Medical Omnipotence and Transactional Analysis:

A Pedagogical Proposal
Beatriz Maria Azambuja B. Guimares
Abstract
This article discusses the problems of
student doctors in community residency
programs in Brazil and the psychological
conflicts and difficulties that arise for them
when working in poor neighborhoods. The
author describes her application of
transactional analysis in process groups to
assist these students in working in different
cultural environments.

In the state of Rio Grande do Sul in

Brazil, the community medicine internship
and residency programs are operated at small
health clinics (HC) supported by the Porto
Alegre
Municipal
Administration
in
cooperation with the Federal University of Rio
Grande do Sul. Dual functions are performed
at these locations: ambulatory care in the HC
setting and extended public health services out
in the community. It is in relation to the latter
that interns and residents are under my charge.
The HCs are located in slums on the
outskirts of Porto Alegre - overpopulated
areas that receive little or no assistance in
terms of urban infrastructure (light, water,
sewer system, streets, pavement). It is obvious
that the people who inhabit such areas are in
need. When going to one of these poor
neighborhoods for the first time, students face
a miserable environment, one they know
exists but, like the rest of us, one they prefer
to forget. This article is about the assimilation
or rejection process students undergo in terms
of this reality and the use of transactional
analysis in
This article was original published in the May
1996 issue of REBAT, the Brazilian
transactional analysis magazine edited by
UNAT-Brasil, the Brazilian Transactional
Analysis Association.

the supervision of interns and residents in an

educational context.
Few popular ideas have such direct
applicability to this situation as the idea that
what is true in terms of theory does not
necessarily lead to good practice when it
comes to the health of the Brazilian
population. Postmodern discourse is full of
terms such as "the individual's totality," "the
social effect," and other various articulations
(more or less sophisticated) that, however
lofty sounding, do not prevent the human
body from being treated like a machine in the
doctor's routine. It is as if each of the body's
separate parts has little or no relationship with
each other, or with the world. The incredible
technological advances that occurred at the
end of this century have contributed to this
Cartesian-mechanist view, hiding the reality
that the exalted use of medical technology
(undoubtedly useful in an individual
emergency) does little for the health of the
general population.
The mechanist view so popular during
the last three centuries leads most people
(including most doctors) to think of health as
something separate from the sick individual
and from humankind's life situation. It is not
surprising that from this biomedical
perspective diseases are viewed as defined
entities with unique causal roots and structural
changes at the molecular level. This
reductionist concept treats a "part" of the
human body as if it were independent from the
other "parts" and from the world in which it
lives. This model leads to iatrogenesis and
toxicity, while those in charge of applying it
the doctorspresent high levels of unhealthy
lifestyles (e.g., a doctor's average life span is
up to ten years less than the average for the
rest of the population). Unfortunately, this
distortion begins in medical schools, which
are ill-prepared to stop stress

from affecting their students, This is also true

of nonmedical institutions, but one would
suppose that physicians, being more directly
concerned with health, would be more knowledgeable in this area.
All the events that occur in a nation are
linked together. We cannot separate attitudes
toward health from political attitudes, or from
education or economic status. Thus, when a
large part of the population of a country is
unhealthy, it is mainly because the
government is neglecting its duty with regard
to public health. We have good laws in Brazil
concerning public health, but these laws are
not effectively implemented. Moreover, when
medical schools are an important part of the
society in which they exist, they must play an
important role in observing and evaluating the
government's concern and actions with regard
to public illness.
Within the large group of Brazilian
people who work in the health professions,
these considerations are not new. Some
teachers, researchers, and physicians like to
say (with pride) that they discuss social
context and its relationship to infirmity.
However, this "social context" seems to be an
imponderable entity that lingers ethereally and
at a distance from the city inhabitants' daily
lives. It is common to hear about "social
causes" and "social effects," although we do
not know exactly how much they affect us. It
is more or less as if "it is there, we are here"
something similar to knowing we need to
worry about the ozone layer, but without any
notion of what to do about it. Incidentally,
isolated efforts on the part of some Brazilian
institutions that are concerned with the health
of the general population are considered by
many medical specialists to be outside the
medical environment because the most
important unit is believed to be the individual
in private practice. Changing this view is
difficult even in debates that consider
controversial issues, such as those that define
health as a public asset.
Seeking social answers to questions
regarding public health cannot be regarded
simply as an intellectual exercise, one distant
from concrete daily life. On the contrary, I
believe that such considerations must be part

of the daily university routine and must be

lived by students and professors in a direct,
continuous, and systemic way. This can, on
the one hand, reduce the overemphasis on
disease reduction in the medical curriculum (a
fact that contributes to physicians feeling
omnipotent) and, on the other, provide a focus
on the social environmentnot merely as an
influence on people and groups theoretically,
but as a presence and force that permeates all
segments of individuals' lives.

