Reflections on the doctor–patient relationship: from evidence and experience
important investigations on doctor-patient relationships have considered on outcome problems with limited-English speaking patients (five studies) or on. The doctor establishes a relationship with the patient To achieve a shared understanding of the problems with the patient. (5) .. Stewart M et al (). As the doctor-patient relationship continues to evolve, there is a need to refresh the approach regarding this dynamic connection. Transforming the.
I have observed countless times how doctors help patients put the fragments of their lives back together into a whole. Having watched whole-person medical practice, I have thought about the various elements that it requires. One is an openness on the part of the doctor to learning about all of the dimensions of a patient's problems. Another is a willingness to meet the patient at an emotional level, not only in order to have an understanding of the problems, but also to facilitate a healing of the whole person.
I have learned, therefore, that this way of being a doctor requires engaging at both the cognitive level the doctor will learn more about the patientand the emotional level the doctor will feel the patient's pain and sufferingbut also tapping into a doctor's intuition, the creative side, which puts together complex webs of different types of information cognitive, emotional and intuitive into a new insight, not singly, but in communion with the patient.
The team of GPs with whom I work, believe that practising medicine that heals, encompasses a change of heart as well as a change of mind. These doctors began their enquiry into the essential features of such medical practice through observation, reflection and several years of teaching.
It was the observation of patients and their responses that is similar to James Mackenzie's legacy. In the 19th century, Sir James Mackenzie made discoveries regarding pain and heart sounds based on meticulous and ongoing observations of his patients in general practice.
Fixing the Doctor-Patient Relationship
Furthermore, Sir James Mackenzie was emotionally engaged with his patients. Throughout this lecture, I will be describing several 20th century discoveries in general practice based on the observations of GPs.
Physicians' battle-cry of the sacred nature of the doctor-patient relationship sounded hollow in their struggles against universal health insurance.
Physicians' high incomes and defense of autonomy appeared to result in both bad medicine and bad health policy, and physician's unaccountable power appeared all the more nefarious because of medicine's intimate invasion of the body, In this context, Eliot Freidson's work,crystallized the notion that professional power was more self-interested than "collectivity-oriented. Freidson's approach to the sick role was influenced by labeling theory Szasz, ; Scheff,and went beyond Parsons to assert that doctors create the legitimate categories of illness.
Professionalization grants physicians a monopoly on the definition of health and illness, and they use this power over diagnosis to extend their control.
This control extends beyond the claim to technical proficiency in medicine, to claims of authority over the organization and financing of health care, areas which have little to do with their training. There are now many studies of the way that professional power has been institutionalized in the structure and language of the doctor-patient relationship.
For instance, a recent study of medical students' presentation of cases demonstrated that physicians were being trained to talk about their patients in a way that portrayed the physician as merely the vehicle of an impersonal medicine acting on malfunctioning organs, rather than a potentially fallible human being interacting with another human being. The more highly regarded presenters were found to 1 separate biological processes from the patient, 2 use the passive voice in describing interventions, 3 treat medical technology as the agent, and 4 mark patients' accounts as subjective the patient "states," "reports," "denies,".
These devices make the physician more powerful by emphasizing technology and eliminating the agency of both physician and patient Anspach, Since its publication, Starr's The Social Transformation of American Medicine has quickly become the canonical history of the institutionalization of professional power, its effect on the organization of health care, and the profession's metastasized influence in the political sphere.
Though Starr draws on many theoretical sources, he paints a picture of the American doctor-patient relationship as a successful "collective mobility project" Parry and Parry,whose contours were not at all determined by the functional prerequisites of society. While Starr does not goes so far as to say that we do not need "doctors" at all, he argues that there are a range of possible structures that medicine could have taken in industrial society, and that American physicians are an extreme within that range.
Marxist and Feminist Approaches Drawing on, and extending the professional power analysts, the growing school of Marxist sociologists interpreted the doctor-patient relationship within the context of capitalism.
In the Marxist analysis, the American doctor-patient relationship is conditioned by the "medical-industrial complex" Ehrenreich and Ehrenreich, ; Waitzkin and Waterman, ; McKinlay, ; Waitzkin, ; profit-maximization drives the innovation of technologies and drugs and constrains physician decision-making. The most orthodox advocate of this analysis, Vincente Navarro,rejects the analyses of those such as IllichFreidson and Starr who see professional power as having some autonomy from, and sometimes being in direct conflict with, capitalism and corporate prerogatives.
For Navarro, physicians are both agents and victims of capitalist exploitation, engineers required to fix up the workers and send them back into community and work environments made dangerous and toxic by capitalism. But the professions are anomalous for traditional Marxist theory; only those who own the means of production are supposed to accrue occupational autonomy and great wealth.
Theorists of physician proletarianization point to the rising numbers of salaried physicians, the deskilling of some medical tasks, and the shifting of some tasks from physicians to less skilled technical personnel.
Parallel to, and often included in the Marxist account, has been the growing feminist literature on medicine. In particular, feminists have focused on the patriarchal nature of the male physician-female patient relationship, documenting the history of medical pseudo-science that has portrayed women as congenitally weak and in need of dubious treatments Ehrenreich and English, ; Arms, ; Scully, ; Mendelsohn, ; Shorter, ; Corea, ; Fisher, ; Martin, ; Todd, There is also extensive work done on the history of exclusion of women from medicine Walsh, ; Levitt, ; Achterberg,and the effects of the growing numbers of female doctors on the doctor-patient relationship.
