 'face' requires one to go along with the bravado as this women surgeon explains: People make sexist jokes all the time. I'm the only female in the department, and when we had a consultants meeting the other day the guy said 'chaps, chaps, quiet' and I went 'chapesses as well'. You just have to make a joke over it, if you make a joke out of it it's alright because a lot of the time they're not meaning to be sexist, but occasionally they are and you do get people who mean to be sexist. You do have to be persistent, more competent than your peers; otherwise they'll say 'it's because you're a woman' (A021, Consultant, Female, 30s).

Feelings in relation to working lives

Demarcation between work and home raised additional emotional challenges. For those working in general practice recent reforms in primary care facilitated a workable balance between the two. Similarly, Jones and Green's (2006) study of non-principled general practitioners in the UK reveals that the hours and flexibility appealed to these doctors as they were able to effectively balance demands of work and home. The hospital doctors were less sanguine as there were times when they felt divided loyalties, especially those who have young children or elderly and sick relatives. This can give rise to feelings of guilt. Some of the older, male doctors explained that with hindsight they could now see that they got the balance wrong earlier in their careers; and this was why their marriages had failed and why they had not given their children the time or attention they felt they should have. As this consultant reflects: I failed once. I think it is difficult. I think there is a lot of spin over this improving working life and all that. I've got two kids aged three and a half and five months, I've got to get them to the nursery, nursery doesn't open 'til eight and finishes at six. I can't go to meetings which are going to go on past five o'clock in order to get to the nursery. When do managers put meetings on? First thing in the morning, or they put it on at 5 because it doesn't influence clinical activities and they think that we as doctors will be able to just turn up and do it. I just can't do that anymore. I'm no longer as competitive a doctor as I was in the past so I feel much more relaxed about saying 'well no, I can't take part in these activities, I've got to go look after the children' (A027, Consultant, Male, 50s).

Delivering medical health care is sometimes mundane, routine, and boring. Technical procedures once accomplished can become dull; form filling, collating data, attending meetings and so on can become tiresome. Seeing patient after patient who present with similar symptoms and re-rehearsing the same advice and guidance can be wearing. A far cry from the TV drama, much medical work is dull and repetitive. But the overwhelming tedium of the work dominated the accounts of only a very small minority. Most felt this was balanced by the rewards. And, in fact, continuums of feelings were found in most of the interviews: satisfaction and frustration; pride and shame; superiority and humility; accomplishment and regret; blamelessness and guilt; praise and hurt; vulnerability and security; fun and sadness; and excitement and boredom. Such contrasting reactions were expressed throughout single interviews about patients, clinical work, technical procedures, colleagues, institutions, and policy reforms.

DISCUSSION AND CONCLUSION

While we have reported on the reflections that individuals have in relation to their work it would be erroneous to run away with the idea that these are merely expressions of autonomous individuals and the 'inner feelings' of independent 'selves'. Indeed, as we argue above we are reporting on 'techniques of feeling' that is the expression of emotional responses that are precipitated by and contingent upon a particular set of circumstances. The feelings articulated in relation to work are rooted within the 'habitus' (Bourdieu, 1990) of contemporary medical practice – thus they are inextricably interlinked with the assumptions, expectations, and prescriptions about medicine which prevail in wider society. Being able to balance effectively between the needs of patients and one's 'self', between empathy and rationality, between one's frustrations and achievements, between the dictates of managerialist regulatory environments and professional integrity, and between work and home, comprises – in a colloquial parlance – 'a well-balanced' professional.

As stated in our Introduction Gothill and Armstrong (1999) note that doctors occupy 'a sort of proto-space' (p.10), which we suggest may be compounded by a contextual tension whereby they represent (and perhaps even embody) the abstract system of medicine, and yet they are required to be caring and able to express feelings such as empathy, sympathy, emotional sensitivity, and so on. These feelings are prescribed within guides to good medical practice (GMC, 2006) and in this sense comprise a form of emotional labour. Such prescribed feelings, however, can be distinguished from the expression of the 'backstage' feelings presented in this paper. These feelings in relation to aspects of doctoring, not surprisingly, are ambivalent. Underpinning this ambivalence is the need to reproduce medicine as an abstract system; an objective, trustworthy, reliable, effective, competent and fair mode of healing. Yet the system and indeed the practitioners who deliver it must also be caring, emotionally intelligent, intuitive, and sensitive. They need to strike a balance between the rational and the emotional self.

Such tensions are exacerbated by the fluidity of the contextual environment. Medicine as an abstract or expert system is being reconfigured as medical knowledge is no longer bounded and confined within elite institutions, but is to be found within the varied 'networks of contemporary info-scapes where it can be accessed, assessed and reappropriated' (Nettleton, 2004, p.674). The consequent instability and fracturing of roles, structures, and boundaries will mean that relationships are likely to be less secure and concurrently open to external evaluations by consumers, mangers, and the public. A trend that is likely to go through a step-change in the near future as the impact of Web 2.0 is felt on medicine (see eg, http://ratemds.com) (Giustini, 2006). Ironically, at a time when doctors are being exhorted to adhere to evidence-based guidelines and protocols, and to eschew personalized and experiential knowledge (Harrison, 2002) they need greater 'emotional intelligence' to negotiate with well-informed patients who have increasingly consumerist expectations.

The extant sociological literature on the medical profession portrays a relatively powerful social elite who occupies a structurally advantageous position. From the data presented here we gain an impression of ordinary men and women who, like those working in many other occupations (the similarities with our own recent experiences as academics is striking), are juggling with the routine realities of everyday work. Managing workloads, dealing with patients, negotiating with colleagues and managers, and balancing the demands of work and a life beyond, occupy the members of this occupational group as they would many others. These commonplace matters are to the fore in the doctors' reflections but woven between them is the awareness that their work touches upon the more profound matters of life, death, and suffering. Thus, their relations with patients and the public, and indeed the public and patients' relationships with doctors will, on occasions, be one of significant intensity. The balancing of the humdrum and the passion may be what makes the public so intrigued by this professional group. Perhaps, it is also time that sociologists become more alert to the same issues.

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Acknowledgements

We are grateful to the ESRC for funding the research project 'On Being a Doctor: a Sociological Analysis' (Reference: RES-000-22-1158) on which this article is based. We also thank Mike Hardey for comments on an earlier draft of this paper.