The image of doctors in the Slovenian daily press: White mafia or hardworking altruists?
Podoba zdravnikov v slovenskem dnevnem tisku: bela mafija ali delavni altruisti?
Melita Poler kovačič, karmen erjavec
Univerza v Ljubljani, Fakulteta za družbene vede, Kardeljeva pl. 5, 1000 Ljubljana
Korespondenca/ Correspondence:
izr. prof. dr. karmen erjavec, Univerza v Ljubljani, Fakulteta za družbene vede, kardeljeva pl. 5, 1000 Ljubljana, telefon: + 386 1 5805264, e-pošta: karmen.erjavec@fdv. uni-lj.si
Ključne besede:
zdravniški poklic, novice, mediji, vrednotenje, Slovenija
Key words:
medical profession, news, media, evaluation, Slovenia
Citirajte kot/Cite as:
Zdrav Vestn 2011; 80: 182-7
Prispelo: 12. okt. 2010, Sprejeto: 27. dec. 2010
Izvleček
Izhodišča: Novinarski prispevki o zdravnikih (so)ustvarjajo javno mnenje o zdravniškem poklicu. Vendar pa obstaja le malo raziskav, ki obravnavajo podobo zdravnikov v medijih, še te pa se osredotočajo zgolj na kakovostni tisk ter ne uporabljajo kvantitativnih metod, da bi izmerile novinarsko vrednotenje zdravnikov.
Metode: Študija poskuša zapolniti raziskovalno vrzel z analizo ustvarjene podobe zdravnikov v petih najbolj branih slovenskih dnevnih časopisih v obdobju od 15. marca do 15. septembra 2010. Za preverjanje hipoteze, da med mediji obstajajo statistično značilne razlike glede vrednotenja zdravnikov, smo uporabili kvantitativno analizo vsebine in kvalitativno kritično diskurzivno analizo.
Rezultati: Največ prispevkov slovenskih dnevnikov je zdravnike predstavilo nevtralno (41,1 »/o), sledi negativno vrednotenje (28,4 %), temu pa pozitivno vrednotenje (20,0 %). Med dnevniki po negativnem predstavljanju zdravnikov izstopa tabloid Slovenske novice, ki je objavil le 1,7 % pozitivnih prispevkov o zdravnikih. Analiza vrednotenja posameznih zdravniških akterjev je pokazala, da sta bila najbolj negativno vrednoteni organizaciji Fides (67,3 % prispevkov) in Zdravniška zbornica Slovenije (77,6 %). V vseh dnevnikih prevladuje ambivalentno predstavljanje zdravniškega poklica: »delavni« in »preobremenjeni« mladi specia-lizanti delajo prekomerno, starejši zdravniki pa so »leni«, »izsiljevalci« in »pohlepneži«.
Zaključki: Raziskava je pokazala, da so najbolj brani slovenski dnevniki v izbranem obdobju, ki je bilo zaznamovano s sprejetjem novele Zakona o sistemu plač v javnem sektorju, pisali o zdravniških akterjih bolj negativno kot pozitivno. Natančnejša analiza, tj. analiza makropropozicij in poimenovanj, je pokazala, da prevladuje ambivalentno in zelo negativno predstavljanje zdravniškega poklica. Izziv za prihodnje raziskave bi
bila študija o pogledih na zdravnike v različnih medijih in javnem mnenju.
Abstract
Background: News media portrayals of doctors (co-)construct public opinion on the medical profession. There have been only a few studies on media representations of doctors, which researched the quality press only and did not use quantitative methods to measure evaluations of doctors.
Methods: The study tries to fill this research gap by an analysis of doctors' representation in five most-read Slovenian daily newspapers from 15 March to 15 September 2010. Quantitative content analysis and qualitative critical discourse analysis were used to verify the hypothesis that among media there are statistically significant differences in doctors' evaluations.
