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Passionate Virtue:
Conceptions of Medical Professionalism in Popular Romance Fiction
Abstract

Medical romance fiction is a subgenre of popular romance fiction that features medical professionals in their work environment. This essay explores the way professionalism is portrayed in popular medical romance fiction written during the early twenty-first century, a period of significant disruption in both the public image and self-understanding of organized medicine. I analyze a selection of contemporary medical romance novels, published between 2008 and 2012, demonstrating that medical romance fiction is a form of public intervention in apparently insular debates over medical professionalism. I conclude that they promote “nostalgic professionalism,” a vision of physicians as a select group of highly educated, self-regulated experts who provide, with a caring and altruistic attitude, a vitally important service to society, while at the same time generating implicit critiques of it.

Medical romance fiction is a subgenre of popular romance fiction that features medical professionals in their work environment. This essay explores the way professionalism is portrayed in popular medical romance fiction written during the early twenty-first century, a period of significant disruption in both the public image and self-understanding of organized medicine. I analyze a selection of contemporary medical romance novels, published between 2008 and 2012, looking specifically at the way they represent the practice of medicine. While not “bio-ethical novels” directly interrogating bioethical issues, these workplace romances featuring medical subplots indirectly represent a physician ideal that continues to enjoy cultural capital.

The Brides of Penhally Bay is a series consisting of sixteen medical romances first published in mass market paperback in the United Kingdom from 2007 to 2010, and then in digital format in the United States from 2010 to 2012. Each book is set in a fictional fishing town in rural Cornwall, England. Most of the action centers around the Penhally Bay Surgery, both a general practice serving the primary care needs of the locals and a growing minor injuries unit. The surgery (the term for “doctor’s office” in the United Kingdom) expands over the course of the novels by building the facilities and hiring the personnel necessary to handle increasing demand, much of it from seasonal tourism.

The professional ideal the series promotes is “nostalgic professionalism,” a vision of physicians as a select group of highly educated, self-regulated experts who provide, with a caring and altruistic attitude, a vitally important service to society. Though the name evokes a fixed, idealized past, nostalgic professionalism itself has evolved in response [End Page 70] to socioeconomic challenges as it competes with alternative models for legitimacy, rendering unsettled the very question of what constitutes medical professionalism. Despite the importance of their implications for laypeople, debates over what doctors are and should be tend to take place primarily within organized medicine, in medical schools, conferences, and journals. As medical sociologist Frederic Hafferty writes, “You have these internal conversations going on within medicine, but not as much of a conversation in the public.”1 In this paper, I analyze medical romance fiction as a form of public intervention in these apparently insular debates.

The narrative turn in bioethics has generated important studies of fiction, but few of them address genre fiction.2 Instead, bioethicists have demonstrated the value of close readings of an emerging canon of bioethically significant literary novels. Works by Tolstoy, James, Ishiguro, Roth, Shelley, and Trollope are “genuine educators about medical ethics,” as literary critic Wayne Booth put it in his reflection on the value of fiction to bioethics.3 As Martha Montello describes “well-written fiction” of this type, “Instead of using an aspect of bioethics as an engine to drive the plot, some authors succeed in using it as a prism that shines new light onto timeless questions about what it means to be fully human.”4 Likewise, Sarah Chen claims the best fictional subjects of narrative inquiry “allow readers to come to a deeper comprehension of philosophical or ethical ‘truth’; and not only that, but also provide us with a worthy diversion.”5 Booth, Montello, and Chen all frame their inquiries in a way that favors literature tackling “fundamental moral questions” and their method of close reading seems best suited to ambiguous, complex, subtle, and subversive—“literary”—writing.6

From that perspective, popular fiction can seem to come up short. Montello, for example, criticizes Margaret Atwood’s science fiction novel Oryx and Crake for lacking “character complexity and realistic psychological motivations” and women’s fiction author Jodi Picoult for “using the contentious bioethics issue as grist for a kind of formulaic writing.”7 However, while individual genre novels, considered in isolation, might seem too simple to bear close reading, medical romance fiction can be studied as a system of narratives, each one proposing a slightly altered iteration of what at first seems a simple representation of its central theme, building to an increasingly sophisticated redefinition. The central theme of romance fiction is of course romantic love, but when the protagonists are also medical staff and the setting is the clinic, the articulation of that theme is inextricably linked to conceptions of medicine. A horizontal reading across a selfcontained [End Page 71] series of medical romance novels whose storylines overlap and unfold over a short period of time uncovers a coherent ideal of contemporary medical professionalism.

