Technical details for the Spanish subsample of the European Manufacturing Survey 2012 edition.
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Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
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Aspects of human herpesvirus simples, varicella-zoster virus, and cytomegalovirus are presented and discussed in this book.",isbn:"978-1-83881-159-4",printIsbn:"978-1-83881-158-7",pdfIsbn:"978-1-83881-160-0",doi:"10.5772/intechopen.73940",price:119,priceEur:129,priceUsd:155,slug:"human-herpesvirus-infection-biological-features-transmission-symptoms-diagnosis-and-treatment",numberOfPages:128,isOpenForSubmission:!1,hash:"beb076fbfc65deb69820f12f934bfdcd",bookSignature:"Ronaldo Luis Thomasini",publishedDate:"April 1st 2020",coverURL:"https://cdn.intechopen.com/books/images_new/7142.jpg",keywords:null,numberOfDownloads:2957,numberOfWosCitations:1,numberOfCrossrefCitations:2,numberOfDimensionsCitations:5,numberOfTotalCitations:8,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"July 3rd 2018",dateEndSecondStepPublish:"September 7th 2018",dateEndThirdStepPublish:"November 6th 2018",dateEndFourthStepPublish:"January 25th 2019",dateEndFifthStepPublish:"March 26th 2019",remainingDaysToSecondStep:"2 years",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"81175",title:"PhD.",name:"Ronaldo Luis",middleName:null,surname:"Thomasini",slug:"ronaldo-luis-thomasini",fullName:"Ronaldo Luis Thomasini",profilePictureURL:"https://mts.intechopen.com/storage/users/81175/images/system/81175.jpeg",biography:"Ronaldo Luis Thomasini is a Professor of Microbiology, Parasitology, Pathology, and Pharmacology at the Faculty of Medicine of Diamantina-Federal University of Jequitinhonha and Mucuri Valleys - UFVJM, Brazil. He is a Coordinator of The Center for Studies of Inflammatory and Infectious Diseases and a Professor in the Multi-Centric Post-Graduation Program in Physiological Sciences (PMPGCF-UFVJM), and Post-Graduation Program in Pharmaceutical Sciences (PPGCiFarm-UFVJM). He is a graduate (Licenciate and Bachelor) in Biological Sciences by Herminio Ometto University Center (2002), Master degree in Pharmacology by State University of Campinas - UNICAMP (2007), and PhD in Clinical Medicine by the same university (2011). He has a post-doctoral fellow in Biochemistry and Immunology from the Federal University of Minas Gerais-UFMG and develops studies in clinical pathology, microbiology, virology, immunology and biochemistry, techniques on molecular biology applied to the diagnosis of infectious disease and host-parasite interactions.",institutionString:"Federal University of Vales do Jequitinhonha e Mucuri",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"State University of Campinas",institutionURL:null,country:{name:"Brazil"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1046",title:"Infectious Diseases",slug:"infectious-diseases"}],chapters:[{id:"69359",title:"Introductory Chapter: Human Herpesvirus - A Short Introduction",slug:"introductory-chapter-human-herpesvirus-a-short-introduction",totalDownloads:198,totalCrossrefCites:0,authors:[{id:"81175",title:"PhD.",name:"Ronaldo Luis",surname:"Thomasini",slug:"ronaldo-luis-thomasini",fullName:"Ronaldo Luis Thomasini"}]},{id:"64844",title:"Sunlight and Herpes Virus",slug:"sunlight-and-herpes-virus",totalDownloads:839,totalCrossrefCites:1,authors:[{id:"273350",title:"Prof.",name:"Vittorio",surname:"Mazzarello",slug:"vittorio-mazzarello",fullName:"Vittorio Mazzarello"},{id:"274197",title:"Dr.",name:"Marco",surname:"Ferrari",slug:"marco-ferrari",fullName:"Marco Ferrari"},{id:"283742",title:"Prof.",name:"Maria Alessandra",surname:"Sotgiu",slug:"maria-alessandra-sotgiu",fullName:"Maria Alessandra Sotgiu"},{id:"283744",title:"Dr.",name:"Stefano",surname:"Decandia",slug:"stefano-decandia",fullName:"Stefano Decandia"}]},{id:"64988",title:"Neurologic Complications of Varicella-Zoster Virus Infection",slug:"neurologic-complications-of-varicella-zoster-virus-infection",totalDownloads:1074,totalCrossrefCites:1,authors:[{id:"43262",title:"Dr.",name:"Hideto",surname:"Nakajima",slug:"hideto-nakajima",fullName:"Hideto Nakajima"},{id:"286199",title:"Dr.",name:"Makoto",surname:"Hara",slug:"makoto-hara",fullName:"Makoto Hara"},{id:"286200",title:"Dr.",name:"Akihiko",surname:"Morita",slug:"akihiko-morita",fullName:"Akihiko Morita"},{id:"286201",title:"Prof.",name:"Satoshi",surname:"Kamei",slug:"satoshi-kamei",fullName:"Satoshi Kamei"}]},{id:"71254",title:"Extracranial Herpetic Paresis",slug:"extracranial-herpetic-paresis",totalDownloads:207,totalCrossrefCites:0,authors:[{id:"271733",title:"Prof.",name:"Vesna",surname:"Martic",slug:"vesna-martic",fullName:"Vesna Martic"}]},{id:"67401",title:"Human Cytomegalovirus Infection: Biological Features, Transmission, Symptoms, Diagnosis, and Treatment",slug:"human-cytomegalovirus-infection-biological-features-transmission-symptoms-diagnosis-and-treatment",totalDownloads:367,totalCrossrefCites:0,authors:[{id:"269379",title:"M.D.",name:"Şule",surname:"Gökçe",slug:"sule-gokce",fullName:"Şule Gökçe"}]},{id:"69076",title:"The Role of the Epstein-Barr Virus Lytic Cycle in Tumor Progression: Consequences in Diagnosis and Therapy",slug:"the-role-of-the-epstein-barr-virus-lytic-cycle-in-tumor-progression-consequences-in-diagnosis-and-th",totalDownloads:272,totalCrossrefCites:0,authors:[{id:"188773",title:"Prof.",name:"Emmanuel",surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet"}]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"220812",firstName:"Lada",lastName:"Bozic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/220812/images/6021_n.jpg",email:"lada@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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Annous and Joshua B. Gurtler",coverURL:"https://cdn.intechopen.com/books/images_new/2061.jpg",editedByType:"Edited by",editors:[{id:"101172",title:"Dr.",name:"Bassam",surname:"Annous",slug:"bassam-annous",fullName:"Bassam Annous"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"51019",title:"Analysing the Adoption of Energy-Saving Technologies in Manufacturing Firms",doi:"10.5772/62852",slug:"analysing-the-adoption-of-energy-saving-technologies-in-manufacturing-firms",body:'\nSustainable development, meaning meeting the needs of present generations without jeopardising the ability of the future generations to meet their own needs [1], implicitly calls for an energy- and resource-efficient society, in which all pillars of the quadruple helix—academia, industry, government and citizens—are challenged to move towards energy and resource efficiency. Generating and enriching the current knowledge base by academia, implementing energy-efficient solutions and producing goods/services by companies towards this end, setting goals and promoting policy measures by local, regional, national and supranational bodies, as well as making informed choices by users/consumers are some of the generic musts towards sustainable societies.
\nEven some progress has already been made; new energy systems are gradually adapting, while the scale of challenge increases. Industrial activity, in particular, is reputedly a primary cause of pollution situating manufacturing firms in the centre of the focus. Nowadays, firms are facing strong pressure from their stakeholders to implement environmental management policies and practices. Moreover, the energy efficiency of the manufacturing processes is gaining importance due to the rising energy costs and the effects of the gas emissions over climate. From the perspective of manufacturers, the challenge is to improve the overall environmental performance of products throughout their life cycle and to boost the demand for better products and production technologies.
\nIn one of the most recent studies on energy efficiency and saving potential in Europe-wide industry [2], the authors make a comprehensive study of the topic, using a sectoral approach as well as detecting barriers and policy measures towards further advances. Global results point towards market competitiveness remaining the strongest driver for energy-efficiency solutions, where the internal barriers to access energy-saving opportunities are not well understood. Another valuable finding is the taxonomy provided by the authors, distinguishing between a series of external and internal aspects that play an important hampering role in implementing energy efficiency and energy-saving potential. The same report calls for innovation as a catalyst towards more energy-efficient manufacturing.
\nInnovation is a key aspect and possible contributor towards novel solutions’ implementation in order to achieve higher energy efficiency. Efforts should be deployed by the targeted promotion and commercialisation of existing solutions, as well as R&D support for emerging alternatives/technologies. The implementation of technologies in the production processes of manufacturing firms falls under process innovation typology.
\nDefined by the Oslo Manual [3] process, innovation is understood as ‘the implementation of a new or significantly improved production or delivery method. This includes significant changes in techniques, equipment and/or software’ (p. 49). According to the same source, the main effects that process innovation might cause are: reduced time to respond to customer needs, improved quality of goods and services, improved flexibility of production or service provision, increased capacity of production or service provision, reduced unit labour costs, reduced consumption of materials and energy, reduced product design costs, reduced production lead times, achievement of industry technical standards, reduced operating costs for service provision, increased efficiency or speed of supplying and/or delivering goods or services, improved IT capabilities, improved communication and interaction among different business activities, increased sharing or transferring of knowledge with other organisations, increase in the ability to adapt to different client demands, development of stronger relationships with customers , improved working conditions, reduced environmental impacts or improved health and safety and meeting regulatory requirements (p. 108).
\nMonitoring particular, singular and specific energy efficiency technologies ultimately means the disposing of firm-level data in all manufacturing areas and in more than one country. Regularly conducted large-scale surveys on innovation (see the Community Innovation Survey) are often multipurpose and remain conceptually global. Having argued the importance and possible benefits of energy-saving technologies (EST) as well as the lack of data on detailed and multiple technologies in manufacturing, we detect a possible gap worth filling with our contribution.
\nTherefore, the objective of this chapter is to map the implementation degree of energy-efficient technologies in manufacturing firms, as well as to identify and understand the structural and operational characteristics that are expected to introduce variations in adoption. The authors also link energy-efficient technologies with perceived saving potential. Using data from the European Manufacturing Survey, we argue the necessity to provide recent data on EST implementation
\nThe chapter is structured as follows. After the introduction, we present the research methodology and methods used to analyse the characteristics of ESTs’ adoption and their adopters. The results and findings are presented for the manufacturing firms with the use of descriptive statistics and simple correlation tests. Finally, we discuss our results and present some implications.
\nOur research is based on data from the European Manufacturing Survey (EMS), 2012 edition [4]. EMS is coordinated by the Fraunhofer Institute for Systems and Innovation Research—ISI, which is the largest European survey in manufacturing activities conducted, to date.