Results: The dailies mostly represented doctors neutrally (41.6 %); a negative evaluation was found in 38.4 % and positive in 20.0 % of news items. Statistically significant differences were established among the media. The tabloid Slovenske novice published the majority of news items that negatively evaluated doctors (33.2 %), and the least with a positive evaluation (1.7 %). Among actors, Fides and the Medical Chamber of Slovenia were evaluated particularly negatively. All dailies published black and white images of doctors: "hardworking" and "overburdened" young residents work overtime, senior physicians are "lazy", "blackmailers", and "the greedy ones".
Conclusions: There is an ambivalent and oversimplified coverage of doctors in the Slovenian press. They are represented both negatively and positively. A challenge for the future research would be a study on views about doctors in diverse media and public opinion.
Introduction
News items about medical errors, medical trade union fights and other issues related to members of the medical profession are often published in the Slovenian and other Western mass media. In numerous media interviews and studies, doctors themselves express concern about the predominantly negative image of their profession in the media, which ruins their reputation in the society.1-2
In the last decades, the mass media have been acknowledged by both media and health sociologists and members of the medical profession as an important element of the social construction of medicine and health. News media portrayals of doctors make an important contribution to the agenda for the development of public opinion of the medical profession.^ To date, however, there has been little attempt to examine how doctors are conceptualized and represented in news media coverage. Lupton and McLean's study of the Austrian quality daily press and magazines' representation of doctors revealed that negative portrayals of doctors were countered by positive repre-sentations.4 They concluded that while the nature of the reporting would suggest that members of the medical profession may be constantly under the spotlight of media scrutiny, they enjoy a significant degree of cultural and social authority. Using discourse analysis of UK national quality daily newspapers, Prosser showed that the press constructs a discrete, contradictory and frequently oversimplified set of characterizations about doctors and medicine.^ Doctors are endowed with powerful life-saving properties and the dominant discourse on medical progress induces hope, faith and anticipation of doctors' ability to control or eradicate disease risk and enhance survival chances. Thus, the existent studies of the media images of doctors analysed only the quality press media, which are mostly read by a smaller, more educated audience.® However, scholars need to go beyond the prevailing studies of news content in major privileged, elite news media and also study the more popular and regional news
media. The existing studies also did not use quantitative methods that would enable a researcher to measure journalists' general evaluations of doctors. Our study tries to fill this research gap. The goal of this article is to present a systematic and comprehensive analysis of the representation of doctors over a period of six months, from 15 March 2010 to 10 September 2010, in the most-read Slovenian daily press.
Methodology
The methodology for the news analysis was based on quantitative content analysis and qualitative critical discourse analysis. We used the method of content analysis, i.e., the systematic and replicable examination of symbols of communication, which have been assigned numeric values according to valid measurement rules and the analysis of relationships involving those values using statistical methods, in order to describe the communication and draw inferences about its meaning.7
With content analysis we wanted to answer the key research question which can be measured quantitatively and which is crucial for uncovering relations between the media and doctors at the general and macro level: How are doctors evaluated in news items in the most-read Slovenian daily newspapers? For the statistical evaluation of results and their testing, we chose a simple analysis of variance. The null hypothesis - that there were no statistically significant differences between newspapers regarding evaluation of doctors - was tested by the F-test.
We also used critical discourse analysis, which is a more interpretative approach when compared to mere content analy-sis.8 We performed an in-depth qualitative analysis of the language, i.e., key words used in news items and macro-propositions. It is widely accepted that the choice of words used by journalists is by no means arbitrary. Analysis of the naming options of doctors was carried out, as journalists have to provide names for social categories; this naming always involves choice and by choosing one social category over another, journalists include actors within a category and exclude
Table i: Share of evaluations of doctors in news items in the Slovenian daily newspapers, 15 March to 15 September 2010, analysis of variance, N=420, sig. 0.00.
Evaluation	Slovenske novice	ŽurnaL24	Daily newspaper DeLo	Dnevnik	Večer	Total
Positive	1.7 %	14.3 %	24.5 %	25.2 %	34.3 %	100 %
neutral	14.9 %	19.8 %	21.3 %	21.4 %	22.6 %	100 %
negative	33.2 %	20.8 %	15.2 %	16.2 %	14.6 %	100 %
them from other categories.® We also performed an analysis of macro-propositions, which define the most relevant pieces of information in the text.® A macro-proposition is derived from the local meanings of words by macro-rules: deletion, generalization and construction. Such rules combine similar meanings with higher-level abstract meanings or construct different meaning constituents in higher-level events or social concepts, which enable us to identify "the main idea unit" in the form of several sentences, a paragraph, an entire news item or even more news items. Close study of macro-propositions made in news items may enable us to reveal the main message(s) about doctors published in the Slovenian daily press. Each macro-proposition will be presented by a typical example.