Bioethicists who analyze popular medical narratives often evaluate their significance in terms of “accuracy,” that is, their ability to mirror the realities of bioscience, health care, or medical technology. This is an important task, but measuring commercial fiction only in terms of its ability to faithfully replicate real-world medicine fails to grasp popular culture as a site where the complex interaction occurs of representations, public expectations, health care practices, and moral norms that sustain particular paradigms within medicine. Like all popular fiction, medical romance is highly sensitive to sales, reader feedback, and social changes. It thus shapes as well as draws on powerful tropes of the ideal doctor, patient, and medical setting. Catherine Belling has recently claimed that even “unrealistic” thrillers like Coma by Robin Cook may have much to tell us about the anxieties of the age. In this essay, I claim that popular fiction can tell us about the ideals of the age as well. If, as Belling puts it, “An effective public bioethics should engage fiction on popular culture’s own indirect terms, reading it not as mere escapism or malign propaganda, but as a legitimate, albeit indirect, voice in the bioethics conversation,” then medical romance fiction can be read as participating in that complex web of interactions that sustain culturally potent symbols of medicine, in this case, the symbol of “the good doctor.”8

In what follows, I first sketch a brief history and contemporary snapshot of the medical romance and then turn to a textual analysis of medical professionalism as portrayed in the American digital editions of the Brides of Penhally Bay series.9 Published over a short period of time, with a single contemporary setting and many recurring characters, the series can be studied as one representation of early twenty-first-century ideals of medicine. It is not, however, only an ideal: the texts take up current challenges facing the medical profession. My third and final section, acknowledging the inescapable complexity of any novel, even the most “formulaic,” explores three complicating narratives that raise critical questions about this ideal, serving as counterpoints to the dominant narrative of nostalgic professionalism.

The Medical Romance

British publishing company Mills & Boon launched in 1908 as a publisher of inexpensive books for a wide readership. By the 1930s, [End Page 72] the company had decided to focus on its most profitable segment, romance fiction, and on serial publishing. Rather than promoting individual authors, Mills & Boon created a uniform style and visually distinct brand that served as a “guarantee of good reading” to consumers. Library patrons would ask for the books by type: “No titles. No authors. Just ‘nurse books.’ So long as the dust-jackets depicted a uniformed nurse and a clean-cut doctor type, [the reader] was obviously going to be quite happy.”10

It was a medical-themed romance that caught the attention of the Canadian firm Harlequin Books, which published its first Mills & Boon novel, Anne Vinton’s The Hospital In Buwambo, in 1957. Harlequin, a family-owned company with conservative values, appreciated Mills & Boon’s wholesomeness and happy endings. In 1958 Harlequin published sixteen Mills & Boon medical romances. By 1972, Harlequin had purchased Mills & Boon, taking the brand global.11

Mills & Boon’s original ambition to appeal directly to the consumer by publisher branding rather than by individual author, title, or plot has been so successful that “Mills & Boon” (in the United Kingdom) and “Harlequin” (in the United States and Canada) function as synecdoche for “romance novel.” Harlequin publishes about half of all books in the romance genre, producing more than one hundred titles a month in thirty-four languages, sold in one hundred and ten international markets. Romance fiction comprises sixteen percent of the United States book market, far outselling all other genres, including literary fiction, mysteries, and science fiction/fantasy, with $1,438 billion in sales in 2012.12

The popular romance novel contains two core elements: a central love story and an emotionally satisfying and optimistic ending.13 The requirement that each romance end with not just a happy ending but “emotional justice” signals two strong currents animating the genre: morally good protagonists, referred to as “heroes” and “heroines,” and an emotional journey to the “happily ever after.” Given the positive social status enjoyed by doctors and nurses, especially in post-World War II United States and England, and the highly charged nature of medical labor, it is no surprise that medical settings have enjoyed enduring appeal for romance readers. As Harlequin medical romance author Betty Neels put it over fifty years ago: “The hospital world is a bit of a mystery to most people—dramatic and exciting. Members of the medical profession are indispensible and for the most part are splendid men and women, modest about their skill, and working for and with them, a nurse realizes that, although she may not feel romantic about it, ‘others’ do.”14 [End Page 73]

Changes in women’s roles helped propel the popularity of medical romances after World War II, according to historian Joseph McAleer. After the war, Mills & Boon believed that newly independent women who had worked in factories or hospitals, or who had traveled overseas during the war, were less likely to be satisfied with love stories in which the heroine’s sole interest was in finding a husband. Nursing was one of a small number of women’s careers that comported with Mills & Boon’s morality-based editorial standards. Thus, while Mills & Boon had published a handful of titles with hospital settings in the 1930s and ’40s, by 1957 “Doctor-Nurse” romances constituted a quarter of the publisher’s sales.15

The growth of the health care industry also fueled interest in romances with a medical theme. The United Kingdom’s National Health Service (NHS), founded in 1949, doubled the number of doctors and nurses within twenty-five years. During this period, both health awareness and appreciation for medical professionals grew. Popular consumption of medical stories included medical television dramas and women’s magazines, which often featured hospital-set stories.16 Women in particular, who utilized the health service more and, at least according to Mills & Boon editors and authors, “were more emotional” about it, got a “particular thrill” in reading books set in hospitals.17 The health care industry in the United States experienced a similar surge in size, reputation, and popularity as a setting for stories in television, film, and women’s magazines.