\nThe 2012 edition of the EMS was carried out in 19 countries, mainly the European ones including Russia and Turkey, plus PR of China and Brazil, covering the 70% of firms within the European manufacturing sector with at least 20 employees, NACE codes from 15 to 37 [5].
\nHowever, our study will only include data from EMS Spanish subsample, formed by 170 responses (Table 1). In this case, no other subsamples from additional countries have been included in order to analyse the major number of different available EST, given that the rest of the subsamples do not contain five of the ESTs kept in the Spanish one for the 2012 edition of the EMS. These five excluded technologies were considered for the 2008 edition of the EMS, but not for the 2012 one in the majority of the involved countries. This fact occurs because, apart from the main body of questions inside the survey, each participant country’s partner can include a limited number of particular questions of its interest.
\nUniverse | \nSpanish manufacturing firms with at least 20 employees CNAE 2009; codes from 10 to 32 16.183 companies | \n
Target population | \n4000 firms | \n
Sample | \n170 firms | \n
Confidence margin | \n95% | \n
Variance | \nMaximum indetermination p = q = 50% | \n
Documentation | \nPaper (8 pages questionnaire) + Return envelope + Presentation letter | \n
Channel | \nPostal | \n
Period conducting the survey | \nMay–September 2012 | \n
Reference period | \n2009–2011; 2011 | \n
Fieldwork | \nOGEDP Department, University of Girona – Girona (Spain) | \n
Data base recording and creation | \nDAP GmbH—Passau (Germany) | \n
Sample distribution | \n\n |
By technological sector | \nLow technology: 38; medium–low technology: 67; medium–high and high technology: 64 (59 + 5) | \n
By relative energy efficiency group | \nLess efficient: 16; equal efficient: 50; more efficient: 71 | \n
Technical details for the Spanish subsample of the European Manufacturing Survey 2012 edition.
In summary, the EMS 2012 Spanish subsample considers nine ESTs, which are as follows:\n
– T0: Dry process/Minimum lubrication; N = 162
– T1: Control system for shutdown of machines in off-peak periods; N = 164
– T2: Electrical motors with speed regulation; N = 162
– T3: Compressed air contracting; N = 156
– T4: Highly efficient pumps; N = 158
– T5: Low-temperature joining processes; N = 157
– T6: Energy retrieval; N = 164
– T7: Bigeneration/Trigeneration; N = 167
– T8: Use of waste materials for energy generation; N = 157
T0, T1, T6 and T7 are the ESTs included in the main body of the 2012 survey for all the countries, of which T0 was not included in the 2008 EMS edition. T2, T3, T4, T5 and T8 are only considered in EMS 2008 and the Spanish subsample of the EMS 2012.
\nAll these ESTs are evaluated for each firm in terms of use, yes or no, and their extent of use, grouped in three categories: ‘low’ for initial attempts, ‘medium’, when partially utilised and ‘high’ for extensive use. This extent of use is represented with an ordinal variable containing values 1, 2 or 3, for low, medium or high, and it is always relative, comparing the present to the most reasonable potential use.
\nIn the present study, the EST for this sample of firms will be characterised through descriptive and frequency analyses.
\nAnother descriptive analysis will be presented for the companies inside the sample, including parameters such as number of employees, turnover in 2008 and 2011, firm R&D expenditures, exportation intensity, implementation of environmental management systems, such as ISO 14000 and ISO50001:200, and energy-saving potential according to the several elaborated homogenous groups, based on their technological intensity or their energy efficiency level. Averages for these descriptive parameters mentioned above were directly calculated from variables obtained from the survey.
\nIn particular, the parameter of energy-saving potential becomes a key factor for our study, since it represents a measure of the energy efficiency degree resulting after different implementation levels of EST in manufacturing firms. In this sample, the energy-saving potential is represented by percent, and it corresponds to the relative amount of energy a company could save if it is highly implemented in its production system and in all the available EST nowadays.
\nCharacteristics of EST adopters will be presented according to OECD’s taxonomy of industries, classified by their technological intensity [6]. In this regard, firms have been classified and also presented in three groups: ‘Low technology’, for firms from NACE codes 15, 16, 17–19, 20–22, 36–37; ‘Medium technology’, with medium–low technology firms from NACE codes 23, 25, 26, 351, 27, 28; and ‘High technology’, with medium–high and high technology firms from NACE codes 24, 31, 34, excluding 2423, 352+359, 29, and 353, 2423, 30, 32, 33.
\nAs shown in Table 2, only five firms of this sample have NACE codes 353, 2423, 30, 32 and 33, corresponding to a high technology industry. It is for this reason that medium–high and high technology firms from the OECD’s taxonomy have been grouped together in a ‘High technology’ category (N = 64), in order to reduce the number of groups and maintain their significance.
\n\n | Low technology | \nMedium–low technology | \nMedium–high and high technology | \nTotal | \n
---|---|---|---|---|
N | \n38 | \n67 | \n64 (59 + 5) | \n169 | \n
% | \n22% | \n40% | \n38% | \n100% | \n
Number of employees in 2011, N = 37 + 66 + 63 | \n97 (σ = 107) | \n112 (σ = 165) | \n276 (σ = 820) | \n171 | \n
Number of employees in 2009, N = 36 + 63 + 61 | \n98 (σ = 113) | \n116 (σ = 173) | \n279 (σ = 875) | \n160 | \n
Turnover 2011 [M€], N = 34 + 59 + 57 | \n44 (σ = 70) | \n188 (σ = 893) | \n183 (σ = 747) | \n154 | \n
Turnover 2009 [M€], N = 31 + 57 + 55 | \n35 (σ = 58) | \n341 (σ = 2381) | \n224 (σ = 1099) | \n229 | \n
Firms with R&D expenditures, N = 38 + 67 + 62 | \n53% | \n60% | \n61% | \n59% | \n
High exportation intensity firms, N = 35 + 60 + 57 | \n40% | \n48% | \n33% | \n41% | \n
Firms with ISO 14000 implemented, N = 37 + 61 + 57 | \n38% | \n36% | \n46% | \n40% | \n
Firms with ISO50001:2001 implemented, N = 36 + 63 + 59 | \n3% | \n2% | \n2% | \n2% | \n
Energy saving potential, N = 29 + 54 + 54 | \n15% | \n13% | \n15% | \n14% | \n
T0: dry process/minimum lubrication, N = 36 + 65 + 61 | \n6% | \n15% | \n13% | \n12% | \n
T1: control system for shut down of machines in off-peak periods, N = 36 + 66 + 62 | \n14% | \n14% | \n23% | \n17% | \n
T2: speed regulation, N = 38 + 64 + 60 | \n76% | \n63% | \n72% | \n69% | \n
T3: compressed air contracting, N = 37 + 62 + 57 | \n38% | \n40% | \n44% | \n41% | \n
T4: highly efficient pumps, N = 37 + 63 + 58 | \n43% | \n30% | \n40% | \n37% | \n
T5: low-temperature joining processes, N = 36 + 62 + 59 | \n3% | \n15% | \n7% | \n9% | \n
T6: energy retrieval, N = 36 + 66 + 62 | \n14% | \n5% | \n18% | \n12% | \n
T7: bigeneration/trigeneration, N = 38 + 66 + 63 | \n24% | \n2% | \n10% | \n10% | \n
T8: waste material for energy, N = 36 + 63 + 58 | \n14% | \n5% | \n14% | \n10% | \n
Summary of descriptive features of the sample by technological intensity.
A discrete variable ‘TechLevel’, with value 1 for ‘Low technology’, value 2 for ‘Medium technology’ and value 3 for ‘High technology’, following the previously explained criteria, was calculated from the NACE code data for each firm in the survey. Corresponding dummy variables ‘LowTech’, ‘MedTech’ and ‘HighTech’, with values 0–1, were also elaborated to obtain three subsets of 38, 67 and 64 manufacturing companies, respectively, according to their technological level.
\nIn a similar way, a second classification of firms in the sample, according to their relative energy efficiency level, was performed. To do that, a response in the survey regarding the potential energy saving in the company was utilised. Firms answered to a question on what percent of their current energy consumption could they save if they utilised all the available technical possibilities in the present.
\nThose percentages are represented by a variable in the survey that was used to elaborate three new dummy variables, ‘Low Efficient’, ‘Equal Efficient’ and ‘More Efficient’, with values 0–1. The purpose was to use these dummy variables to obtain three separated groups according to their relative energy efficiency level, comparing its present situation with a hypothetical stage where the company highly used all the available EST today.
\nTo build these categories and collapse the continuous variable with percentage data into three approximately equal groups, a frequency analysis calculating percentiles at 33.33 and 66.66% was performed [7]. The obtained cut-off points for the percentiles 33.33 and 66.66% were 10 and 20%, respectively. In consequence, firms with a relatively low percent of energy-saving potential from 0 to 10% are considered in the ‘More Efficient’ group (N = 71). The reference group ‘Equal Efficient’ (N = 50) includes companies with relative energy-saving potential greater than 10% and lesser than 20%. The rest of the firms with relative energy-saving potential greater than 20% are included in the ‘Less Efficient’ group (N = 16).
\nFinally, in order to explore the possible relationships and their strength and direction (positive or negative) between several continuous and dichotomous variables describing firms’ characteristics and the use or extent of use of ESTs, a simple bivariate Pearson correlation analysis has been conducted. When a positive correlation between a pair of variables is significant, it indicates that as one variable increases, so does the other. Analogously, a negative significant correlation indicates that as one variable increases, the other decreases.
\nGiven that the data corresponding to the size of the companies in the survey do not follow a normal distribution, neither in the number of employees, nor in the case of the turnover, a transformation of these variables is required to use parametric statistics [7]. As these data in the histogram appear left-skewed, a recalculation, using the logarithm of the original values, has reset the histogram into a normal bell-shaped distribution.
\nOther mapping analyses were performed on the EMS 2008 edition Spanish samples, as in the case of [8], and from Spanish and Slovenian samples in [9]. Palcic et al. also mapped EST implementation in manufacturing firms, following a similar methodology.
\nResults about the typology of the manufacturing firms in our sample, with regard to their technological intensity according to the OECD’s taxonomy, are shown in Table 2.
\nWe can observe that companies with higher technological level have, on average, a considerably higher number of employees (276 vs. 112 and 97 in 2011), a strong use of environmental management systems such as ISO 14000 [10], but a lower number of firms with a high exportation intensity (more than 50% of sales abroad).
\n‘Medium–Low Technology’ and ‘High Technology’ groups have higher number of companies with R&D expenditure compared with the low technology ones.
\nFirms in low technology industrial sectors also had an average turnover in 2009 and 2011, of less than a quarter of each one of the other two technological groups (35 vs. 341 and 224 M€ in 2009, and 44 vs. 188 and 183 M€ in 2011).
\nNo significant differences can be observed with regard to energy-saving potential according to the firms’ technological intensity. These averages of energy-saving potential for each technological group are represented by a percentage, with values between 13 and 15%.