We analysed 420 news items covering doctors, published in the five most-read Slovenian daily newspapers, i.e., the tabloid Slovenske novice (305,000 readers), the free newspaper Žurnal24 (287,000 readers), the regional newspaper Večer (129,000 readers), the national newspaper Delo (129,000 readers) and the regional newspaper Dnevnik (113.000 readers), from 15 March 2010 to 15 September 2010.1® This period was chosen because we wanted to include news items published before the adoption of the new Public Sector Wage System Act (7 September 2010), which reduces doctors' wages for standby duty and has led to a trade-union struggle, lasting until 9 September 2010, when the Ministry of Health and Fides arrived at a decision that the payment for doctors' standby duty and doctors' consent to work overtime should be reverted to the level as it was before the adoption of the new law. We included all news items that referred to the medical profession/doctors as a
whole. Each clipping was categorized by the same coder (one of the authors) for a number of features: date, daily newspaper, news actors and evaluation of doctors, i.e., positive, negative or neutral." A pilot analysis was first carried out to devise and test the actor categories on a sample of clippings, with both authors participating in this process to check the consistency of rating. A total of five news actor categories were subsequently devised.
Results
Evaluations of doctors in the slovenian dailies
During the six-month study period, a total of 420 news items made reference to doctors. Most of them were published in the major Slovenian daily newspaper Delo (30.7 %), the free newspaper Žurnal 24 (26 %), the regional daily newspaper Dnevnik (19.5 %), and the regional daily Večer (16 %) and least of all in the tabloid Slovenske novice (7.9 %).
Frequencies for evaluation show that all the dailies were mostly writing neutrally (41.6 %), which means that they did not explicitly express a positive or a negative opinion. A negative evaluation was found in 38.4 %o and positive evaluation in 20.0 %o of analysed news items. We can conclude that the Slovenian daily newspapers write about doctors ambivalently, although more negatively than positively. Table 1 shows that Slovenske novice published the greatest percentage of news items that negatively evaluated doctors (33.2 %o), and the least with a positive evaluation (1.7 %).
How did Slovenian daily newspapers evaluate individual actors? According to Table 2, Fides (67.3 %) and the Medical Chamber
Table 2: Share of evaluations of actors in news items about doctors in the Slovenian daily newspapers, 15 March to 15 September 2010, analysis of variance, N=420, sig. 0.00.
Actor	Negative	Values Neutral	Positive	Total
Doctors	33.7 %	40.3 %	26 %	100 %
Fides trade Union	67.3 %	30.9 %	1.8 %	100 %
Medical chamber	77.6 %	20.4 %	2 %	100 %
Slovenian Medical association	0	98.3 %	1.7 %	100 %
Hospitals and health centres	19.8 %	69.7 %	10.5 %	100 %
of Slovenia (77.6 %) were evaluated explicitly negatively, while some doctors were evaluated positively (33.7 »%). The functioning of hospitals and health centres was evaluated relatively neutrally (69.7 %).
Key messages about doctors and their naming in Slovenian daily newspapers
The macro-proposition analysis enabled us to discover that the following ambivalent macro-proposition was adopted by all analysed newspapers: "some doctors (predominantly the younger ones) are the good ones (they work a lot, are paid little, their work is responsible, self-sacrificing and without errors), while others are bad (they work little and are paid well, and they work because of earnings) and defend their positions by blackmailing to the detriment of patients, which is inadmissible in times of economic crisis, when all citizens tighten their belts". All newspapers published stories on young residents working overtime on the one hand and reports on the high salaries of senior physicians (especially in comparison to other salaries in the public sector), who work relatively little, on the other hand. The former were labelled as "hardworking", "overburdened" and "altruistic", while the latter were described as "lazy", "blackmailers" and "the greedy ones". Because this is a macro-proposition on the highest level, i.e., the level of different news items, it is difficult to present it by one example only:
State enemy number one?
