Mary Duffy was lying in bed half-asleep on the morning after her breast cancer surgery in February when a group of white-coated strangers filed into her hospital room.
Without a word, one of them - a man - leaned over Ms. Duffy, pulled back her blanket, and stripped her nightgown from her shoulders.
Weak from the surgery, Ms. Duffy, 55, still managed to exclaim, "Well, good morning," a quiver of sarcasm in her voice.
But the doctor ignored her. He talked about carcinomas and circled her bed like a presenter at a lawnmower trade show, while his audience, a half-dozen medical students in their 20's, stared at Ms. Duffy's naked body with detached curiosity, she said.
After what seemed an eternity, the doctor abruptly turned to face her.
"Have you passed gas yet?" he asked.
"Those are his first words to me, in front of everyone," said Ms. Duffy, who runs a food service business near San Jose, Calif.
"I tell him, 'No, I don't do that until the third date,' " she said. "And he looks at me like he's offended, like I'm not holding up my end of the bargain."
Entering the medical system, whether a hospital, a nursing home or a clinic, is often degrading. At the hospital where Ms. Duffy was a patient and at many others the small courtesies that help lubricate and dignify civil society are neglected precisely when they are needed most, when people are feeling acutely cut off from others and betrayed by their own bodies.
Larger trends in medicine have made it increasingly difficult to deliver such social niceties, experts say. Many hospital budgets are tight, and nurses are spread thin: shortages are running at 15 percent to 20 percent in some areas of the country. Average hospital stays have also shortened in recent years, making it harder for patients to build any rapport with staff, or vice versa.
Some hospitals have worked to address patients' most serious grievances. But in interviews and surveys, people who have recently received medical care say that even when they benefit from the expertise of first-rate doctors, they often feel resentful, helpless and dehumanized in the process.
In a nationwide survey of more than 2,000 adults published last fall, 55 percent of those surveyed said they were dissatisfied with the quality of health care, up from 44 percent in 2000; and 40 percent said the quality of care had gotten worse in the last five years. The survey was conducted by Harvard University, the federal Agency for Healthcare Research and Quality and the Kaiser Family Foundation, an independent nonprofit health care research group.
"The point is that when they talk about quality of health care, patients mean something entirely different than experts do," said Dr. Drew Altman, president of the Kaiser Foundation. "They're not talking about numbers or outcomes but about their own human experience, which is a combination of cost, paperwork and what I'll call the hassle factor, the impersonal nature of the care."
Loss of Identity
It is practically a patient's birthright to complain about arrogant doctors, foul hospital food and the sadistic night nurse. These are real problems at some places, and since at least the early 1980's, medical schools and hospitals have worked to solve them, giving doctors classes in bedside manner and including patient representatives on staff, among other things.
Yet the deeper psychological transformation from citizen to patient that occurs in almost any medical setting can be more jarring, and anthropologists say it begins immediately at admission.
A clerk, often distracted, often sitting behind glass, hands out confusing forms that demand detailed personal information. The newly designated "patient" then strips to underwear and puts on a flimsy hospital gown, open at the back, a humiliating uniform that often bears the name of the institution.
The psychological dynamics of this identity change have evolved little since the 1950's, when the sociologist Erving Goffman detailed the depredations of life inside a mental institution in his classic book, "Asylums."
After a patient's admission, Dr. Goffman observed, a kind of psychological contamination occurs. In normal life, people can keep intimate things like ailments, thoughts and their bodies to themselves. In an institution like a hospital, "these territories of the self are violated," he wrote. "The boundary that the individual places between his being and the environment is invaded and the embodiments of the self profaned."
Sandra Ramundt, 52, felt this so deeply that she decided to break out of the hospital while recovering from brain surgery last year.