What is like to be a devoted doctor? An analysis of book reports on The Painted Veil.

PURPOSE: The aim of this study is to see what medical students think about the role of spouse of a devoted medical doctor through the book reports of The Painted Veil (1925).
METHODS: The 53 medical students were asked to read Maugham's The Painted Veil and to have a discussion. In their book reports, following questions were asked to be included: What it is like to be married a devoted medical doctor? Do you think that patients realize, value, and respect the importance of doctor's work? In the outbreak of highly infectious and fatal disease, can you carry out a heroic fight to control it?
RESULTS: Among the 53 respondents, seven students (13%) answered that they would be happy if they marry a devoted doctor and scientist and 34 (64%) unhappy. The remaining 12 (23%) could not make a decision. The six students (11%) answered that doctor is valued and respected by patients while 46 (87%) answered doctor is neither valued nor respected. The remaining one (2%) could not decide. The 20 students (38%) answered that they would fight for the infectious disease and the remaining 30 (57%) answered that they would not. The remaining three (5%) could not determine their mind.
CONCLUSION: The Painted Veil induced a virtue of "life of balance and harmony" and "attitude of doctor who give superiority to responsibility and duty over prestige and wealth" from the medical students. It could be a good teaching material for medical humanity.

Introduction

Nowadays we occasionally encounter the breakage of medical doctors’ family relationships in the mass media. The famous writer Somerset Maugham (1874–1965) was trained at St Thomas’s Hospital Medical School, London, but he did not complete his studies because of his early success in literature. Through his inborn empathy and ability to help other people to reveal their intimate stories, we can see that he had many qualities that would have made him a first class general practitioner or psychiatrist [1]. The Painted Veil is one of good examples. He could recall on his many travels to far east, his loveless marriage, and his medical knowledge [1].

In Korea, several attempts have been introduced to use the literatures in the medical education. Through telling, hearing, reading, and writing illness narratives, Hwang [2] insisted that medical doctors and medical students can learn empathy and clinical wisdom. Lee & Rhee [3] said that medicine in the literature can give deep understanding and insight of the patients. She insisted doctors also find a process of self-awareness in the literatures.

We would like to know how the medical students think “What is it like to be married to a devoted doctor and scientist?” and in the outbreak of highly infectious and fatal disease, can they carry out a heroic fight to control it.

The purpose of this study is to see what medical students think about the role of spouse of a devoted medical doctor and whether they would want to perform a heroic fight in front of an outbreak of highly infectious and fatal disease.

Subjects and methods

1. Participants

Participants included 53 medical students in their junior class (third year of a 4-year course). The mean overall age was 28.9±3.0 years. A month before the classroom lecture, they were asked to read Maugham’s The Painted Veil (1925) and have a discussion in groups of seven [2].

Korean translation of Maugham’s The Painted Veil and DVD of The Painted Veil (Director: John Curran; Stars: Edward Norton and Naomi Watts; 1938) were provided to students.

2. Semi-structured theme lists

In their book reports of Maugham’s The Painted Veil, following questions were asked to be included:

What it is like to be married a devoted medical doctor?

Do you think that patients realize, value, and respect the importance of doctor’s work?

Students were divided into seven focus groups and seven to eight students were allocated in each group. Each group had focus group discussion and during their discussion, yes/no/undecided options and the reason why were drawn.

These discussions were summarized in Power Point slides and a member of each group presented in open forum discussion in front of all students and two moderating professors.

After the forum, they were asked to write a book report. The answers to the questions were in textual data. However, through the focus group discussion and open forum, it could be analyzed as yes/no/undecided options. Factors which may affect their decisions were also analyzed (age, sex, marital status, number of family members, and volunteer work hours).

The program SPSS version 19.0 (IBM Corp., Armonk, USA) was used for a statistical analysis. For the comparison of the answer from each group, chi-square test was used. For the odds ratio and 95% confidence intervals, logistic regression analysis was used. When the p-value was less than 0.05, the data were interpreted as statistically significant.

In publishing the data from medical students, principles outlined in the Declaration of Helsinki were followed.

Results

1. What it is like to be married a devoted medical doctor?

Among the 53 respondents, seven students (13%) answered that they would be happy if they marry a devoted doctor and scientist and 34 (64%) answered they would be unhappy. The remaining 12 (23%) could not make a decision.

Reasons for happiness were mature love (8%), fame and finance (5%). Reasons given for unhappiness were negligence to family or spouse (54%), absence of a common denominator (8%), and absence of humanity (2%) (Table 1).

Table 1.

What It Is Like to Be Married a Devoted Doctor and Scientist?