Harlequin medical romances are “category romances,” published under a common imprint or series name, numbered sequentially and released monthly, in paperback and, later, digital formats. About fifty thousand words each, they have an easily recognizable cover brand: a logo that says “Medical Romance” followed by a short EKG strip. Editorial guidelines for authors stipulate a “contemporary medical setting” in which the protagonists, medical professionals with “complex characters,” must work together.18 Indeed the couple’s working relationship must propel the romantic relationship. They are set in every imaginable health care setting, from urban teaching hospitals in the United States to rural family practice clinics in Wales to refugee camps in the developing world. Protagonists engage in a wide range of occupations in health care, including doctors, nurses, EMTs, social workers, critical care transport, and even administrators.19 Television dramas such as House and Grey’s Anatomy serve as models for the books’ tone and scenarios. However, “the focus of each Medical Romance story is first and foremost a heart-racing romance.”20 Over [End Page 74] seventeen hundred medical fiction books are in print, with six new titles published each month.

While the core of the popular romance novel—“a work of prose fiction that tells the story of the courtship and betrothal of one or more protagonists,” in Pamela Regis’s formulation—has remained intact since the genre’s beginnings, it would be incorrect to view such works in terms of a static formula.21 As commodified fiction written with the goal of publication and commercial success, it is a constantly morphing cultural form, shaped by its publishers’ and writers’ sensitivity to both societal changes and readers’ desires. Titles such as Falling for the Playboy Millionaire and The Doctor’s Royal Love-Child notwithstanding, the contemporary setting of medical romances necessitates enough realism not to throw the reader out of the story, which is why the publisher places appeals for authors in nursing journals such as the Nursing Standard.22 Authors “need to give enough detail about treatments and procedures for the background to be convincing.”23 Five of the ten authors of the Brides of Penhally Bay series have medical backgrounds and four have significant personal connections to medicine. Editors, while seeking “contemporary and correct” portrayals of medicine, encourage authors to consult a wide variety of sources, including representations of medicine in women’s magazines, films, and television.24 Thus, other presentations of medical professionalism influence the portrayals by romance writers, many of whom are nurses, complicating any simplistic mapping of “representation” onto “reality,” and connecting these books to more widely circulated images in popular culture.

It may have once been true, as critic T. K. Mangat put it, that medicine in popular medical romance novels was exclusively “a heroic and interventional enterprise practiced by granite-jawed young surgeons in the theatres and acute surgical wards of London teaching hospitals,” but the Penhally Bay series balances the excitement of trauma with less acute medicine: normal pregnancies, preventative care, chronic illness, and safely aging in place.25 In fourteen of the sixteen books, the hero and heroine are both health care professionals, representing not just “brilliant surgeons” but a range of health care providers. This is a change from the 1950s, when the pairing of a female nurse with a male doctor was so common that medical themed romances were called “doctor nurse” romances. The heroines in the Penhally Bay series include six physicians, four nurses, three midwives, one physiotherapist, and one veterinarian. Owing to genre demands that male protagonists exemplify power and success, the heroes’ occupations are less varied: fourteen are physicians, practicing across a range [End Page 75] of areas including general practice, obstetrics, pediatrics, orthopedics, and cardiothoracic surgery.

Medical Professionalism in the Brides of Penhally Bay

The question of professionalism—what it is, how it is threatened, how to preserve or modify it—has preoccupied medicine for at least three decades, when socioeconomic changes began to threaten the traditional understanding of the physician’s role. Commercialization, financial incentives that lead to overtreatment and undertreatment, conflicts of interest, challenges to occupational autonomy from insurance companies and the consumerism movement, a measurable loss of public trust in and social standing of physicians, and a generational shift in physician attitudes towards work have all emerged to jeopardize medicine’s traditional self-image.26 In response, organized medicine, represented by a wide array of global partners, including national medical organizations, specialty groups, accrediting bodies, and private companies, launched a coordinated and comprehensive professionalism project. This project has sought to define professionalism (most famously in the Physician Charter of 2002, an internationally endorsed statement), develop curricula to teach professionalism in medical schools and residency programs, and introduce and refine codes of conduct.27

Within organized medicine, the professionalism project has been framed in terms of nostalgia for a lost era of professional primacy. Terms such as “rediscover,” “recommit,” and “return” are typical of this literature.28 Named “nostalgic professionalism” by outsiders (primarily medical sociologists), its roots are at least as deep as Scottish physician John Gregory (1724–1773) and English physician Thomas Percival (1740–1804), both of whom were concerned with the ethical concept of medicine as a profession.29 From this perspective, medicine provides a uniquely important social function: healing the sick and promoting health. It develops and acts on a socially valuable body of knowledge, the content and standards of which its members define, determine, and transmit through a lengthy process of socialization into the professional community. Doctors are not parties to a business arrangement, but fiduciaries entrusted with the power to use their technical skill and good judgment to serve their vulnerable entrustors—their patients. They must do so while comporting themselves with the highest standards of confidentiality and trustworthiness. Medicine is thus a service vocation, not just a career, requiring first and foremost a pledge to put the needs of patients above one’s own personal interests.30 [End Page 76]