\nWith regard to the ESTs, according to each technological intensity group, we can stress that low technology firms have a relatively lower use of T0 but a higher use of T7, compared with other industrial sectors with higher technological intensity. ‘Medium–Low technology’ firms have a higher percentage of use of T5, and a lower percentage for T2, T4, T6, T7 and T8.
\nCompanies in high technology sectors have a considerably higher percentage of use of T1 and a slightly higher one for T3. Percentage of use of T3 increases homogenously with the technology intensity of the sector.
\nIn the case of MST (T9 and T10), their percentage of use decreases with the technology intensity of the sector.
\nResults about the typology of the manufacturing firms in our sample and their relative energy efficiency are shown in Table 3.
\n\n | Less efficient | \nEqually efficient | \nMore efficient | \nTotal | \n
---|---|---|---|---|
N | \n16 | \n50 | \n71 | \n137 | \n
% | \n12% | \n36% | \n52% | \n100% | \n
Number of employees in 2011, N = 15 + 49 + 71 | \n83 (σ = 75) | \n136 (σ = 289) | \n236 (σ = 755) | \n171 | \n
Number of employees in 2009, N = 14 + 49 + 68 | \n81 (σ = 73) | \n138 (σ = 295) | \n243 (σ = 809) | \n160 | \n
Turnover 2011 [M€], N = 14 + 44 + 65 | \n19 (σ = 21) | \n41 (σ = 55) | \n137 (σ = 519) | \n154 | \n
Turnover 2009 [M€], N = 13 + 44 + 63 | \n17 (σ = 16) | \n36 (σ = 49) | \n73 (σ = 244) | \n229 | \n
Firms with R&D expenditures, N = 16 + 49 + 70 | \n63% | \n61% | \n58% | \n59% | \n
High exportation intensity firms, N = 16 + 45 + 65 | \n25% | \n33% | \n48% | \n41% | \n
Firms with ISO 14000 implemented, N = 16 + 47 + 64 | \n38% | \n47% | \n38% | \n40% | \n
Firms with ISO50001:2001 implemented, N = 16 + 47 + 65 | \n0% | \n2% | \n2% | \n2% | \n
Energy saving potential, N = 16 + 50 + 71 | \n32% | \n18% | \n7% | \n14% | \n
Technology level (1–3 from low to high), N = 16 + 50 + 71 | \n2.25 | \n2.10 | \n2.23 | \n2.15 | \n
T0: dry process/minimum lubrication, N = 15 + 50 + 67 | \n20% | \n6% | \n16% | \n12% | \n
T1: control system for shutdown of machines in off-peak periods, N = 16 + 50 + 67 | \n19% | \n22% | \n15% | \n17% | \n
T2: speed regulation, N = 16 + 49 + 71 | \n81% | \n78% | \n61% | \n69% | \n
T3: compressed air contracting, N = 16 + 47 + 67 | \n50% | \n38% | \n46% | \n41% | \n
T4: highly efficient pumps, N = 16 + 49 + 68 | \n50% | \n41% | \n38% | \n37% | \n
T5: low-temperature joining processes, N = 16 + 49 + 66 | \n19% | \n4% | \n11% | \n9% | \n
T6: energy retrieval, N = 16 + 50 + 68 | \n13% | \n20% | \n7% | \n12% | \n
T7: bigeneration/trigeneration, N = 16 + 50 + 69 | \n6% | \n12% | \n9% | \n10% | \n
T8: waste material for energy, N = 14 + 48 + 69 | \n7% | \n10% | \n10% | \n10% | \n
Summary of descriptive features of the sample by relative energy efficiency in production.
As it is observable in Table 3, companies with higher relative energy efficiency have, on average, a considerably higher number of employees (236 vs. 136 and 83 in 2011) and a considerably higher average turnover in 2009 and 2011, compared with the other two relative energy efficiency groups (73 vs. 36 and 17 M€ in 2009, and 137 vs. 41 and 19 M€ in 2011). Both, the average number of employees and the average turnover, are directly proportional to the relative energy efficiency level. The same effect occurs with the average exportation intensity (more than 50% of sales abroad) being significantly higher in the case of the more efficient group than in the other two groups (48 vs. 33% and 25%, respectively). On the other hand, the average of R&D expenditures is slightly higher in the lower relative energy efficiency groups.
\nThe ‘Equally Efficient’ group has a higher percentage of firms with ISO14000 environmental management system. A very low percentage of firms have implemented ISO 50001:2001 (2%). The average relative energy saving is 7% for the group of ‘More Efficient’ firms, 18% for the ‘Equally Efficient’ group, and a 32% in the case of the ‘Less Efficient’ ones. On an average, manufacturing companies in Spain could have declared a 14% of relative potential energy saving.
\nIn relation to the implemented ESTs according to each relative energy efficiency group, we can stress that firms in ‘More Efficient’ group have a relatively lower use of T8 but a higher use of T4, compared with other industrial companies in less relative energy efficiency groups. Firms in the ‘Equally Efficient’ group have a higher percentage of use of T1 and T7 and a lower percentage for T0, T3 and T5.
\nCompanies in the ‘Less Efficient’ group have a considerably higher percentage of use of T4 and a slightly lower one for T8. Percentage of use of T4 decreases in groups with higher relative energy efficiency.
\nIn Figure 1, we can observe the use of the different analysed EST. In the first place, T2 is the most implemented EST with 69% of the companies in the sample; second comes T3 (with 41% and in the third place T4 with 37%).
\nUse of EST for all manufacturing sectors.
The rest of the ESTs are implemented by a significantly lower percentage of the firms compared with the top ranked ones.
\nFurthermore, the most used EST, that is T2, has a considerably higher percentage of use than the rest of the ESTs. This fact could be caused by a wide interpretation of the concept ‘electric motors with speed regulation’, as almost any system producing movement or rotation powered by an electric motor with a basic speed control could be included in such category. The problem is that, sometimes, this is not an option for this system that could be considered an EST, but a mere intrinsic characteristic of these particular machines.
\nAn exploration of the extent of use of each of these ESTs according to their degree of implementation, ranked from the highest to the lowest percentage for the ‘High degree’ group, is shown in Figure 2. The first effect perceived when studying the extent of use of the ESTs is the radical variation in the ranking for the group of firms that has an extensive use of ESTs and a perceptible reduction of the variance between percentages of high use.
\nDegree of implementation of EST for all manufacturing sectors.
This effect also supports the idea stressed above, regarding a possible wide interpretation of the concept of T2 that now is in seventh position for the group of companies with higher level of implementation of ESTs. Only 14% of the companies declared an intensive use of this technology of the 69% that had declared its use.
\nT0 is the first EST in the ranking of high implementation with 53% of the firms that use it, followed by T1 with 52% and T7 with 47%.
\nOnly 36% of the companies that use T8 declared an extensive use of it, representing the lowest percentage for the ‘High degree’ group.
\nA classification of the companies that have implemented ESTs by technological sector is presented in Figure 3. The ESTs are ranked in the graphic, according to percentages in the ‘High Tech’ group.
\nImplementation percentage of EST by technological sector.
Companies using T5 are mainly 57.9% of firms within the High Tech group. Moreover, 50% of the companies that have implemented T7 and T1 are the high technological ones.
\nT6 is implemented by 56.3% companies in the ‘Low Tech’ group. Only 7.1% and 10% of firms using T4 and T0, respectively, belong to the ‘Low Tech’ group, while 64% and 50% of the companies in the ‘Med Tech’ group, respectively, implemented these particular ESTs.
\nWhen the same classification is made, considering only an intensive use of the ESTs by technological levels in Figure 4, and also ordered according to the percentages in the High Tech’ group, a new ranking is established.
\nHigh implementation percentage of EST by technological sector.
About 63% and 60% of companies with an intensive use of T6 and T8, respectively, are firms within the ‘High Tech’ group. On the other hand, only 17% within this group highly implemented T5.
\nOtherwise, 71% of the companies that have an intensive use of T7 are the low technological ones. However, only 11% of firms using T0 belong to the ‘Low Tech’ group, and there is not any company in this group with a high implementation of T5.
\nT5 is implemented by 83% companies in the ‘Med Tech’ group; 56% of the intensive users of T0 also belong to this group.
\nImplementation percentage of EST by level of efficiency relative to the energy-saving potential.
Results in Figure 5 are obtained by classifying companies according to their relative energy efficiency level and ranking the percentages of the ESTs’ use from the ‘More Efficient’ group.
\nHigh implementation percentage of EST by level of efficiency relative to the energy-saving potential.
More than 50% of the companies implementing T0, T5, T3 and T8 belong to the ‘More Efficient’ group. Firms in the ‘Less Efficient’ group do not represent more than 25% of the companies using any of the analysed ESTs. These results point to a probable relation between the use of ESTs and the relative energy efficiency of a company.
\nResults in Figure 6 are obtained by analysing the same relative energy efficiency groups, considering only an intensive use of the ESTs.
\nGenerally, the average percent in the intensive use of ESTs in the ‘More Efficient’ group is higher than that when considering only their use, apart from the cases of T0, T1 and T5 that are slightly lower, but quite close. In seven of the nine ESTs studied, the percentage of companies belonging to the ‘More Efficient’ group that have highly implemented them, represents more than 50% of the firms. Only companies in this group have highly implemented T8.
\nThese facts suggest that a high implementation of the ESTs also contributes to the relative energy efficiency of manufacturing firms.
\nHowever, T6 and T1 are highly implemented at 57% and 54%, respectively, by companies in the ‘Med Tech’ group.
\nPossible relationships between use or high use of ESTs in manufacturing companies and other parameters such as technological level, size, environmental management systems implemented, export intensity, R&D expenditure and potential energy saving are presented in Table 4, by means of a correlation test.