From month to month, doctors are at the top of the scale of public officials' salaries.
The best paid doctor in the University Clinical Centre Ljubljana, anaesthesiologist Tomislav Mirkovic, received 11.315 Euros for his work in March, i.e., 4817 Euros gross for regular work and 5877 Euros gross for standby duty work. . On the scale of best-paid leading public officials, there are 12 doctors among the 15 best-paid leading public officials. At the top there is the manager of the hospital Ptuj Robert Čeh with 8096 Euros. . In times of economic crisis, when all public officials tighten their belts, doctors' withdrawal of their consent to work overtime is blackmailing with the weakest members of the society. . But the story also has its other side. Young residents are overburdened and badly paid. According to the data of Fides, the regular work of a young doctor-resident is paid at 10.72 Euros gross or 6.89 Euros net per hour. As everywhere in the world, here too a very large part of standby duty work is carried out by residents. . (Delo, 6 June 2010)
All newspapers represented doctors who work both in the private and public sector particularly negatively and they more or less explicitly indicated a negative attitude towards double work, which does not solve the problem of long waiting lists. The main message of these reports was that "the key motive of doctors' work in the public and private sector is earnings, while the waiting lists are not getting shorter". These doctors were labelled as "amphibians" or even as "frogs". A typical example:
Will Marušič kiss a frog? In clinics, where every second doctor also works in a private practice, there is hard fighting between interests
A doctor from this story is an amphibian. For four hours he works at the University Clinical Centre in Ljubljana (UKC), but he also has his own private orthopaedic practice with a half-time concession. For four hours of work in the private practice, he earns five thousand gross, and two thousand at theU-KC. He says that he has a concession because the minister Bručan had an idea to make the waiting lists shorter in this way. But, please, one plus one is never three or four. How could a doctor, just because he used to spend all eight hours in UKC before, and now spending there only four hours and four in his private practice, examine altogether substantially more patients? (Žurnal24, 2. 5. 2010)
In news items which covered medical errors, we identified the macro-proposition "doctors do not admit their errors", and doctors were often named "Gods in white", "white Gods", or "white mafia". Typical is an example from Slovenske novice (27 March 2010), which in the title ("Judging Gods in white coats") and the subtitle ("Doctors regret, but do not admit guilt") indicated a journalist's negative attitude towards doctors in general.
On the individual level, journalists of the most-read Slovenian dailies were writing negatively about the president of Fides, Konrad Kuštrin, who was presented as "a doctor who wasted the moral capital, reputation and dignity of his colleagues", and presented him as one of "those eager to earn money". Often he was named as "fighting" and "arrogant", "destroyer of doctors' dignity and reputation". A typical example:
Moral capital at the test
Under the leadership of Konrad Kuštrin, the medical trade union Fides developed a fighting spirit. In this way doctors get higher salaries, but at the same time waste moral capital . Of course a society cannot give to doctors more than it has and as it belongs to them according to its development. (Delo, 15. 6. 2010)
Journalists of the analysed dailies were particularly negative when writing about the president of the Medical Chamber of Slovenia, whom they unanimously labelled as "a doctor who destroyed the reputation of Slovenian doctors" and usually they presented her as an "ice queen", "arrogant machine", "twisted first lady", "notorious", a person who "changed doctors to criminal ignoramuses" and "ashamed in front of the public". A typical example:
Fall of the ice queen
Mrs. Kalan, a clinical example of a human being with only her own opinion, will go down in history as with no trouble and no great pain she managed to ruin the reputation of Slovenian doctors. Although something like this is a mission impossible in normal circumstances, not to say a state, how you can change doctors into criminal ignoramuses, it was easy for her to do it with her hands and talking. (Slovenske novice, 23 April 2010)
Discussion
The quantitative research showed that the majority of news items in the most-read Slovenian daily Slovenske novice represented doctors neutrally or negatively. Among dailies, there are significant differences in covering doctors, as the most-read newspapers in particular, such as the tabloid Slovenske novice and the free newspaper Žurnal24, rarely represented doctors, while these representations were mostly negative. Therefore, readers of tabloid dailies - and based on the same logic of discourse construction we may claim that the same messages are offered by all tabloid media - can get a more negative image of doctors than the audiences of other media.^^ The trade union and the medical association were particularly negatively represented. However, the study revealed that the representation was not one-sided, as doctors' success was also frequently covered. Critical discourse analysis enabled a more detailed insight into the representation of doctors. The dailies represented a black or white image. On the one hand, young doctors were represented very positively, as the ones who are badly paid
and who are overburdened, while on the other hand, the older doctors were represented negatively, as the ones who get very high salaries for less work and a lot of free days. The older doctors were represented as the ones who have lost their moral capital and who exert their social power. They were especially blamed for blackmailing in today's crisis times, when the great majority of workers must consent to smaller payments and doctors are an exception. The analysed press was particularly unanimous in the representation of doctors who do not admit their errors and those who work both in the private and public sector. The presidents of both doctors' organizations, Konrad Kuštrin and Gordana Kalan Živčec, were also represented negatively.