Nostalgic professionalism strongly values altruism, interpersonal skills, personal morality, technical competence, and professional autonomy.31 Rather than viewing a morally neutral contract in which both parties have reciprocal obligations as the ground of its authority, professionalism itself is the basis of medicine’s contract with society. Professionalism is first and foremost a quality of an individual doctor, rather than a relationship between a doctor and patient, or a function of an organization. It can refer almost indiscriminately to values, character traits, attitudes, or behaviors, but always in relation to a particular agent. In other words, nostalgic professionalism has not responded to challenges by shifting its focus to social organization, by exploring themes such as power and privilege, or by recognizing the ways its own values and principles may be circumscribed or thwarted by larger social structures. Instead, organized medicine has emphasized personal integrity while acceding to incremental internal changes that allow it to maintain continuity with the past, continued adherence to its core values, and, importantly, self-regulation and moral autonomy.

The core of that self-image is technical competence. Each book in the Penhally Bay series quickly establishes the superior medical skills of its protagonists. In A Mother for the Italian’s Twins, Dr. Luca d’Azzaro, a new doctor at the clinic, is assigned to shadow Dr. Polly Carrick. As he observes to himself,

That Polly was an incredible doctor had been apparent from that first consultation with Sandy Murray. She was a wonderful listener, empathetic and instinctive, and adept at assessing what patients responded to—an arm around the shoulder, a challenge to motivate them, or a push to face up to reality and to take back control of their lives and their bodies. She wanted the best for them and she gave of herself to help them. And Delia was right about the feistiness. Polly gave total support to her patients, fighting battles for them and prepared to take on their problems.32

In turn, Polly, also a general practitioner, reflects that, “In the last few days she’d discovered that Luca was a fabulous doctor, medically skilled and wonderful with patients, setting young and old at ease.”33 The protagonists are depicted again and again interacting with patients and families in supremely competent, effective ways. As these passages suggest, the series, owing to its core romantic themes, promotes a vision of medicine as not just scientific expertise and technical mastery but also, even predominantly, a human, caring endeavor. In Penhally [End Page 77] Bay, medical experts are not only highly educated and technically gifted, but also naturally adept at developing caring, respectful, and mutually trusting relationships with patients, even though they may have difficulty negotiating adult romantic relationships. This vision of what makes a good health care provider is driven in part by genre: acknowledgement of each other’s medical skill gives the protagonists a basis of mutual respect and shared values when other factors, such as a disapproving family, or distrust based on a tragic past, push them apart.

The rise of evidence-based medicine, along with patient access to medical information on the internet, has transformed medical knowledge. It is no longer a discrete body of information transmitted during training from mentor to mentee but a life-long cooperative practice in which fellow practitioners as well as patients are continuously engaged. As a result of these changes, the scope of individual physician judgment has been increasingly limited in recent years. In the Penhally Bay series, in contrast, individual judgment, based on training and experience, rules the day. Sometimes medical knowledge is portrayed as so esoteric that even practitioners cannot explain from whence it arises. This passage, from the point of view of an EMT, is typical: “She’d been part of the medical profession long enough to respect her colleagues’ intuition about a situation. Often it flew in the face of logic, but it was uncanny how often it was right, so if [the doctor] had a bad feeling about Tel’s condition,” it should not be ignored.34

In Nurse Bride, Bayside Wedding, nurse Madeleine Granger admires Dr. Ed Tremayne’s skills: “He seemed to know almost instinctively what was the right dose, the right treatment.”35 Similarly, Dr. Oliver Fawkner, explaining how he discovered a brain bleed in a patient who had been medically cleared, says, “can’t explain it, but I had a hunch, one I didn’t want to ignore.”36 Medicine is based on a discrete, rarified body of knowledge, not something an average resident of the fishing village might share. These “hunches” are shorthand references to the kind of practical wisdom doctors must develop to successfully apply their knowledge and experience to the needs of a particular patient. Practical wisdom is a significant medical and ethical skill showcased in the Penhally Bay books.37