\n\n | Number of EST implemented | \nNumber of EST highly implemented | \nTechnology level | \nFirm size log 10 (turnover) | \nFirm size log 10 (employees) | \nISO14031 implemented | \nISO50001 implemented | \nHigh export intensity (>50% of sales) | \nR&D expenditure | \nPotential energy saving | \n|
---|---|---|---|---|---|---|---|---|---|---|---|
Number of EST implemented | \nPearson correlation | \n1 | \n0.713** | \n.013 | \n0.210** | \n0.157* | \n0.131 | \n0.178* | \n0.073 | \n0.027 | \n0.098 | \n
Sig. (two-tailed) | \n\n | 0.000 | \n0.864 | \n0.010 | \n0.044 | \n0.105 | \n0.025 | \n0.375 | \n0.728 | \n0.253 | \n|
N | \n169 | \n169 | \n169 | \n150 | \n166 | \n155 | \n158 | \n152 | \n167 | \n137 | \n|
Number of EST highly implemented | \nPearson correlation | \n\n | 1 | \n0.001 | \n0.208* | \n0.14 | \n0.049 | \n0.05 | \n0.027 | \n0.099 | \n–0.001 | \n
Sig. (two-tailed) | \n\n | \n | 0.985 | \n0.011 | \n0.070 | \n0.541 | \n0.530 | \n0.743 | \n0.205 | \n0.987 | \n|
N | \n\n | 169 | \n169 | \n150 | \n166 | \n155 | \n158 | \n152 | \n167 | \n137 | \n|
Technology level | \nPearson correlation | \n\n | \n | 1 | \n0.12 | \n0.160* | \n0.069 | \n–0.027 | \n–0.070 | \n0.015 | \n0.019 | \n
Sig. (two-tailed) | \n\n | \n | \n | 0.151 | \n0.039 | \n0.396 | \n0.740 | \n0.394 | \n0.851 | \n0.825 | \n|
N | \n\n | \n | 169 | \n150 | \n166 | \n155 | \n158 | \n152 | \n167 | \n137 | \n|
Firm size log 10 (turnover) | \nPearson correlation | \n\n | \n | \n | 1 | \n0.632** | \n0.344** | \n0.14 | \n0.005 | \n0.113 | \n–0.171 | \n
Sig. (two-tailed) | \n\n | \n | \n | \n | 0.000 | \n0.000 | \n0.094 | \n0.958 | \n0.170 | \n0.059 | \n|
N | \n\n | \n | \n | 150 | \n149 | \n139 | \n142 | \n138 | \n149 | \n123 | \n|
Firm size \tlog 10 (employees) | \nPearson correlation | \n\n | \n | \n | \n | 1 | \n0.378** | \n0.05 | \n–0.047 | \n0.121 | \n–0.132 | \n
Sig. (two-tailed) | \n\n | \n | \n | \n | \n | 0.000 | \n0.540 | \n0.568 | \n0.124 | \n0.127 | \n|
N | \n\n | \n | \n | \n | 166 | \n153 | \n155 | \n150 | \n164 | \n135 | \n|
ISO14031 implemented | \nPearson correlation | \n\n | \n | \n | \n | \n | 1.000 | \n0.180* | \n–0.061 | \n0.100 | \n–0.001 | \n
Sig. (two-tailed) | \n\n | \n | \n | \n | \n | \n | 0.027 | \n0.474 | \n0.215 | \n0.994 | \n|
N | \n\n | \n | \n | \n | \n | 155 | \n151 | \n142 | \n155 | \n127 | \n|
ISO50001 implemented | \nPearson correlation | \n\n | \n | \n | \n | \n | \n | 1 | \n–0.024 | \n–0.136 | \n–0.077 | \n
Sig. (two-tailed) | \n\n | \n | \n | \n | \n | \n | \n | 0.780 | \n0.089 | \n0.387 | \n|
N | \n\n | \n | \n | \n | \n | \n | 158 | \n143 | \n158 | \n128 | \n|
High export intensity (>50% of sales) | \nPearson correlation | \n\n | \n | \n | \n | \n | \n | \n | 1 | \n0.084 | \n–0.160 | \n
Sig. (two-tailed) | \n\n | \n | \n | \n | \n | \n | \n | \n | 0.307 | \n0.074 | \n|
N | \n\n | \n | \n | \n | \n | \n | \n | 152 | \n150 | \n126 | \n|
R&D expenditure | \nPearson correlation | \n\n | \n | \n | \n | \n | \n | \n | \n | 1 | \n0.035 | \n
Sig. (two-tailed) | \n\n | \n | \n | \n | \n | \n | \n | \n | \n | 0.684 | \n|
N | \n\n | \n | \n | \n | \n | \n | \n | \n | 167 | \n135 | \n|
Potential energy saving | \nPearson correlation | \n\n | \n | \n | \n | \n | \n | \n | \n | \n | 1 | \n
Sig. (two-tailed) | \n\n | \n | \n | \n | \n | \n | \n | \n | \n | \n | |
N | \n\n | \n | \n | \n | \n | \n | \n | \n | \n | 137 | \n
Correlation matrix between environmental management systems use, export intensity, R&D expenditure, potential energy saving and the use and high use of EST.
Correlation is significant at the 0.01 level (two-tailed).
Correlation is significant at the 0.05 level (two-tailed).
We can find different author criteria for the determination of the strength of relationships from the value of Pearson’s correlation coefficient (r); however, Cohen [11] suggests the following guidelines that will be used in the present study: small strength for |r| = 0.10–0.29; medium strength for |r| = 0.30–0.49 and large strength for |r| = 0.50–1.
\nThe quantity of EST implemented in a company results in having a positive relationship with the firm size, in terms of turnover as well as number of employees, and with ISO50001:2001 implementation. This relationship is more significant (at 0.01 level; two-tailed) with respect to the company’s turnover.
\nWhen the extent of use of these ESTs is considered, only a significant relation with its turnover remains at a medium level of strength.
\nFirms’ technology level in our sample has only a light significant relationship with companies’ size in terms of number of employees.
\nFirms’ size, both in terms of turnover and in terms of number of employees, is also interrelated in a medium level of significance.
\nWith regard to the environmental management systems, in the case of ISO14000 implementation, a medium level of strength relationship appears with the company size, both in terms of turnover and number of employees.
\nFor the case of ISO50001:2001, there are small strength relationships with ISO14000 implementation and also with EST use.
\nHigh export intensity in companies and the existence of R&D expenditures are not linked with any other studied firms’ characteristics according to this test.
\nFurthermore, and directly related to the main objectives of this study, no significant relationships are revealed between the relative potential energy saving and any other variable in the correlation, especially with the use and high use of ESTs.
\nIn a previous study [12], a relationship was determined between the use, and mainly a high implementation level, of ESTs and energy efficiency in manufacturing firms.
\nFor that reason, an additional Chi-square test is presented in Table 5. In this table, a crosstab is shown between the number of ESTs highly implemented in a firm and the relative potential energy saving, scaled according to the three energy efficiency groups: ‘More Efficient’ (value = 3), ’Equal Efficient’ (value = 2) and ‘Less Efficient’ (value = 3). This test can be done between two categorical variables as is the case, and it allows the exploring of their possible relationship.
\nCrosstab | \n||||||
---|---|---|---|---|---|---|
\n | Relative potential energy saving (scaled in three groups) | \n\n | ||||
1 (Less efficient) | \n2 (Equal efficient) | \n3 (More efficient) | \nTotal | \n|||
Sum high use EST | \n0 | \nCount | \n7 | \n29 | \n33 | \n69 | \n
Expected count | \n8.1 | \n25.2 | \n35.8 | \n69.0 | \n||
% within sum high use EST | \n10.1 | \n42.0 | \n47.8 | \n100.0 | \n||
% within potential saving scale | \n43.8 | \n58.0 | \n46.5 | \n50.4 | \n||
% of total | \n5.1 | \n21.2 | \n24.1 | \n50.4 | \n||
1 | \nCount | \n2 | \n14 | \n15 | \n31 | \n|
Expected count | \n3.6 | \n11.3 | \n16.1 | \n31.0 | \n||
% within sum high T0 | \n6.5 | \n45.2 | \n48.4 | \n100.0 | \n||
% within potential saving scale | \n12.5 | \n28.0 | \n21.1 | \n22.6 | \n||
% of total | \n1.5 | \n10.2 | \n10.9 | \n22.6 | \n||
2 | \nCount | \n5 | \n2 | \n14 | \n21 | \n|
Expected count | \n2.5 | \n7.7 | \n10.9 | \n21.0 | \n||
% within sum high use EST | \n23.8 | \n9.5 | \n66.7 | \n100.0 | \n||
% within potential saving scale | \n31.3 | \n4.0 | \n19.7 | \n15.3 | \n||
% of total | \n3.6 | \n1.5 | \n10.2 | \n15.3 | \n||
3 | \nCount | \n0 | \n2 | \n7 | \n9 | \n|
Expected count | \n1.1 | \n3.3 | \n4.7 | \n9.0 | \n||
% within sum high use EST | \n0.0 | \n22.2 | \n77.8 | \n100.0 | \n||
% within potential saving scale | \n0.0% | \n4.0% | \n9.9% | \n6.6% | \n||
% of total | \n0.0 | \n1.5 | \n5.1 | \n6.6 | \n||
4 | \nCount | \n2 | \n1 | \n0 | \n3 | \n|
Expected count | \n0.4 | \n1.1 | \n1.6 | \n3.0 | \n||
% within sum high use EST | \n66.7 | \n33.3 | \n0.0 | \n100.0 | \n||
% within potential saving scale | \n12.5 | \n2.0 | \n0.0 | \n2.2 | \n||
% of total | \n1.5 | \n0.7 | \n0.0 | \n2.2 | \n||
5 | \nCount | \n0 | \n2 | \n2 | \n4 | \n|
Expected count | \n0.5 | \n1.5 | \n2.1 | \n4.0 | \n||
% within sum high use EST | \n0.0 | \n50.0 | \n50.0 | \n100.0 | \n||
% within potential saving scale | \n0.0 | \n4.0 | \n2.8 | \n2.9 | \n||
% of total | \n0.0 | \n1.5 | \n1.5 | \n2.9 | \n||
Total | \nCount | \n16 | \n50 | \n71 | \n137 | \n|
Expected count | \n16.0 | \n50.0 | \n71.0 | \n137.0 | \n||
% within sum high use EST | \n11.7 | \n36.5 | \n51.8 | \n100.0 | \n||
% within potential saving scale | \n100.0 | \n100.0 | \n100.0 | \n100.0 | \n||
% of total | \n11.7 | \n36.5 | \n51.8 | \n100.0 | \n
Chi-square tests | \n|||
---|---|---|---|
\n | Value | \ndf | \nAsymp. sig. (two-sided) | \n
Pearson Chi-square | \n22.812a. | \n10 | \n0.011 | \n
Likelihood ratio | \n22.850 | \n10 | \n0.011 | \n
Linear-by-linear association | \n0.010 | \n1 | \n0.921 | \n
N of valid cases | \n137 | \n\n | \n |
Chi-square test crosstab between the number of highly used ESTs and the relative energy-efficiency group.
11 cells (61.1%) have expected count less than 5. The minimum expected count is 0.35.
However, despite this, there exists a low significance in the relationship between these variables, as the Pearson Chi-square is 0.011 < 0.05, and the assumption required for this test concerning the minimum expected cell frequency of 5 or more in the 80% of the cases is not respected.
\nIn the increasingly competitive and changing world, the use of EST has emerged as a strategic imperative for most companies, especially for the manufacturing firms, due to the progressively stricter legislation. Therefore, it is important to have an overall awareness of the current use of those technologies in order to establish future policies for encouraging a higher adoption.
\nIn order to map the current situation of the degree of use of these ESTs in the manufacturing sector, this chapter provides evidences based on data from the 2012 European Manufacturing Survey edition. The case of the Spanish survey is specifically exceptional, since it is a national survey that includes the highest number of ESTs. In total, nine ESTs are included in the analysis. Moreover, the technology intensity variable and the self-elaborated parameter energy efficiency degree are also included in order to contrast their role in the energy-saving performance of the adopters. Finally, some control variables (number of employees, turnover in 2008 and 2011, firm R&D expenditures, high exportation intensity and implementation of environmental management systems such as ISO 14000 and ISO50001:2001) are also included. According to the results, five main conclusions can be formulated.