The study showed that authoritative actors, who regularly appear in the media, are not always represented positively. For example, Fides was the key actor in more than a half of all analysed news items and was thus identified as a socially powerful actor; journalists resented Fides for its aggressive approach and they represented it negatively (particularly its president), as being aggressive and arrogant and ruining the reputation of the medical profession. The research also confirmed findings from previous studies that journalists are particularly negative in the evaluations of individual doctors or their organizations keeping information secret from them or the public.^-^
The combination of both research methods turned out to be very useful, as it enabled the macro- and micro-view and revealed differences among the media. The study showed that there is no single homogeneous representation of doctors covered by all dailies; the tabloid media scarcely covered issues related to members of the medical profession, but when they did, their representations were very negative. A research challenge for the future would be to perform a study on views about doctors in diverse media (press, radio, television and web sites) and public opinion.
Conclusion
To sum up, there is an ambivalent and oversimplified coverage of doctors. On the one hand, they were represented negatively as representatives of the socially and culturally most powerful profession, who allow themselves to not admit their own errors, show their power by blackmailing that those who are the most vulnerable in the society will get less care, have a special status regarding their income in the times of crisis, work in the public and private sectors and manage their professional associations (the trade union and the chamber) arrogantly, while on the other hand some doctors were represented positively as hardworking and overburdened.
References
1.	Karpf A. Medicine and the Media. Br. Med. J. 1988; 296: 1389.
2.	Elston MA. The Politics of Professional Power. In: Gabe J, Calnan M, Bury M, eds. The Sociology of the Health Service. London: Routledge; 1991. p. 58-88.
3.	Seale C. Health and Media: An Overview. In: Seale C, ed. Health and the Media. Oxford: Blackwell; 2004. p. 1-19.
4.	Lupton D, McLean J. Representing Doctors: Discourse and Images in the Australian Press. Soc. Sci. Med. 1997; 46: 947-58.
5.	Prosser H. Marvelous Medicine and Dangerous Drugs. Public Underst. Sci. 2010; 19: 52-69.
6.	Maibach E, Parrott R. Designing Health Messages. London: Sage; 2005.
7.	Riffe D, Lacy S, Fico FG. Analyzing Media Messages: Using Quantitative Content Analysis in Research. Mahwah: Lawrence Erlbaum Associates;
1998.
8.	Richardson JE. Analysing Newspapers. New York: Palgrave MacMillan; 2007.
9.	Van Dijk AT. News as Discourse. Hillsdale: Lawrence Erlbaum; 1988.
10.	Nacionalna raziskava branosti 2010. Valutni podatki (2009II-2010 I). Accessible at: http://www. nrb.info/podatki/index.html.
11.	Malek A. New York Times' Editorial Position and U.S. Foreign Policy. In: Malek A, ed. News Media and Foreign Relations. Norwood: Ablex; 1997. p. 225-48.
12.	Langer J. Tabloid Television. London: Routledge;
1998.