The major impetus for the professionalism project within medicine is the threat of commercialism. The Physician Charter refers to “market forces” twice in its brief preamble, and names “managing conflicts of interest” one of the ten professional responsibilities of physicians. The Penhally Bay series depicts medical professionals who are not only immune [End Page 78] to the lure of making extra money by “going private,” but for whom the comfortable lifestyle afforded to physicians (even to “lowly” General Practitioners working for the National Health Service) is, at best, an afterthought. In a typical passage, Dr. Jack Tremayne reflects: “when he had discovered the difference he could make to people’s lives through plastic surgery, he’d known he had found his true calling.”38 These doctors strive not for peer recognition but for the health of their patients. While they are grateful for the material comfort their occupations provide, money is not their primary motivation. In one book, a doctor muses that the life of a GP “wasn’t the media version of a doctor raking in the cash and dumping their patients on an outof-hours call system either—at Penhally Bay Surgery, they did their own calls.”39 Rather, these fictional health care professionals love their work because of the inherent pleasures of doing medicine. As one doctor puts it, “He loved the work of being a GP, loved the variety, the chance to meet and to know his patients.”40 One female plastic surgeon, a rival for Jack Tremayne’s affections in The Surgeon’s Fatherhood Surprise, has “had enough of the NHS and all its problems” and sets up a private surgery for “regular hours and a top salary.”41 Her decision is implicitly critiqued when Jack chooses to stay in Penhally Bay with his partner.

As part of the NHS’s primary care service, the physicians employed at the Penhally Bay Surgery are more insulated than their American counterparts from the lure of “market forces.” Nevertheless, they are subject to their fair share of financial constraints, specifically spending limits and understaffing which necessitate unusually demanding schedules. Long hours and jam-packed days are an accepted norm in the Penhally Bay Surgery, along with “ten-minute slots”42 and a “mountain of paperwork.”43 In Christmas Eve Baby, Dr. Lucy Tremayne “had a busy day, starting with Tony Penhaligan and ending with an overrunning surgery, and she’d hardly had a minute to herself in between.”44 But a pressured schedule is never an excuse to abandon a caring, comforting demeanor, not even for surgeons in the busy St. Piran’s hospital thirty minutes from Penhally Bay:

[Dr. Khalil] kept up a brutal pace. … [H]e arrived at St Piran’s in the early hours of the morning to deal with the unending office work entailed in the organisation of such a specialist unit, because he was always there before she arrived for her shift. He then continued through a twelve-hour shift of ward rounds, consultations, assessments and operations, and in between all that he still managed [End Page 79] to find time to speak to worried parents and play with the children or just give them a comforting cuddle.45

Rather than complaining, colleagues cover for each other: cardiology registrar Dr. Walker “didn’t seem to bat an eyelid about doing a colleague’s rounds: she just got on with it.”46 Such dedication serves several narrative purposes: it brings the protagonists together, it demonstrates positive character traits, especially industriousness, and it gives the hero and heroine something to “throw themselves into” when they are emotionally overwrought by the ups and downs of their romantic relationship. Responding to the problem of a constantly full-on-the-verge-of-overcrowded clinic with teamwork and a strong work ethic highlights the personal virtues of the protagonists, in keeping with nostalgic professionalism. However, this “heroic” response undercuts analysis of the systemic issues that result in such a constantly precarious situation, insulating organized medicine, and the practitioners of it, from sustained critique.

All of these behaviors and attitudes are in service to one ethical ideal: altruism. Placing the welfare of the patient before self-interest is the fundamental ethical norm emphasized in the professionalism project, and it is ever in evidence in the Penhally Bay series. As midwife Chloe MacKinnon puts it, “The patients’ needs are the most important thing.”47 Likewise, the most dramatic scenes in any given Penhally Bay novel involve a protagonist putting aside a specific fear or traumatic memory in order to help a patient in need. In a tongue-in-cheek letter to The Lancet in 2007, Dr. Brendan Kelly opined that “These novels draw attention to … the inevitability of uncontrolled passion” in the medical setting.48 On the contrary, however, while the novels are rife with intrusive thoughts about the attractiveness of colleagues that build the kind of sexual tension romance readers enjoy, passions themselves are tightly controlled in the Penhally Bay Surgery, never affecting work. Indeed, it is much more likely in these novels that the couple’s commitment to medicine interrupts the romance. Answering a cell phone during lovemaking, stopping to help an accident victim while en route to a romantic restaurant, and cutting short a vital personal discussion in the clinic to avoid making a patient wait are typical actions taken in the name of altruism.

Nostalgic professionalism has historically emphasized work to the exclusion of other pursuits like family, hobbies, civic commitments, and leisure, but today’s younger doctors (Millennials, or Generation Y—the cohort born after 1981) tend to seek a more balanced lifestyle.49 As [End Page 80] younger physicians with different ideas of appropriate work-life balance (sometimes labeled lazy or selfish by senior practitioners) enter the professional ranks, medicine’s traditional emphasis on selfless dedication has been subject to scrutiny, leading to some structural changes such as shorter duty hours for residents. The protagonists in the Penhally Bay series tend to be just a year or two older than Generation Y, yet, unlike many of their real life counterparts, they accept that a career in medicine requires a dedication to work above everything else. Indeed, this particular professional norm allows the protagonists to meet early and often, a necessity in a courtship story with a relatively low fixed maximum word count, and ensures a high level of mutual understanding, minimizing conflicts over availability. The Harlequin Medical line, like much of the genre, portrays a heterosexual marriage with children as the appropriate culmination of the romantic relationship, and nearly every couple is married with children by the end of their story. While some of the female protagonists decide to leave work to care for their children full time, they do not question the professional structure that forces this choice.50