\nA general observation on the use of EST shows that their adoption in manufacturing firms is still relatively low. Except for the case of speed regulation (T2, 69.1%), possibly due to a wide interpretation of the term, the technology with the highest percentage of adoption is compressed air contracting (T3, 41%). However, it is interesting to point out how these results vary according to the degree of implantation. Dry process/minimum lubrication (T0) and control system for the shutdown of machines in off-peak periods (T1) are the technologies with the highest degree of implementation, both over 50%.
\nSecond, it has been observed that the more relative energy-efficient companies are, on average, characterised as relatively bigger, both in terms of turnover and number of employees, than the equal and less efficient ones. This group of companies also has a higher average of export intensity (more than 50% of sales abroad). However, R&D expenditures are, on average, higher in the less relative energy-efficient group of firms, and the equal relative energy-efficient group is the one with a higher percentage of environmental management systems implemented.
\nThird, according to the technology intensity, six out of nine ESTs are implemented higher in low and medium–low technology sectors. Only the control system for shutdown of machines in off-peak periods (T1, 23%), compressed air contracting (T3, 44%) and energy retrieval (T6, 18%) are implemented higher in the group of high technology firms.
\nFourth, the results are more significant when the degree of adoption is contrasted with the energy efficiency of the firm, since none of the ESTs are mostly adopted by firms that declare being more efficient than the other firms of the sector. Five ESTs are mostly implemented in less efficient group and four in the equally efficient group.
\nFifth, in analysing ESTs, we focused on manufacturing firms that showed high implementation of these technologies. We have analysed these technologies according to their use in different technology-intensive sectors and based on the energy efficiency of the firms. We found that the analysed ESTs are predominately highly implemented in low and medium–low technology groups, except for two technologies, namely, waste material for energy (T8) and energy retrieval (T6). However, we could discard the significance of these ESTs, since the number of adopters is very low. Therefore, we could conclude that most of the highest implemented ESTs are more usual in sectors of low technology, confirming the same conclusion obtained when we generalised for all degrees of implementation. On the other hand, in seven out of nine ESTs studied, a high implementation of these ESTs occurs in the majority of the cases inside the more efficient group of companies. This fact could suggest a possible positive relationship between the high use of ESTs and firms’ energy efficiency. However, this potential relationship has not been demonstrated for this sample with the Pearson correlation and Chi-square analysis.
\nOur research has two main limitations: the statistical analysis applied and the geographical scope of the sample. The first is that only descriptive statistics and correlation tests were used to map the characteristics of EST and their adopters. Therefore, the next step is to use several advanced statistical methods to draw further conclusions. Related to the narrow geographical coverage, the option to focus our analysis on the Spanish survey is explained by the fact of having higher number of technologies. Practical and academic implications of having detailed, single and high number of ESTs convert into a strong argument towards a shared list of such ESTs, which remains further explorable in forthcoming EMS rounds.
\nIn conclusion, this study contributes to disclose to practitioners that Spanish manufacturing companies are recognised to have, on an average, 14% of relative energy-saving potential. It has also been illustrated which ones of these ESTs are the most implemented for each firm typology, in terms of use and extent of use. Moreover, firms have been characterised according to the relative energy efficiency groups to facilitate policy makers to take the right decisions, oriented to improve the energy efficiency in these sectors. Some clues have been pointed at for further researches in order to explore the possible relationships between energy efficiency and the implementation of ESTs, using more powerful statistical tools.
\nThe authors are grateful for the financial support from the University of Girona (Spain) MPCUdG2016/093.
\nWith medical and pharmaceutical costs rising and the politicization of healthcare, not a week goes by without mention of the industry in news reporting. New media aside, the print news has been a stronghold news source for centuries covering a wide range of topics. Though journalism is meant to be impartial to cultural values, news-content, including the editorial cartoon, can be filled with the implicit opinions of the author no matter the topic of the story or the medium used. The author’s voices and opinions are at the forefront of mass media with potential to influence the masses. These voices are what define and maintain culture. On trend with current debates surrounding healthcare, the analysis presented in this work asks what beliefs are present in medical interactions, how they are represented in mass media such as through editorial cartoons, and the implications that these beliefs have on society. This work uses a methodology that attempts to further relations between medical and humanities scholarship [1, 2].
It was formerly assumed that mass media had a grand influence on the minds of its viewers with the ability to directly influence their actions [3]. Though recent theorists suggest that media plays a lesser role—rather than directly influencing people’s decision-making and actions, societal discourse may frame or position receivers versus producers, or in other words, it may build society by elevating certain roles [1]. In this theory, culture may be viewed as formed from discourse through a reflexive process.
Cultural discourse, such as news media, simultaneously influences and is influenced by culture [4] and may cause the social environment of the individual to slightly change. This could influence cognitive processing in individuals during opinion formation [3]. This theory of framing within cultural discourse follows suit with media communication models of cultivation and media ecology theory. Cultivation theory states that media may cultivate beliefs in viewers [5], while Moreno and Koff’s media ecology theory [6] posits that media is within every aspect of society, influences perceptions, and has an inescapable presence. Regardless of the depth of media’s grasp in society, it is known to have an influence.
Mass media’s influence extends from television commercials, to podcasts, to editorial cartoons; how society feels about various issues is extended into various media. Coming from news-media, the editorial cartoon can be seen as a product of society [7]. Not only do editorial cartoons reflect the artists’ opinion on politics and pop culture, but they also reflect, describe, poke fun of, and document the experiences of the everyday person. Just as editorial cartoons are a product of society, they are also a product of their time; ideas and storylines represented reflect cultural beliefs. This extends to the experiences people have with healthcare. Unlike written language contained in articles, comics provide readers with a different way of understanding, coping with complex issues, and creating a deeper bond with the stories told and the information given [1, 8].
One way to further understand the ideologies and beliefs behind comics is to perform a close reading through a discursive framework. In the study of discourse, more than just language is considered—the study of discourse goes well beyond the sentence, including conversations, literature, storytelling, and written, spoken, and visual texts [1]. Through the examination of visual discourses, such as comics, the reader can interpret the way in which the author of the work positions characters within the visual text. These visual texts oftentimes point to the world views of the authors [4, 9].
In an attempt to further understand the view of the creators of a discourse, this analysis employs a visual semiotic framework. Within semiotics, the authors employ on the existence of the study of the sign and the meaning-making practices [10, 11, 12].
Meaning-making is the design apparatus combining all elements both visual and textual as well as their size, color, distance, and arrangement. This interplay of design elements simultaneously creating meaning, or perhaps more properly worded, as telling a story, are what the viewer of a discourse interprets as according to Kress and Van Leeuwen’s ongoing research and writings [2, 10, 11]. The interpretation may vary depending on the complexity and obviousness of the symbols, signs, and everything else represented. In the meaning-making process, viewers may interpret overt meanings through obvious symbols but also may interpret, subconsciously that is, the covert meanings, or stories, and a visual discourse displays [12].
Using this type of spatial display, art has the power to create deeper imagery and bond with the audience [1]. It is through the analysis of these elements that viewers will discover cultural values and beliefs influencing the visual text [7].
Language or narrative, as created by the ego, works to maintain and construct culture and is the lingua franca of human life. Medicine is to treat the human as a whole and as the body exists within a specific cultural narrative, the discourses of the culture in which the patient exists must be kept in mind. This means not treating the human body as simply a corpse on a cadaver cart, but resisting the medical gaze [13] and treating both the body and the ego [14]. The ego as lived through narrative is one of the few things that set humans apart from other flora and fauna. Whether it is dialogue between a patient and a practitioner, survivor stories, billing statements from an insurance company, or comics depicting medical contexts, language is hugely important in the treatment and cure of the human body.
Graphic medicine, or comics depicting illness and medical narrative, is a form of storytelling in clinical settings through the use of paneled visual and text. These stories are not limited to that of the patient but can include the family’s and practitioner’s perspective as well [15]. The study and creation of graphic medicine was born out of a push toward the intersection of the humanities with the medical sciences as a medium with potential to lead clinicians toward a more empathetic approach to medical treatment [8]. Comics in medical contexts can help patients and families come to terms with hospital visits, illness, and trauma.
Aside from graphic medicine created in hospitals, comics with medical contexts, such as popular comics in newspapers, may be viewed as having a similar effect: an ability to create further understanding of difficult topics. This further understanding is partially created through the medium of pen and paper. Drawings are ineffable: they can speak to the human mind in different ways than language and can express things that language cannot. Comics have an accessible and informal approach to the presentation of their information—neither language nor image needs to be intricate to depict intricate meanings. Along with an informal approach, comics often remove the jargonous vocabulary of doctors and replace it with images that are compelling, easier to understand, and create a larger impact on the viewer [15, 16, 17, 18].
The comics presented in graphic medicine are “also potentially far more complex, in that a narrative arc provides a scaffold within which an almost endless array of cultural values and preconceptions can be set up, questioned, reinforced, or negotiated” [1, 18]. These comics can present a range of storylines from sweet, to funny, to serious, and to depressing, all of which can appeal to a wide variety of audiences, and are potentially filled with cultural markers [19, 20].
For years, detached concern was an accepted approach to take in the medical field. Detached concern is a method in which doctors may be viewed as looking beyond the patient’s narrative and not considering aspects of identity when making diagnoses. In other words, detached concern is an ideology stating that physicians should not engage emotionally with, or be influenced emotionally by, patients [21]. Though envisioned with good intent, this method has been found to be dehumanizing and could be viewed as an aloofness on the job or a lack of caring from the patient’s perspective which could further patient distrust [14]. Detached concern stems from the argument that an over-emotional physician’s judgment would be clouded and therefore leaving them unable to make the best decisions for their patient. It could also be viewed as a method of burnout prevention for practitioners [16, 22]. Though detached concern is losing favor as an accepted form of practice, it can still be found in the medical field today even as medical care shifts toward developing the patient-practitioner relationship [14].
This idea that attachment, or perhaps viewing the patient with empathy, would negatively affect a physician’s ability to diagnose could be interpreted as an extension of the medical gaze. According to Foucault [13], the medical gaze is the concept of separating the patient’s ailment and body from their personality and identity, thus allowing the doctor to diagnose without regard to the patient’s self. This medical gaze has been criticized as presenting the doctor fully as the decision-maker, or “the eye that knows and decides, the eye that governs” [13]. The mindset of the doctor being in total power could be interpreted as hegemonically positioning patients as the lesser individual in the interaction. This could be viewed as problematic when it comes to treating patients across a variety of cultures. For example, without considering the patient’s identity, a doctor may perform a treatment deemed unacceptable or taboo in the culture of the patient; by listening to the patient’s story, regardless of lack of medical knowledge, the practitioner could gain valuable insight into the patient’s narrative, increase treatment efficacy, and decrease feelings of inferiority within the patient.