The Social-Educational Context:

The Beginning of Conflict
For a better understanding of what
happens with graduate students and residents,
let us consider what occurs when they
experience the misery (and everything it
causes) found in the slums that surround large
Brazilian cities. I believe it is useful to focus
on the role of the university in the education
of young people and how it works to reinforce
the social-family atmosphere. The student
who enters the university has had a long
history of didactic teaching that is continued
within the university walls, a history that
discourages autonomous thinking. Students
are limited to reproducing, as faithfully as
possible, the course contents that are
presented to them, without daring to think
critically about them. Any challenging
proposal, any new concept that diverges from
the generally accepted model and stimulates
students to use their neurons independently
seems to isolate them and prevent them from
acting autonomously.
It would be simplistic to suggest that an
attitude of passivity is the only answer in this
stressful situation. No family (or the individuals who replace it) exists in isolation.
Everyone lives and acts within a cultural
context that suggests implicitly or explicitly
how to live and act in that specific society. In
addition,
social-cultural
and
genetic
tendencies are constantly being reinforced by
other institutions such as schools (from
elementary to postgraduate levels) that give
meaning to values and other appropriate
parameters for living learned by the individual
when very

young. Perhaps it would not have to happen

this way if the university would play the role
it awards itselfthat of an agent of social
transformation.
The university justifies its existence
through the production of knowledge, which
obviously includes transmission of this
knowledge, because people cannot reconstruct
accumulated knowledge with every new
generation. The production and transmission
of knowledge is intended to integrate
information for the student and at the same
time encourage the transformation of
knowledge. This transformation is not meant
to alter the Pythagorean theorem or destroy
the law of gravity, but to lead to the adoption
of an attitude of questioning and seeking
better understanding not only of the
knowledge but also of how knowledge
reproduces itself. This makes possible a
process of teaching-learning that allows for
critical evaluation of itself, but, aside from
isolated heroic efforts, our universities have
limited themselves to reproducing knowledge
and do not allow the creation of new
knowledge and viewpoints.
In the school of medicine in which I
teach, although a few professors are involved
in discussions that focus on population health,
its praxis centers almost exclusively on
illness. Although the solely biological concept
of illness is considered obsolete, in fact,
teaching is designed to identify pathology
taxonomically, to concentrate on it, and to
forget, many times, the ill person. It should be
different, however, for as Lobato (1987) said,
"There is no such thing as illness. . . . There
are ill people." Thus, the concept of illness is
an abstraction (p. 99). There are viruses and
bacteria that, in contact with certain
organisms, will result in the person's
symptoms. So, "one should not speak about a
man with an illness or about an illness in the
man, but only about an ill man" (p. 99).
From this premise, one can infer that if
infirmity is part of a person's life, each of us
creates our own infirmity, which includes
biological, psychological, and social factors
that condition the pathological state and are
previous to this "state." Unfortunately, this
view is still limited to a few people in the
medical environment, and most of them

continue thinking and acting in a Cartesian

way, betting on "superspecialized" knowledge
(which can be linear and fragmented) that
provides the holders of this knowledge with a
defensive wall with which to protect themselves, solidifying their positions as "keepers"
of knowledge.
It is probable that this position, one
taken by medical schools, is a strong
contributing factor to the sense of
omnipotence felt by doctors. Medical students
spend their entire academic lives accountable
for an isolated and abstract entitythe
infirmityan aggressive enemy, something
extreme for the individual. They are not
trained to consider the problem as a result of
multiple
and
perhaps
idiosyncratic
contingencies. To change this view is to fight
a desperate battle; however, it is this battle
that I have focused on, hoping that those
students who reach a level of understanding,
behavior, and attitude different from the
prevailing approach may, on their own,
become agents of transformation of the sad
and desperate health reality of the Third
World.