The relationship between doctors and patients has also been transformed in recent decades. Many patients desire to be full partners in the health care decisions that affect them, rejecting paternalism (“doctor knows best”) in favor of a more autonomy-enhancing approach (“no decision about me without me”). The idealized dyad of “doctor-patient” has been replaced by health care teams and destabilized by “outsiders” ranging from third-party payers to independent health-related websites. Organized medicine is increasingly likely to ask patients to bear some responsibility for their own health, whether in the form of “patient’s responsibilities” documents in hospitals, “healthy living” incentives from health insurers, or “contracts” with primary care physicians to encourage compliance with diet, exercise, or abstinence programs. Also affecting clinician-patient relationships is a greater awareness of the inevitability of medical errors, of the possibility of malpractice litigation, and of the threat of workplace violence perpetrated by patients on health care professionals.

By highlighting a renewed physician commitment to patient welfare, nostalgic professionalism tends to de-emphasize these changes. Similarly, the Penhally Bay Surgery is a place where the physician-patient dyad is not mediated by technology, threatened by conflict of interest, influenced by fear of litigation, or tested by disruptive behavior or noncompliance. The threat of lawsuits, for example, is mentioned twice in the series, but never influences treatment decisions. [End Page 81] In Christmas Eve Baby, when a patient teasingly asks if she is practicing defensive medicine, Dr. Lucy Tremayne reflects: “Would she send the sample off just so she didn’t get sued if it later turned out to be a melanoma? Or was it belt and braces? The latter. Being sued would be horrible, but the chances were it would happen in her working lifetime. Being responsible for someone’s death because she hadn’t taken enough care—that was quite different. It would destroy you, unless you simply didn’t have a conscience.”51

Disruptive patients are nowhere in evidence in the Penhally Bay Surgery, and noncompliant patients are scarce. In most cases, patient noncompliance arises from one of two sources: an independent, stubborn streak, or ignorance-fueled skepticism about the treatment plan, both of which are overcome by concerned clinicians using their powers of persuasion. In an era when these sorts of challenges lead to circumscribing the physician’s role and setting clear boundaries between doctor and patient, the fictional Penhally Bay doctors not only have good medical relationships with their patients, but often go “above and beyond,” helping them with personal matters as well.

This is not to say, however, that social changes and the challenges they present to clinicians are entirely absent from Penhally Bay. Despite Susan deVries and colleagues’ claim that “the fantasy world [of Harlequin medicals] endures with none of the traumas or problems faced in today’s society such as domestic violence, rape, murder, or sexually transmitted disease,” the Penhally Bay series at least mentions, and sometimes features significantly in its plots, social issues including abortion, domestic violence, stalking, drug abuse, PTSD from combat during the Iraq War, infidelity, bullying, and teenage pregnancy.52 For example, in Falling for The Playboy Millionaire, cardiologist Charlotte Walker is a sexual assault survivor who spends several hours a week volunteering at a new rape crisis clinic. As she explains to Dr. James Alexander:

“No, you listen to me, James. Rape’s the most under-reported crime in the country, for a good reason. Women who’ve been attacked feel dirty, feel as if it’s their fault, when it isn’t. They’re scared nobody’s going to believe them. Four out of five don’t even go to the police—and even if they do go to the police, a quarter of those have left it more than a day and it’s too late to …” She choked for a moment. “Too late to collect the evidence. And the trials are a mockery. It’s slowly getting better, but still so many jurors just think the woman’s asking for it or making it up [End Page 82] to get revenge on the bloke. And it’s not like that. The majority of women know their attacker, but it doesn’t mean they want to be forced into having sex.”53

Dr. Walker’s speech is typical in that she acknowledges a social problem and situates organized medicine as both outside of it and as capable of ameliorating its worst effects. This deft positioning of organized medicine is even clearer when the focus is medical inequalities. Nostalgic professionalism tends to portray inequalities in health as due to “outside” forces without fully acknowledging either medicine’s own role in perpetuating these inequalities, or fully addressing the extent to which social inequalities themselves produce health disparities. In the Penhally Bay series, hard work, good will, and patience inevitably bring a positive result, as when doctors convince the NHS to fund a large clinic expansion and additional staff. Never in the texts does lack of access to health care result in a truly disastrous outcome, but when it threatens to do so, the protagonists step in and work for free, as when one surgeon agrees to perform facial reconstruction on a child who would otherwise have to wait over a year on an NHS wait list and whose family cannot afford private insurance.54 The narrative effect of such charitable acts is to draw attention to the personal qualities of the Penhally Bay Surgery staff and to cast organized medicine, somewhat paradoxically, as an agent of distributive health care justice.