By interacting with the patient’s narrative, the doctor becomes more invested in the relationship increasing treatment efficacy and patient satisfaction [23]. A big part of the patient’s story that could be viewed through graphic medicine is the reclamation of the story that may have been diminished or dehumanized by long hospital visits or indifferent doctors [24]. Spending time in medical institutions can be frustrating, and patients’ voices can be replaced by numbers, medical records, and diagnoses [24, 25]. The reclamation or retelling of the patient’s story can be a therapeutic process in which the story-teller gets in touch with their own feelings and gets back on track to healthy recovery [26]. By reading graphic medicine, viewers can discover new ways of thinking about hospital visits and illness in order to gain an increased understanding of the patient experience [27, 28].
It is no surprise that in clinical settings, patients may feel powerless. This could be attributed to the all-seeing eye or the medical gaze of the doctor; the powerful apparatus is the doctor possesses that allowing them to diagnose, operate, and drastically change the patient’s life without much input from the patient themselves [13]. In some cases, perceived unprofessionalism or insensitivity can cause environments where patients are not speaking up to get the care they need [29]. The professional-looking white laboratory coats were not always the status quo in the medical profession. They could have been adopted to visually distinguish the doctor over others within a medical setting. The white may represent purity or the doctor’s vow to do no harm, and the coat itself positions doctors as scientists. Altogether, the outfit could be viewed as positioning physicians as authority figures with the hanging of medical school diplomas as the final mark of authority [30].
When it comes to trusting practitioners, patients are often stressed, vulnerable, and may grant more discretionary power to doctors than normal [31]. Trust is at the forefront of patient care. Without trust in a doctor, a patient may not reveal the full extent of what they are experiencing, and it may prevent proper care. With a disproportionate power dynamic between doctors and patients, as well as the stressful setting of these interactions, it is no surprise that a lack of trust can be found within these interactions. However, trust is of huge importance and may go so far as to positively influence patient outcomes including enhancing the prescribed treatment [31]. Along with enhancing treatment by psychologically building trust, humor is known to play an important role in coping [32]. Humor can help patients come to terms with the psychological trauma that may be experienced in clinical settings.
Though it is not known if the authors of the following comics create specifically from their own illness experiences, these experiences can be viewed as originating from somewhere. Human thought is so nebulously intertwined with society that it would be nearly impossible for authors to eschew cultural context. With the importance of communication in medical contexts and the knowledge of graphic medicine as laden with cultural markers, medical comics have great potential to shed light into the life of the clinical experience.
It is with all this in mind that this study seeks a further understanding of comics and their role in the expression of the human experience in medicine. A random survey of popular cartoons from well-circulated publications was analyzed. The comics surveyed include Bizarro by Dan Piraro, Carpe Diem by Niklas Eriksson, Dustin by Steve Kelley and Jeff Parker, Intelligent Life by David Reddick, Sherman\'s Lagoon by Jim Toomey, The Lockhorns by Bunny Hoest and John Reiner, Rhymes with Orange by Hilary Price, and Six Chix by Bannerman et al. [33].
Using Kress and Van Leeuwen’s research on meaning-making [34], this study will focus on the three metafunctions: the representational, interpersonal, and compositional. The three metafunctions are resources that can be interpreted to find the meaning of a visual [35]. The representational metafunction encompasses all of the things represented in the images, including characters and non-human elements also known as represented participants (RPs) [1]. Usually connected by vectors, or strong lines, the participants within the image tell a story through hand gestures, gazes, and planes [34, 36].
The interpersonal metafunction focuses on how the creators convey meaning to their audiences through the elements of the representational. Various devices can be used by creators of images to connect with their viewers, including demand and social distance. Demand is the use of a character in an image to connect directly with a viewer by appearing to look directly at them [34]. The distance between two characters or elements take from each other can also inform the audience. Characters closer to each other or to the audience are building relationships, while characters further from each other or the audience are not [34].
Where the representational and interpersonal are somewhat sequestered from each other, the compositional examines elements together for effectiveness. Authors have the ability to use salience, or size and focus, iconic displays of emotion, including happiness, anger, and sadness to portray complex emotional situations. The compositional metafunction also looks at modality or whether or not the images are convincing in general [1]. This analysis gains inspiration from the related works of Kaplan-Weinger [34], Juricevic and Horvath [36], Kowalewski [37], and Dalbeto and Oliveira [38], to name a few. This research uses methods founded in the humanities to seek insight into the medical industry and the surrounding ideologies, as well as how these ideologies are conveyed in graphic narrative. The following chart based on Kress and Van Leeuwen’s [12] work on metafunctions, with inspiration from the previously cited visual analyses, will serve as the foundation for this study:
Representational metafunction: In the representational metafunction, who and what is being represented will be considered. Vectors and themes will be gathered from both human and non-human RPs.
Interpersonal metafunction: This metafunction will examine the interpersonal relationships created between the viewer and author by the use of visual demand and conceptions of social distance.
Compositional metafunction: This metafunction examines the piece as a whole considering the salience of the RPs and the information they provide, as well as modality and iconic displays of emotion.
With the consideration of the three metafunctions, the selected comics were analyzed in three rounds. During the first round of analysis, the representational metafunctions were considered. The represented participants, both human and non-human, were identified, vectors were highlighted and analyzed, and themes were interpreted. After the representational metafunctions of the comics were mapped out, the interpersonal metafunctions were studied. During this time, the represented participants were examined in relation to the viewer of the comics—the interpersonal relationship between the RP (or the represented participant) and the reader as created through social distance and visual demand was identified and analyzed. Finally, the compositional metafunctions were examined. The comics as a whole were studied to determine which RPs were most salient; facial displays of emotion were interpreted, and modality was considered.
For each of the metafunctions belonging to each of the comics, the author created a spreadsheet to organize the results side-by-side for a comparison. This comparison yielded the major themes as identified in this study.
About 24 comics were chosen for analysis from King Features Syndicate. As syndicated in around 5000 newspapers worldwide, the comics of King Features Syndicate have distinguishable breadth, potentially reaching millions of readers. After choosing a syndicate with extensive reach in order to use data that have measurable influence, the data pool was selected. On King Features’ website, 24 comics were chosen at random using key words such as doctor, nurse, medicine, and illness, entered into an appendix, and assigned an arbitrary letter (a–x). To further randomize and refine this selection, an Excel algorithm was used to select four comics from the data pool. Each letter (a–x) was entered in a spreadsheet and assigned a random number. Through the Excel RANDBETWEEN function, each letter was given a number (1–24). The final step of the selection process used the Filter and Sort function to order the numbers (and the letters) from lowest to largest (between 1 and 24). The four lowest numbers were selected for a more thorough investigation as presented below.
After a close reading of the four comics selected, the following themes have been identified: (a) the salience of the doctor over the patient, (b) the expression of vectors, (c) the salience of white coats and hanging diplomas, (d) patient distrust of medical professionals, (e) humor, and (f) the role of women in medical care. To merit analysis, discussed themes occurred at least twice within the comics analyzed.
Salience of the doctor over the patient
In many of the comics surveyed, the doctors were often portrayed in positions more salient than that of the patient. This presents a rather interesting dichotomy between the competing represented participants as those that created these cartoons are likely composing from the patient’s perspective and have still chosen, whether consciously or not, to portray the doctor in a position of power over the patient.
Vectors from the doctor’s gaze
One of the tools used in comics to give meaning, or tell stories, is that of vectors. Vectors are lines that are drawn—whether verbatim lines, or lines creatively displayed—and used to direct the reader’s eye in order of importance. Of the comics analyzed, many vectors were drawn from the eye-level plane of the doctor. In many cases, the doctor is portrayed looking down upon the patient or looking through the deep sides of the eyes toward the patient. This could be interpreted as the doctor being portrayed as higher status than patients, or the doctor as being annoyed or unbothered by the patients.
Diploma and coat
From a critical perspective, the white laboratory coat and the framed and hanging medical diploma of the doctors can be seen as setting the tone of the interaction. Framing the interaction by positioning the doctor as the one with power as expressed through the coat and diploma could be compared to the scepter and cape of that of royal authority. By extension, without such agency-granting artifacts, the patient may be portrayed as inferior.
Patient distrust
Within the selected comics for analysis, many of the authors portray the patients as dumb or air-headed. This paints an interesting perspective as the authors likely have more experience from the side of the patient than that of the practitioner. Through the portrayal of patients as dumb or air-headed, the authors could be interpreted as expressing feelings of inferiority. These feelings of inferiority, as displayed through visual and textual evidence, may lead to distrust in the exam room and are supported through both visual and textual evidence. Doctors are often portrayed as aloof or even lazy when it comes to practitioner-patient interactions, which could be viewed as adding to patient misgivings. Nurses, however, are sometimes portrayed as compensating for these incoherencies by extending compassion to the patient, which the doctor does not.
Funny, Doc
Comics are known and often assumed to be humorous [39]. Some of the comics analyzed give way to humor. Though, perhaps these comics, while using humorous appeals, are actually showing readers something further. Humor is a known coping mechanism for many when experiencing increased stress levels during medical visits. These comics could be seen as appealing to humor as a means to make due with tough situations. That humor used in this way could suggest that medical experiences are stressful in and of themselves.
Women can be doctors too
Within this data pool, all doctors are portrayed as male. Though fewer instances of the portrayal of nurses occur, when nurses are depicted, they always appear as female. The viewer may interpret an implicit bias toward men in the role as physicians, though recent statistics show that the number of women enrolling in medical school is higher than men [40].
Bizzaro is a highly satirical comic with larger than life characters and a bizarre worldview. Starting in 1985, this comic has been entertaining readers with explosives and thought-provoking dry humor. The author offers eccentric visualizations and commentaries on the oddities of our everyday life and culture; oftentimes poking fun of things, we may consider normal. To make commentaries on society and human interaction, the author places visual devices in the comics, including things such as The Eyeball of Observation, The Fish of Humility, and The Crown of Power to name a few. This comic has won many awards such as “best newspaper cartoon panel.”
In this frame (Figure 1) by Wayno and Piraro, the audience is invited to view what appears to be an exam room interaction. The authors use vivid colors which draw attention to the patient and a rather minimalistic style throughout the rest of the image. In this image, the viewer can see the patient sitting atop an exam table and a doctor standing next to them. The doctor is wearing a white laboratory coat with a stethoscope around their neck and a reflex-hammer in hand. The patient is dressed as a clown and above the scene is hanging what appears to be a diploma from a medical school.
Bizarro by Dan Piraro and Wayno, published on February 24, 2018 [41].
In this image, the main represented participants include the doctor, the patient, the exam room, and the diploma. As it appears, the doctor is in the middle of an exam having just tested the patient’s gag reflex. In a word bubble, the doctor states, “Your gag reflexes are fine but we still need to get your jinks a little higher.” The major themes in this image include the salience of the white coat and diploma, and the portrayal of the patient as of a lesser intellectual level.