	No. (%)
Happy
Mature love	4 (8)
Fame and finance	3 (5)
Subtotal	7 (13)
Unhappy
Negligent to family or spouse	29 (54)
Absence of common denominator	4 (8)
Absence of humanity	1 (2)
Subtotal	34 (64)
Cannot make up own mind	12 (23)
Total	53 (100)

There was no significant difference in age groups, gender, number of family member, or voluntary work hours for being happy in marriage with a devoted doctor (Table 2).

Table 2.

Characteristics for Marrying a Devoted Doctor

Variable	Happy	Unhappy	Total	OR (95% CI)	p-value
Age (yr)
Under 28	4	17	21	0.750 (0.145–3.870)	0.731
Over 29	3	17	20
Gender
Male	4	24	28	0.556 (0.105–2.948)	0.490
Female	3	10	13
No. of family members
4 or more	5	24	29	1.042 (0.173–6.290)	0.965
3 or less	2	10	12
Voluntary work (hr)
More than 100	2	13	15	0.646 (0.109–3.831)	0.631
Less than 100	5	21	26

OR: Odds ratio, CI: Confidence interval.

2. Do you think that patients realize, value, and respect the importance of doctor’s work?

Among the 53 respondents, six students (11%) answered that doctor is valued and respected by patients while 46 (87%) answered doctor is neither valued nor respected by the patients. The remaining one (2%) could not decide.

The reason for doctor’s winning respect was because patients realize they need doctors in suffering from diseases. Reasons given for doctor’s losing respect were distrust to medical doctors (63%), prejudiced influence from the media (19%), seeking for prestige and wealth (3%), and lack of understanding for doctor’s work (2%) (Table 3).

Table 3.

Patients Realize the Importance of Doctor's Work and Doctor Is Valued and Respected by the Patients?

Valued and respected	No. (%)
Yes
Imperatively necessary to patients	4 (8)
In suffering from a disease patients realize	2 (3)
Subtotal	6 (11)
No
Distrust to medical doctors	33 (63)
Prejudiced influence from medias	10 (19)
Seeking for prestige and wealth	2 (3)
Lack of understanding for doctor’s work	1 (2)
Subtotal	46 (87)
Cannot make up own mind	1 (2)
Total	53 (100)

There was no significant difference in age groups, gender, number of family member, or voluntary work hours for thinking doctors are valued and respected from the patients (Table 4).

Table 4.

Characteristics for Patient’s Respect to Doctor

Variable	Valued and respected			OR (95% CI)	p-value
	Yes	No	Total
Age (yr)
Under 28	5	25	30	4.200 (0.454–38.83)	0.206
Over 29	1	21	22
Gender
Male	4	29	33	1.172 (0.194–7.092)	0.863
Female	2	17	19
No. of family members
4 or more	5	34	39	1.765 (0.187–16.671)	0.620
3 or less	1	12	13
Voluntary work (hr)
More than 100	1	17	18	0.341 (0.037–3.170)	0.344
Less than 100	5	29	34

OR: Odds ratio, CI: Confidence interval.

3. In the outbreak of highly infectious and fatal disease, can you carry out a heroic fight to control it?

Among the 53 respondents, 20 students (38%) answered that they would fight for the infectious disease and the remaining 30 (57%) answered that they would not. The remaining three (5%) could not determine their mind.

The reasons provided for fighting were sense of duty (15%), sense of ethics (10%), responsibility (8%), and social duty (5%). The reasons given for not fighting to the disease were worry regarding family (19%), safety not ensured (19%), inefficiency (14%), and needless of sacrifice (5%) (Table 5).

Table 5.

In the Outbreak of Highly Infectious and Fatal Disease, Can You Carry out a Heroic Fight to Control It?

Enter the area	No. (%)
Yes
Sense of duty	8 (15)
Sense of ethics	5 (10)
Responsibility	4 (8)
Social duty	3 (5)
Subtotal	20 (38)
No
Worry regarding family	10 (19)
Safety not ensured	10 (19)
Inefficiency	7 (14)
Needless of sacrifice	3 (5)
Subtotal	30 (57)
Cannot make up own mind	3 (5)
Total	53 (100)

Males were more likely to fight than were females (odds ratio [OR], 3.06). Students who had performed more than 100 hours of volunteer work were more likely to fight than were students who had done less than 100 hours (OR, 3.29) (Table 6).

Table 6.

Characteristics for Entering or Not-Entering the Infectious Area

Variable	Enter or not			OR (95% CI)	p-value
	Yes	No	Total
Age (yr)
Under 28	10	18	28	0.667 (0.213–2.087)	0.486
Over 29	10	12	22
Gender
Male	16	17	33	3.059 (0.823–11.362)	0.095
Female	4	13	17
No. of family members
4 or more	17	21	38	2.429 (0.567–10.403)	0.232
3 or less	3	9	12
Voluntary work (hr)
More than 100	10	7	17	3.286 (0.972–11.110)	0.056
Less than 100	10	23	33

OR: Odds ratio, CI: Confidence interval.