The series addresses racial prejudice (against a Romani Gypsy patient) just once, and the question of racial and ethnic diversity among staff is never raised. All of the protagonists are white, except for Dr. Zayed, who is a member of the ruling class in his home country, the imagined “desert kingdom” of Xandar.55 The Physician Charter acknowledges the need to “eliminate discrimination in health care” and one might reasonably conclude that increasing diversity among medical professionals is part of that, but discussion of diversifying the ranks of medical professionals is surprisingly scant. Similarly, while a significant number of new physicians are hired to the Penhally Bay Surgery over the course of the sixteen books, no explicit attention is paid to the question of diversity.56

Complicating Narratives

Following the editorial guidelines of the Harlequin medical romance line, authors utilize culturally compelling representations of medicine [End Page 83] to create a narrative with both realistic and fantasy elements. As a portrayal of professionalism, the dominant narrative in the Penhally Bay series is nostalgia for a perceived past in which a personal relationship with a capable, caring physician determines everything significant about a patient’s medical course. Changes in the structure and delivery of health care, and internal debates among medical professionals about how to respond to those changes, hardly show up at all. However, underneath the master narratives of romantic courtship and nostalgic professionalism subsist a few foil narratives that suggest the authors are attempting, within the constraints of series guidelines, to recognize, and even accommodate, some critiques. I will just briefly describe three such counterpoint narratives below.

First, in his essay, “Love, Romance, and the National Health Service,” which analyzes 1950s medical romance fiction and the early years of the NHS, Joseph McAleer writes: “While the traditional elements of the Mills and Boon ‘formula’ are intact—escapism, the ‘Alphaman’ hero, the desire for marriage and security, the happy-ever-after ending—the almost fanatical endorsement of the medical profession is striking. The message sent, and met with approval by adoring readers, was this: nurses are heroic and selfless; doctors are larger than life; the delivery system works and hospitals are places of romance as well as healing. The NHS could not have asked for a better endorsement.”57

Sixty years later, while the gender roles have changed with the times, the Brides of Penhally Bay portrays a similar vision of medicine closely aligned with medicine’s idealized self-image. But in the twenty-first century, the social context of eroding trust in medicine due to research and quality of care scandals, commercialism, and suspicion of allied organizations as diverse as government, drug companies, and private insurers cannot help but suggest a more ominous interpretation of the “constantly busy” practitioner. It may have been true in the 1950s that Harlequin medicals served as an unqualified endorsement of the NHS, but Penhally Bay Surgery’s constant staffing issues, struggle to get an expansion approved, and occasional need to step in where the NHS has failed a patient all suggest a critique of the system. Sometimes this critique is quite explicit: “Nick shook his head. ‘It’s not private health care we need here, but more investment in local services. St. Piran’s Hospital struggles to balance its books year after year and it needs extra funding.’”58 More often, it is implicitly hovering as the unacknowledged reason these practitioners are so busy. Indeed, without these systemic failures, which are rarely named yet cast dark shadows on the bright success of medical labor, the integrity [End Page 84] and conscientiousness of the providers—so vital to their ability to serve as ideals of both professionals and romantic partners—would be less in evidence.

Second, hierarchies within medicine are well established, with more money and prestige accruing to more specialized services. Nostalgic professionalism feeds into this hierarchy by emphasizing expertise, and by defining expertise as a discrete, highly specialized body of technical knowledge. Arguably, this hierarchical structure of medicine reflects and exacerbates the growing commercialism of the profession. In the fictional village of Penhally Bay, in contrast, while the fact of professional hierarchy within medicine is acknowledged, the general practitioner and his or her relatively low-tech interventions reign supreme. Conventional wisdom suggests that generalists don’t become specialists because they are not intelligent or driven enough, but in Penhally Bay, this is reversed when a specialist is told he is not cut out for GP work due to his poor bedside manner.59 Several of the protagonists have left “impersonal” positions at city hospitals in order to practice more rewarding “proper community medicine” at the Penhally Bay Surgery.60 The Brides of Penhally Bay reasserts in each text the equal importance of personal qualities to medical knowledge and technical skill. The ideal of nostalgic professionalism itself does little to effect displacement of the hierarchical structure of physician specialties, but when set within a romance narrative that prizes caring and compassion, a more direct critique is rendered possible.