At first glance, the eye of the viewer may go straight to the patient then travel along vectors from the patient’s head, to the diploma, to the doctor. While the patient is where the eye seems to land at first glance, this could be viewed as the authors placing emphasis on how doctors may make patients feel belittled. Whether or not the patient is an actual clown or is portrayed as a clown in this image may not matter—clowns are traditionally used to denote people who are not to be taken seriously. For example, one might say about a friend who is perceived as unintelligent that they should go to clown college. Clowns are also often portrayed in media as clumsy, humorous, or dopey. This representation of the patient as a clown could be seen as serving to increase the gap between perceived intellectual levels between the doctor and the patient. The patient is displayed as sitting, as most patients are; sitting is a weaker social position than standing in many circumstances.
The represented participants within this panel are represented in close social distance to each other; this could be interpreted as suggesting a closer relationship between this doctor and patient even with the anticipated torment that comes with “jinks” testing. Though the two human RPs are close in proximity to one another, neither are directly addressing the reader of the strip. Even as not directly facing the reader, the reader may still interpret the patient’s face as an iconic facial expression of anger or perhaps more accurately, frustration. As far as modality goes, this image is purely fictional in its situation, though it may be argued to still have a sense of believability to it. The viewer of this comic might find it obvious that this situation would never happen in a medical setting, but at the same time, they recognize the frustration the authors may be trying to convey.
Another important theme is the salience or positioning of the doctor’s diploma and laboratory coat. Represented participants in this frame are given the positions of power. The white laboratory coat is a symbol of power. It is known that doctors wear such coats to stand out among colleagues and patients [42]. This practice as is manifest in this comic form could be seen as drawing attention to the prestige associated with medical practice. The diploma could also be interpreted as a symbol of power. The diploma is more salient in this frame than the white coat and is seemingly looming over the room. This framed document could be interpreted as an artifact that lends authority to the practitioner. The diploma also contains an eye peering toward the doctor, directing the reader’s attention to them. This could be interpreted as the authors suggesting that the doctor has the power of audience in this interaction. Along with the hidden eyeball, under the exam table is a stick of dynamite. This can be seen as contrasting the eye: stating that while eyes are on the doctor, the patient may find themselves in trouble.
This comic by Wayno and Piraro uses the three metafunctions to tell a story that is anything but superficial. At the surface, someone reading the comic might see a funny exam room scene. But with a closer examination, themes of power dichotomies between practitioners and patients are represented. As we know from media and cultural studies, both culture and media are interdependent and constantly shaping one another. Whether or not the authors intentionally represented these themes to publicly disclose their opinions on medical practice, or whether they did so subconsciously, these themes have become present in this comic and are a byproduct of society.
From aliens, to pets, to demons, and to ghosts, you will never know what Carpe Diem will hold. Translated as “seize the day,” this comic is about a day in the life of a seemingly endless number of characters. Tackling issues such as iPhone versus Android, self-automated cars, and three-dimensional printers, the author offers commentary on contemporary life. Along with the contemporary is the ancient and the metaphorical—from cavemen, to Vikings, and to knights, historical humor can be found. And for figurative scenes, the commentary is no less humorous; it is simply coming from the mouths of fictional characters, such as the Grim Reaper, the Devil, dogs and cats, or even talking volcanos. This satirical panel has a far reach and has received international attention and awards.
In Niklas Eriksson’s comic (Figure 2), we see the first example as shown in this analysis of a doctor and what is arguably a nurse in the frame alongside the patient with the identifying factor being the nurse’s cap. This picture portrays a doctor attempting to read an X-ray and a nurse intervening. This panel uses pastel colors and is simplistic in illustration.
Carpe Diem by Niklas Eriksson, published on January 30, 2017 [43].
The main represented participants in this image include the doctor, the patient, the nurse, and the word-bubbles. In this image, the doctor appears to be yelling at the X-ray atop of the X-ray film viewer and saying, “Hell’s bells, Dawson, there’s a skeleton inside you!” As the patient looks dumbfounded, a nurse is hurrying behind with a mug of coffee replying, “Really sorry, sir. The doctor hasn’t had his morning coffee yet.” This panel introduces the patient’s distrust of the doctor and the salience of the white coat.
In this panel, the doctor is arguably portrayed in the strongest position and claims authority through the framing-work done by their laboratory coat. Although the nurse is dressed in a similar white coat, her position of authority is questioned because of nurse’s cap which could be viewed as outdated and perhaps insulting that a nurse is portrayed in this particular uniform, and is arguably portrayed as female, may be interpreted as a reflection of society’s view of nurses in healthcare.
The patient in this image has the least powerful position as can be reckoned by their lack of height. Even as the doctor is portrayed as aloof, the patient too could be interpreted as being portrayed as rather goofy, dumbfounded, or inferior to the doctor who is calling the shots, no matter how off they may be. By illustrating the patient with such a mountainous head and bulbous nose, the author could be viewed as suggesting the patient’s inferiority through humorous assets.
With a closer social distance, the author of this comic may be suggesting something about the relationship between the three human RPs. Compared with the other comics, the people in this image are portrayed from the waist up suggesting close proximity, which could be viewed as an invitation to gain a closer relationship with the RPs in this panel.
Along with this close proximity, the author may be reaching out to the readers by using an iconic representation of anger in the doctor’s face. This representation is immediately recognizable, and the reader of this comic may quickly connect with this RP. This image is both believable and unbelievable. It may be interpreted as highly believable that a groggy doctor may make a mistake without caffeine, but could be viewed as implausible that a doctor could have such huge oversight.
The portrayal of the patient also gives insight into their feelings. With bulging eyes and a slightly opened mouth, the patient could be interpreted as dumbfounded at the doctor’s incoherence on the job. This portrayal may lend itself to the theme of patients distrust in medical professionals.
In Eriksson’s work, readers can interpret the author as highlighting the perceived aloofness of doctors, the patient’s distrust of practitioners, the authority of doctors as partially maintained by the laboratory coat, and the positioning of doctors versus nurses. Arguably, the most prominent theme in this panel as can be interpreted by the viewer is that of patient distrust and the aloofness of medical professionals. The author of this comic uses coffee-humor and alludes to the doctor’s lack of caffeine as the source of incoherence. As the reader may interpret, even without coffee, a doctor should not be so much aloof as to misread an X-ray in this way. The patient’s bulging eyes give away their emotion as they stand behind the doctor.
To make fun of married couples and the trials and tribulations they experience, the author illustrates sticky scenarios through two recurring characters: Loretta and Leroy Lockhorn. Whether it is Leroy rolling eyes after Loretta says something, or Loretta telling the therapist how Leroy never helps around the house, readers cannot help but relate to this couple’s experiences. Leroy is a stark contrast to Loretta with a strong personality, stubbornness, and ability to sit for hours in front of a TV sleeping. When not worried about Leroy, Loretta is a shopping addict and spends more than any person should. Loretta loves to cook and helps Leroy’s strong character type.
In this image (Figure 3) by Hoest and Reiner, readers view the inside of an exam room in a doctor’s office. In the upper right, a doctor is portrayed holding an X-ray, and in the off-center left, the patient sitting on an exam table. The color choices of the authors are very minimal with two tones of a yellowish-beige being the most vivid. The scene of the exam room is represented with straight lines and angles and is altogether very uncluttered. The patient is wearing socks and a hospital gown and the doctor is wearing a laboratory coat.
The Lockhorns by Bunny Hoest and John Reiner, published on December 1, 2017 [44].
The main represented participants in this frame include the patient, the doctor, the diploma, the laboratory coat, the X-ray, and the exam room. The patient as a represented participant in this frame is portrayed wearing a blue hospital gown, sitting down on an exam table, and looking sideways toward the doctor, and appears to be irate. The doctor as an RP in this image is portrayed facing away from and glancing at the patient from the side, wearing a laboratory coat, and holding an X-ray of what could be interpreted as a knee joint, and appears to be mid-sentence. The exam room as a whole is represented in a minimalistic or sterile way with one of the focal points being the framed med-school diploma. In terms of the lack of detail, or sterility of the scene, the authors could be portraying a sense of bleakness or an emotionally cold experience in a medical context. At the bottom of the frame, the doctor is saying to the patient, “What you have is curable, Mr. Lockhorn…the tough part will be figuring out the paperwork.” The themes identified in this frame include the salience of the diploma and the coat, vectors from the doctor’s gaze, and patient distrust.
In this image, the medical school diploma seems to dominate the horizontal plane. Framed with thick black lines and surrounded by empty white space, the eye tends to wander to the diploma. In this image, the laboratory coat is neither as salient as the diploma nor as salient in comparison with the other comics. In fact, the laboratory coat could be interpreted as grey in this image. While the diploma could be seen as hovering over the room as with the previous example, vectors are a stronger form at play within this image.
Looking over their shoulder and down the patient, the doctor could be interpreted as positioned or framed in a position of power via vectors. Not only standing is a more powerful position than sitting, the position in the upper right-hand corner places the doctor at a higher eye-level-plane than the patient. The reader might question why the authors have decided to portray the doctor speaking to the patient in this way while giving a diagnosis or speaking of a cure rather than turning around and addressing the patient directly. This could be interpreted as the doctor placing a higher-level importance on handling the X-ray and other tasks than the patient’s needs for an empathetic delivery of medical information.
The two human RPs in this image are not portrayed in close proximity—this far distance between them suggests a degree of separation. While the doctor and patient are looking at each other, neither is creating visual demand with the audience of this image. However, through the iconic display of anger on the patient’s face, the reader is invited to empathize with the RP. Along with the distance between the two human RPs, the authors have chosen to show the reader the entire bodies of these characters; by doing so, the authors have presented the scene as further away, or perhaps given us the perspective of an outsider looking in, rather than being up close and a part of the conversation.
Through the facial expression of the patient in response to the doctor’s comments, the reader may interpret the distrust of or frustration with medical care by the patient. The eyes of the patient may be viewed as frustrated or defeated upon the delivery of this news while already out of their comfort zone from being in the hospital. This may be viewed as a metacommentary on societal opinions of medical care in the United States and that of the authors, however, infinitely intertwined the two may be.
Discursive analysis of this comic by Hoest and Reiner yields themes of patient distrust or dissatisfaction, positioning of the doctor at a higher level, and the authority of the medical-school diploma. While looking at this image in terms of modality scope, considering all of the elements, the reader may interpret this image as highly plausible and likely to have happened.
With over 400 non-recurring characters, the author still has not found anything that rhymes with orange. This high energy comic strip examines the universal truths of the ordinary: in-laws, driving, pets, children, and love. With recreations of daily life of its readers, this comic often points out just how weird, yet wonderful, humanity is.