The Context of the Slum:

The Establishment of the Conflict
The misery in the Third World is shown
regularly in the media; however, it only
reaches the upper classes directly when, by
chance, a child approaches a driver who stops
at a traffic light, a beggar becomes insistent,
or some similar situation occurs. On those
occasions, we try not to look. We walk or
drive faster and put the uncomfortable and
accusing figures out of our thoughts. We deny
their existence to maintain our psychic
equilibrium. For that very reason, new doctors
or postgraduate students, when faced with
locations in which "these people" (meaning
very poor people with a connotation of
prejudice implied in the quotation marks) live,
feel shaken and shocked, to say the least, by
the menace that they represent to the
doctors'/students' once safe, structural somatopsychic-social framework.
This shock can be attributed to two
inseparable and complementary factors: first,
the students' family and

environments, which educated them to obey

rules, and second, the institutions that
reproduce and reinforce parental figures who
emphasized
that
the
social-cultural
environment in which they work is a strange
and separate reality. The students' knowledge
is encapsulated. They were taught that humans
must be treated within the space that was
previously assigned to them, dissociated from
their environment.
When beginning ambulatory service in
the HC, little by little the students' selfconfidence recovers from the initial shock as
they start playing the role of doctor in the
well-established power relationship for which
they were trained: "I have the knowledge (I
am a doctor), you do not have the knowledge
(passive patient), and you will follow my
directions. You have an illness that I can
identify." While they are "protected" within
the four walls of the HCs, things go alright,
and even when working in a poor
neighborhood, they can work comfortably,
confident in the work they have been trained
to dothat is, to be doctors.
However, once away from the HC,
working outside their comfortable territory
in the slums with the inhabitants and on equal
terms with them things become
complicated. In the community centers, in
which labor unions are active, the people
many of whom may be politically critical and
angry may contest the application of the
students' medical knowledge (and sometimes
even the content), protest, and insist on to
better service for the infirmities that afflict
them. This makes unexpected demands on the
doctor to adapt.
This confrontationwhich for many
student doctors is experienced as a
questioning of their personal performance
creates a conflict and threatens their psychic
organization. Their defensive structure, once
so well-prepared, becomes disorganized,
without their being aware of it. And from the
certainty of their omnipotence, which they
experienced in the ambulatory clinic, they
become uncertain, blaming technicians and
teachers with complaints such as "I do not like
to work like this" or "This schedule is no
good" and so on. To survive, the students erect

a series of defenses so that their threatened

equilibrium can be restored. The most
common defense mechanisms used are denial
and dissociation from the reality that
surrounds the students. They come to regard
the population not as economically
disadvantaged human beings, but as a "gang
of criminals."
This type of mechanism reinforces the
position of medical omnipotence that was
probably well-established before the students'
first contacts with the hospital because it
seemed to be a protection against the fear
experienced while treating the poor in the
H.C. On other occasions, the curriculum is
called "absurd," and professors are blamed for
being "disorganized" because they do not
present the same type of didactic plan students
find in conventional disciplines, with rigid
contents and time structures. Sometimes
students request conventional classes and
adequate places to meet their needs, refusing
to accept that the goals of this type of training
and residency program are incompatible with
traditional teaching. In erecting such barriers,
students make it difficult to understand the
need to discuss with people their most
common health problems. The solution for
this conflict, for many, is established through
"autism." They do not want to see, listen, or
feel anything around them. They prefer to
label professors and slum dwellers as
"communists" and think about something else.
It is at this point, when work becomes
difficult because of these circumstances, that
it is necessary to interrupt the medical work in
order to process what is happening with the
students. At this point, a new dimension is
about to be perceived and perhaps accepted.

The Intra- and Interpersonal Context:

The Possibility of Conflict Resolution
This interruption means that work in the
community is suspended so that, together with
the students, a review of medical knowledge
(including its role in society and the meaning
of its formation) may begin. I start by using
some transactional analysis principles in meeting with the group. I do not give a 101 course.
I only use concepts that I consider relevant to