Discussion

Plot summary of The Painted Veil is as follows: Kitty Garstin married Dr Walter Fane, a microbiologist who barely knows to escape from her family and to marry before her younger sister. At a ball, Walter was attracted by Kitty and loved her truly. When they moved to China, she became involved with another man, Charlie Townsend, a government official. When Walter found out about the affair, he volunteered to move with her to a distant town in China, suffering from cholera epidemic. Kitty has no choice but to follow him, even though she knew that his intention was to punish her. She reconsidered her life alone when Walter was working as the only doctor in the town. She realized the importance of Walter's work and how much he was valued and respected by the patients, nuns, and children and undergone a profound personal transformation. Though Walter stopped the epidemic, he himself fell into an illness and passed away. Kitty returned to England and she started to dedicate her life to their only son who did not see his father [4].

In The Painted Veil, by eating a fresh garden salad that was understood to be grown with human sewage fertilizer, a microbiologist committed suicide during a cholera epidemic [5].

In a paper from Cardiff, a literature and medicine special study module was designed and evaluated for third-year undergraduate medical students, by tutors from an academic department of general practice. Developing subjects was challenging for students and tutors [6].

In this study, seven to eight students were allocated in focus group and yes/no/undecided options and the reason why were drawn during their discussion. Also, they were asked to write a book report. We think our method used is a combination of focus group with semi-structured theme approach as some previous authors performed [7,8].

It is surprising that most of the students surveyed (64%) replied that the spouse of a devoted medical doctor would not be happy although they themselves would dedicate to medical profession. Medical students seemed to pursue a life of balance and harmony without leaning to one side. This finding was reflected in various researches over the last decade. Schwarz et al. [9] suggested that students preferred a specialty where work hours were controllable. Students preferred fewer numbers of hours at work and less night on calls which in turn allowed more time to spend other than carrying out professional duties. These finding was re-literated in a study of U.S. medical graduates by Dorsey et al. [10] They statistically analyzed different resident matching systems and suggested that controllable lifecycle alone accounted for 37% in variability in specialty preference. Income, work hours, and years training followed in the ranking.

Most of our respondents (87%) from our survey answered doctors are neither valued nor respected by their patients. This is quite a contrary to the situation in England where doctors and nurses are the most respected of professions in England according to a BBC poll [11]. Although some respondents thought that this may be due to the prejudice generated by media or health insurance program. Majority (63%) said that the reason for this disrespect is from medical doctors themselves especially who prefer profits, such as cosmetic surgeries. It is thought that students reflect on the doctor’s motivation being more income oriented compared to responsibility, duty, devotion and overall professionalism. Student’s view hopefully will contribute to raising doctor’s status and improve the doctor-patient relationship.

It is thought that to some extent of Korean culture and the practice system have impacted on the perception of the book and the reaction of students, disclosing some intercultural perspective. Lee [12] surveyed 150 South Korean medical students in 2011. The determining factor for the specialty was income followed by controllable lifestyle and workload.

Among the 53 respondents, 20 students (38%) answered that they would enter the area of fatal infectious disease and the remaining 30 (57%) answered that they would not. It is encouraging that two-fifths of students answered they would go and the remaining three-fifths suggested reasonable alternatives such as developing vaccines.

In The Painted Veil, the medical doctor volunteered to move with his wife to a remote area of China suffering from cholera epidemic when he realized his wife’s unfaithfulness. Doctor’s wife has no choice but to follow her husband, even though she knew that his intention was to punish her.

In Campbell’s review for motivations in recruitment and retention of rural and remote area, the most frequently mentioned positive extrinsic incentives were rural lifestyle and diverse caseloads. The most cited positive intrinsic incentives were autonomy and community connectedness. Negative intrinsic incentives were mentioned least frequently. Among them, feeling overwhelmed and that your work was not valued by the community were the most commonly reported [13].

Since the present study is not a kind of pretest and posttest design, we could not see impact of this teaching mode on students’ beliefs or attitudes in a qualitative means, which is a limitation of this study. Another limitation is a probable high type II error in assessing factors which may affect students’ opinions (age, sex, marital status, number of family members, and volunteer work hours). Standardization of the questionnaire may be a factor to consider as well.

Though it is not certain whether reading and discussing the book has any influence on the students, The Painted Veil allows the readers to reflect on the virtue of life of balance and harmony and attitude of doctor towards responsibility and duty. Thereafter, it could be a good teaching material for medical humanity.