In this comic titled Modern Medicine (Figure 4) by Hillary Price, readers are taken into a care unit. This comic has livelier colors than the previous with pastels of green, orange, and blue. The author pays little attention to extraneous detail with a focus on the image at whole. In the first frame of the comic, the title of this strip is introduced. At the bottom of the panel, the reader can see the doctor asking the patient “Can you give me a hand?” In the second panel, the reader of this comic gets a zoomed-out image of the scene. A doctor is in an exam room looking for their stethoscope which is apparently tangled up with headphones. The patient is sitting in their bed watching as the doctor says, “Shoot, my earbuds.”
Rhymes with Orange by Hilary Price, published on January 16, 2018 [45].
The main represented participants in these two panels include the doctor, the white coat, the patient, the earbud-stethoscope knot, and the patient’s room. The doctor in these two panels is portrayed wearing a white coat with business attire underneath. The patient is portrayed as presumably elderly, with grey hair, and glasses. The room is portrayed rather bare, lending attention to the other RPs. Themes contained within these panels include the aloofness of the doctor, the salience of the laboratory coat, and humor.
Surrounded by a sea of green, the doctor’s laboratory coat seems to stick out as a prominent represented participant within this image. Combining the length of the two panels together, the doctor and their coat are in the true center of the comic. The center position lends power to this RP.
Another theme that can be seen across the data pool of comics, including this panel specifically, is the perceived or illustrated aloofness of doctors. As the reader follows the composition of the art, their eye moves from the foot of the bed up to the patient’s face who is looking at the knot. From vectors drawn, emphasis is placed on the knot that the stethoscope and earbuds are in. This knot could be interpreted as a symbol for the doctor’s mind while making rounds. Perhaps the author has been a patient and felt, consciously or subconsciously, that doctors can be distracted by out-of-hospital issues. Along with distracted doctors comes distrust in healthcare and healthcare professionals. For example, if a patient was in pre-op and a doctor was seemingly distracted or not fully present, the patient could suffer higher levels of distress.
The fact that the author has chosen to portray the doctor and the patient at a further social distance may suggest something toward the relationship between these two RPs. In the same way, the author has not utilized any form of directly addressing the reader of this comic to enhance viewing. However, with the analysis of facial expressions, the reader may get a strong sense of the situation. While not necessarily iconic displays of emotion through facial features, the reader could envision themselves as the patient or the doctor and imagine themselves in this context. This image has both believable and unbelievable aspects to it: that a doctor would keep a stethoscope in their pocket with earbuds rather than taking a different approach to avoid such tangled circumstances could be viewed as fiction; however, readers may look into this setting and empathize with how easy it can be to get earbuds tangled in a knot.
These two comics have a sense of humor interjected into their illustration. The way the author portrays the expression on the doctor’s face versus the expression on the patient’s face could be interpreted as using humor in stressful situations to cope, or perhaps to relate to those who have felt in similar ways.
This comic by price portraying a doctor entering a patient’s room continues the trend of media portraying—or reflecting—societal distrust of practitioners, the use of white coats to position practitioners over patients, and humor as used in stressful situations.
Through this close reading of Carpe Diem, Rhymes with Orange, The Lockhorns, and Bizarro, explicit and implicit cultural beliefs held about medicine, including practitioners and patients, have been revealed through the study of signs and symbols and the meaning-making work they perform [10, 11]. It could be argued that these beliefs as conveyed through comics are more salient than those in the articles of the same newspapers as comics provide readers more tools for understanding than words do on their own [1, 34].
For example, the authors of the comics usually portrayed doctors in positions of higher power. As we know from Kress and Van Leeuwen [12] and de Rothewelle [1], and through the findings of Kaplan-Weinger’s study of graphic medicine [34], the placement of a represented participant and the distance between represented participants within an image are meaningful. Through these four comics, the doctors were portrayed in positions of higher power. For example, just as Kaplan-Weinger analyzed the planes of characters represented in comics, it could be viewed that the doctors are portrayed on higher planes than patients and looking down upon them when addressing the patients. These vectors painted with the eyes of doctors and patients serve as valuable insight. Also lending emphasis to the doctors in these comics are the artifacts that give them agency and power. Kress and Van Leeuwen [12] demonstrate that the salience of an object within an image is a meaning-making function used by authors. Kowalewski found that signs representing cultural ideologies created to lend a form of cognitive salience in the readership have impact [37]. In the same way, representations of medical school diplomas and white laboratory coats could be portrayed as signs or icons representing implicit cultural values and usually positioned in more salient forms than that of other RPs. These visual artifacts could be interpreted as visually separating doctors from nurses and patients within these comics. These two items serve as tangible artifacts that appear to lend power to the doctor’s position.
Whereas the diploma and the laboratory coat lend power to the doctor’s position, within this data set and the four comics on which the close reading was performed, the position of doctor or physician is always portrayed as a male-presenting role. According to Schiffrin [9] and Davies and Harré [4], identity is performed and co-constructed through positioning. By positioning doctors as above those who they treat, the authors may be reinforcing the idea of a doctor’s autonomy. Kress and Van Leeuwen [12] also posit that proximity in relation to other humans can be used to interpret meaning. As is known from similar studies, such as that of Kaplan-Weinger [34], the closer two human RPs are portrayed to each other, the more likely they may be to become intimate, which is typically represented by a friendly conversation or a handshake. On the other hand, characters portrayed further from each other could be interpreted as seeking no interaction. In the comics, the doctors were usually portrayed in a distant proximity to the patient, which could be interpreted as a lack of interest by the doctor in becoming too close to the patient.
The analysis of these four comics in particular shows that they all portray patients as inferior to doctors. This could be viewed as an extension of a patient’s distrust of doctors and a visual representation of how patients may be made to feel during interactions with doctors. Along with this distrust of doctors is what could be viewed as the portrayal of doctors acting aloof or pre-occupied at times when they could be more attentive to patients. These portrayals could be viewed as made through vectors and continued through the compositional metafunctions [2], including the use of written language. These portrayals of the doctors’ and patients’ opinions of each other could also be interpreted through facial features. The idea of patient’s distrust of doctors is more of a metaphorical device painted by the visual text such as the ones Juricevic and Horvath found in their work. Whereas metaphors may not have a specific and previously defined sign and signified correlation, icons do [36]. Anger, sadness, and happiness are all posited to be iconic emotional displays, that is, whenever these faces are made, one immediately knows what the other is feeling [1]. This window to the feelings of the represented participants lends ease to the reader when empathizing with the portrayed characters.
A lesser theme in the four comics examined in this analysis is the lack of portrayal of female presenting doctors. The author pays no homage to a binary gender system, though realizes these comics were created in a society where such a system is upheld by the cultural majority. Just as Dalbeto and Oliveira [38] located cultural stereotypes of women of color through visual analysis, this study found stereotypes of women in medical practice; within the male and female stereotypes as represented in these comics, doctors are always portrayed by men, and nurses are always portrayed by women. In the four closely dissected comics, and throughout the entire data pool of 24 comics, the results remain the same. Humor is another less prominent theme as displayed throughout the comics and is trickier to grasp as the medium itself is traditionally considered to be humorous. However, these comics could be interpreted as containing humor to cope with stressful situations during medical exams and hospital stays. For example, in Carpe Diem, it is humorous that the doctor has misidentified the X-ray, but it is also a scary situation as one wrong move in a procedure could be life-threatening. Perhaps it is the author’s way of attempting to distress a portrayal of a situation, where a doctor is aloof on the job.
These comics are products of the society, and they were created in and may be found to reflect the ideologies of that society [7]. Cohn et al. [46] have found that the interpretation of visuals and rhetorical devices in comics is culturally dependent. Whereas all of the identified themes and ideologies presented in this analysis may yield great insight into the medical industry, they may not be the representative of the various cultures of the world. For example, the push toward a relationship-based approach to the doctor-patient relationship may be a product of United States culture and may not transfer over—the person reading these comics as distributed in India may not elicit the same responses. Just as we know that comics can help bridge the understanding of difficult topics and create a response in the readership [8], it is also known that if comics do a poor job at depicting their story, the reader can become all the more confused as Farinella points out [47].
As Grice [48] states, all communication must uphold four maxims to be effective: the maxims of quantity, quality, relevance, and manner. Viewing these comics outside of their original cultural context could be viewed as violating communicative maxims and would almost certainly be cause for different results. For example, in terms of the iconography of the white laboratory coat and the framed medical school diploma, the maxim of relevance might be violated in a culture that does not practice Western medicine. In other cultures, a doctor or a healer might be designated with a different type of attire and retained different types of artifacts on display to assert their knowledge.
Another consideration for these comics is the reflexive nexus that continues to construct culture by creators and receivers of discourse [4]. These comics have the potential to provide insight in what may be viewed in a positive light by creating change and improvement in medical care—or these comics may create a spiral effect that continues to sway popular opinion of medicine. For example, news media coverage of certain events is known to create an illusory truth effect [49]. This portrayal of what could be interpreted as negative ideologies surrounding medical care could continue to foster negative ideologies when medical associations and practitioners are moving in a different direction.
Whereas these comics may be a representation of the author’s beliefs and a reflection of cultural beliefs in general, just as Dalbeto and Oliviera have found [38], these comics are in distributed newspapers worldwide and may have a sizable impact. After all, comics are a product of the culture they are created in, and the artistic choices of the authors offer valuable cultural insight and potential to influence readers [38]. It is no longer assumed that the media has such an intrusive influence on the life of the individual; it is suggested that this discourse may aid in the framing of represented participants [1, 3]. With the reflexive nature of media in mind, the co-construction of cultural discourses by authors and audiences [4], these media may be viewed as a reflection of cultural opinion and having the ability to influence cultural opinion [3].
Taking into consideration media theory and the analysis of the comics, medical associations and practices may find valuable insight into the opinions and beliefs of not just the authors of these comics but of society as a whole. According to Dalbeto and Oliveira [38], “a critical analysis of comics, and of any cultural asset, is necessary because […] they are not free of ideologies.” With this in mind, the themes of doctors as more powerful and more important than patients, doctors presenting as one of the two culturally accepted genders rather than the other, aloofness of doctors on the job, and distrust in doctors and the medical system were interpreted. These themes could be interpreted largely as the reflections of societal opinions of medical practice and could be taken as pointers to improve patient satisfaction by reducing stress through building doctor-patient trust [5, 6]. Comics pull readers in and help them to imagine themselves in the situations pictured; therefore, practitioners may find comics as a powerful tool for improving patient care and understanding the patient’s experience [34].
This research purposely works with a small sample size from one news syndication to make data manageable. To establish a farther-reaching analysis of how medicine is represented in editorial cartoons and the influence these cartoons have on culture, a larger sample size from multiple sources could broaden the results. To facilitate a scope this large, a data-analytic technology to aid research would be necessary. Along with a larger scope, it is known that images may mean different things in different cultures and thus would be worthy of dissection from a cross-cultural standpoint [46].
This work was made possible with the advice of my colleagues at Harry S. Truman College and Northeastern Illinois University. Permissions granted by King Features Syndicate. Thanks to those who helped copy edit.
.
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