the occasion, such as transactions and rackets

or ego states and psychological games as
applied to a practical situation involving a
doctor-patient relationship. Most of the time I
do not even name the ego state. I only point
out the way the person acted or behaved in
certain situations. This does not mean I am
avoiding the term "transactional analysis"; it
means that I do not use it indiscriminately.
I consider it an advance when the
students begin to notice that their university
education is directly linked to their family
organization, their background, and their
personal development and individualization.
That is why one of the main foci of discussion
is medical omnipotence and how it functions
as a defense against one's own insecurity or
fear of failure. When this can be openly
discussed in an Adult-Adult context,
omnipotence is also seen as the individual's
answer to demands from the Parent ego state.
People often do not search randomly for jobs
or professions. The surface reasons may be in
conscious awareness (and are, most of the
time), but behind this is often a need to
conform to parental demands and to satisfy
the need for affection and acceptance in the
family. A group process often occurs in which
one of the participants raises a difficulty, and
when others admit to the same kind of
problem, the group becomes involved in an
intra- and interpersonal process.
This kind of material is worked on
differently by each group of students. Some
almost immediately accept the challenge by
discussing and arguing until they realize at
least two polarities that they had not
considered seriously before: (1) in relation to
the social context, to admit that the individual
does not live on his or her own, isolated, being
both subject and object of the environment;
and (2) in relation to himself or herself, that
the unconscious acts independently from the
conscious will, and that logical-formal
thinking, which the students had been used to
in their lives, is only part of the mental
structure. Moreover, they learn that this
"logical thinking" may be contaminated by
Parental prejudice, which interferes with the
Adult's autonomous thought and action.

Some members of the group are more

resistant. Although they take a little longer
because each group has a different rhythm for
accepting or rejecting new approaches,
eventually they still "get there." Finally, there
is a third group that denies that their restricted
and "autistic" behavior exists because of
environmental and developmental factors.
They insist that their views are correct, and
they do not allow themselves any other
options. They assert their viewpoints in a
cathexis of exclusion.
It is important to point out that not all
conflicts are solved satisfactorily. This way of
working with students was carried out empirically and intuitively until recently, without my
knowing exactly why I acted in this way. It
was only when I began to apply the
transactional analysis approach that I realized
that, although what I did with students was not
exactly group therapy, it was certainly therapeutic work in the sense that it facilitated their
self-awareness and favored change in their
thinking and behavior.
As a result, I began to study harder to
understand my own goals better and to use
various resources that could be useful in
confronting traditional approaches. Since then
I have attempted to give theoretical support
for this activity (from Levin [1935] to Rogers
[1970] and Berne [1964, 1966, 1972/1988]),
as well as to continue to modify my own
views and attitudes. Currently, I do not wait
for students to "explode" in order to act.
Seminars are already planned ahead (some
with specific contents, others to be decided) to
provide theoretical foundation, and the groups
are formed so that students work on
themselves therapeutically while working with
the community.
It is clear to me that this group has an
Adult function (manifested as behavior)
discussing applicable theoryand also a
Parent-Child function (more internally
focused) serving as therapeutic support
against the threat of disorganization caused by
the confrontation between the student's
previous reality and the one lived in the
present. This confrontation seems to be
similar, on another level, to the conflict

proposed by Berne, who said that humankind's

destiny is decided when people confront what
they want from others with the realities
encountered in the actual world. At this time it
is useful to have a facilitator who helps build
bridges between there and then and here and
now. When people are in the process of
change they are vulnerable and need all
possible protection to facilitate change. The
mediator does not always succeed in helping,
but one needs to dare to reach for new solutions.

Beatriz Maria Azambuja B. Guimares

is professor of the internship and residency
program of community medicine in the School
of Medicine, Federal University of Rio
Grande do Sul, Porto Alegre, Brazil. She is
also in private psychology practice. She is a
Certified Member of UNAT Brazil (the
Brazilian Transactional Analysis Association).
Please send reprint requests to her at Rua
Coronel Bordini 1180, apto, 11, 90440-003,
Porto Alegre, R.S., Brazil.

Conclusions
I believe that the task of a professor is
not only to inform students, but more
importantly, as a parent figure a professor
must provide students with tools that can help
them in building their own lives. As a
university teacher, transactional analysis has
greatly assisted me in being understanding and
empathic with student problems, rebellions,
and weaknesses. It can be an effective and
powerful tool in the teaching/learning process.

REFERENCES
Beme, E. (1964). Games people play: The
psychology of human relationships. New
York: Grove Press.
Berne, E. (1966). Principles of group
treatment. New York: Grove Press.
Berne, E. (1988). 0 que voc diz quando diz
ol? [What do you say after you say
hello?] (R. Krausz, Trans.). So Paulo:
Nobel. (Original work published 1972)
Levin, K. (1935). A dynamic theory of
personality. New York: McGraw Hill.
Lobato, O. (1987). O homem e a doena
[Man and the disease]. Revista HCPA.
7(2). 9-11.
Rogers, C. (1987). Grupos de encontro [On
encounter groups] (J. Proena, Trans.). So
Paulo: Martins Fontes. (Original work
published 1970)