Finally, nostalgic professionalism, because it emphasizes personal virtue, tends to underplay the ways settings, environment, and multiple social roles affect medical professionals. Critics of the professionalism project contend that until the broader social forces that constrain individuals’ actions are accounted for, calls for change will have little impact.61 The Brides of Penhally Bay rarely includes overt references to the particular contextual issues with which those critics are concerned. However, the series does accommodate this critique in its own way. In Penhally Bay, clinicians are well aware of the importance of the rural setting to their ability to practice medicine by their own lights. The close-knit, caring community (another nostalgic fantasy, this time of rural life) makes it possible for doctors to know their patients as people and to use this intimate knowledge to help prevent, detect, and treat disease. Time and again, the features of their social environment—high levels of mutual trust, strong familiarity with local history, traditions, and culture, long-term relationships with not only patients but entire families—are crucial to good outcomes. The fantasy rural [End Page 85] setting also, of course, plays an important role in the “happily ever after” required by the romance fiction genre: the protagonists will be fulfilled not only by each other and their professional roles, but by the supportive, friendly, and caring setting in which they will live. In this manner, the series finds a way to respond to one particular critique of nostalgic professionalism without sacrificing the overriding significance of individual noble character in medicine’s success.

Conclusion

Scholars often analyze popular fiction in terms of the very bestselling and most widely read books, but as entertainment becomes more fragmented and individualized in the twenty-first century it is increasingly important to acknowledge the cultural significance of popular niches. Ninety percent of romance readers in the United States (and likely worldwide) are women, and the largest percentage of readers are middle-class, and are older than thirty.62 This is a demographically narrow group, but its significance widens when we consider that it also consumes other popular images of medicine in literature, film, television, and the web, and that the picture of medical professionalism presented in medical romance fiction overlaps considerably with that depicted in other media. The cynical misanthrope Dr. House of television fame, for example, may seem to have little in common with the caring, compassionate GPs of Penhally Bay, but he shares with them several traits of nostalgic professionalism, such as confidence, medical competence, technical mastery, and a tendency towards paternalism. In short, medical romance fiction, despite being consumed in the United States and United Kingdom by a niche audience, participates in a significant way in drawing on, altering, and sharing much more widely disseminated popular conceptions of medical professionalism.

Rather than offering timeless truths about medicine, the Penhally Bay series engages indirectly with current debates. In attempting to negotiate the sometimes divergent demands of realism and fantasy, of romantic love and professionalism, of creativity and commercialism, authors have built courtship stories that narrate the allure of nostalgic professionalism while also offering emendations to and subtle critiques of that ideal. The unusual vantage point of romantic love necessitates a slight shift in perspective, which opens opportunities for reflection on what is valuable in nostalgic professionalism and what is problematic when placed in the context of the good life, inclusive of personal and [End Page 86] social relationships. Which particular images are utilized (and which are forgone), how they are deployed or altered, and their relationship to current struggles over what a medical professional should be, illuminate important issues rather than providing answers. While these are “just” representations, they interact in a complex system with institutions, practices, and individual moral agents, sustaining a raft of relevant beliefs and values, the kind of beliefs and values about physician practice which remain central to the ethical practice of medicine. Although popular romance fiction appears an unlikely place to find any intervention in insular debates about medical professionalism, a closer analysis demonstrates that a particular historically grounded and well-known image of doctoring remains, for better or worse, not just the nostalgic fantasy of a powerful cohort within organized medicine, but a socially salient ideal.

Jessica Miller

Jessica Miller is associate professor and chair of the philosophy department at the University of Maine, where she teaches courses in biomedical ethics, ethical theory, and philosophy and literature. She is also clinical ethicist at Eastern Maine Medical Center, where her work includes ethics consulting and staff education. Her research interests include the ethics of trust, clinical ethics, and the intersection of popular culture and moral psychology.

NOTES

I would like to thank Elizabeth Neiman, Stephen Miller, Laura Vivanco, and Sarah Mayberry for their invaluable assistance with this paper.

1. Quoted in Collier, 1347.

7. Ibid.

9. First published in print in the United Kingdom from 2007 to 2010. Harlequin medicals are published in digital format only in the United States.

11. Ibid., 139.

13. This particular formulation is from the Romance Writers of America, “About the Romance Genre.” There are, of course, competing definitions in the scholarly literature. See, for example, Pamela Regis, A Natural History of the Romance Novel, which develops an account of the eight formal features of the genre, and Barbara Fuchs, Romance, which treats romance as a strategy rather than a genre.

19. According to Val Williamson, it was reader and writer requests that led to a wider range of professional roles featured in medical romances. See “Labour of Love,” 107.

28. See, for example, Bernat.

33. Ibid., loc. 686.

50. None of the male protagonists leave work for this reason. The series does not question the gendered structure of domestic life that makes such choices seem natural. Nostalgic professionalism and ruling conceptions of (white, middle class, heterosexual) masculinity shore each other up in interesting ways.

56. Of course, the population of Cornwall England is overwhelmingly (95%) white. NYC Angels, a 2013 Harlequin Medical Romance series set in a fictional New York City children’s hospital, also features no protagonists of color. Popular romance fiction’s lack of diversity, which extends well beyond the borders of the Harlequin medical subgenre, is rooted in history, audience, and culture, like that of much popular commercial fiction.

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