Women physicians tend to choose poorly paid primary care fields over the more lucrative, male-oriented surgical specialties, are more likely to be employed as opposed to in private practice, and are less likely to be in positions of authority Martin, Women providers are also better communicators Weisman and Teitelbaum, ; Shapiro, Economic Approaches The growth of studies on cost-containment, and the economistic trend of 's social science, led to the rise of methodologically individualistic "rational choice" studies of the doctor-patient relationship.
These studies usually ignored the functionalists' interest in norms and roles, as well as the critical theorists' interest in power and exploitation. Instead, the economists' model starts from the assumption of a mutual "utility-maximizing" agency contract between the doctor and patient Dranove and White, ; Buchanan, The patient is interested in maximizing consumption of health, and the physician is interested in maximizing income.
The studies then focus on the effects of insurance, reimbursement and utilization control structures on doctor behavior, the doctor-patient relationship and the success of medical agency Eisenberg, ; Salmon and Feinglass, For instance, a number of studies have documented that patients without health insurance have less access to doctors, and receive less care from them when they have access Hadley, Steinberg and Feder, ; Kerr and Siu, Research has also demonstrated that different payment structures affect physician behavior Moreno, ; Rodwin, For instance, a recent study of Medicaid case-management found that pediatricians who received augmented Medicaid fees provided a higher volume of services to children than either a group receiving fees-for-service, or a group covered by capitation Hohlen, et al.
Another strain of economistic research picks up on the Freidson observation of physicians' power to define illness, and explores the degree to which physicians "induce demand. Communication and Outcomes Two trends led to the rapid growth of research on doctor-patient communication.
The first trend was the interest of physicians and medical educators in improving their ability to elicit patient histories and concerns, and inform patients of their conditions and treatment needs, and thereby achieve successful diagnosis and treatment compliance. Literally thousands of analyses of consultations have been done since the s to develop methods to teach and improve physician communication skills Stewart and Roter, A second trend, the rise of health consumerism, has encouraged more contractual and conflictual relationships between patient and doctor.
An increasingly well-educated population has begun to challenge medical authority, and treat the doctor-patient relationship as another provider-consumer relationship rather than as a sacred trust requiring awe and deference Reeder, ; Haug and Lavin, Opinion polls indicate a steadily declining faith in physicians, and in the American medical system in general Blendon, The consumer, women's health Ruzek,the holistic health movements, and the perception of physician indifference and greed, have also encouraged patients to distrust physicians.
Fixing the Doctor-Patient Relationship
These trends were often portrayed by medical sociologists as democratizing Haug, ; Haug and Lavin, but perceived by physicians with alarm, especially in light of the rise of malpractice litigation.
Encouraged by these two trends, symbolic interactionists Anderson and Helm, ; Strauss, and discourse analysts began detailed analyses of doctor-patient communication to tease apart the workings of power and authority within them. In particular, Howard Waitzkin,has drawn attention to the way that American medical communication reinforces individualistic, bio-medical interpretations of problems with social origins and social solutions, and thus reflects and reproduces social inequality and disenfranchisement.
Another example is the work of Hayes-Bautista who studied the bargaining between the patient and the doctor over treatment. The patients were observed using "convincing tactics" of a demands, b disclosure that the treatment has not worked, c suggestions, and d leading questions. If these did not achieve the desired change in treatment, they turned to "countering tactics" of arguing that the treatment is too weak, too powerful or insufficient.
To augment their authority, the doctors used tactics of a wielding overwhelming knowledge, b medical threats about the consequences of ignoring advice, c disclosures that the treatment may take longer to work for the patient; or d a personal appeal to the patient as an acquaintance. The outcome measures of this game theoretic situation were a continuation of the relationship, b patient termination of relationship, c physician termination, and d mutual termination.
Health care marketing became a third major impetus for studies of doctor-patient communication, largely with the goal of identifying the kinds of interactions that improved patient satisfaction. Research found, not surprisingly, that people like to have doctors talk to them in an egalitarian way, listen, ask a lot of questions, answer a lot of questions, explain things in a simple way that the patient can understand, and allow patients to make decisions about their care DiMatteo, ; Hall, Roter and Katz, ; Roter, Hall and Katz,; Roter and Hall, ; Gerteis, Edgman-Levitan, Daley and Delbanco, Researchers also began to demonstrate that different patterns of communication have effects on the clinical outcomes of patient care.
The kinds of medical care that patients find satisfying tends to alleviate psychosomatic symptoms and make patients more compliant with their treatment regimes, and thereby produce better clinical outcomes Egbert, et al.
The Decline of the Professions and the Doctor-Patient Relationship To change the health system at all, much less to create a medical system which maximally utilizes self-help and mutual help and which encourages an active rather than a passive role for the patient, will require radical deprofessionalization.
We will have to expand radically the use of community health aides; to spread medical knowledge to patients and to non-physician health workers; to minimize the social distance between doctors and patients. I should emphasize that deprofessionalization has nothing to do with eliminating the skills of the doctors. Skills are of course needed, and I am not proposing that incompetent people perform medical services-we have too much of that as it is!
It is the privileges, the power, and the monopolization of medical knowledge that I am speaking of removing when I speak of deprofessionalization. Ehrenreich and Ehrenreich, But a number of social trends have converged to reduce the ability of patients to have these relationships with physicians.
The critical theorists, in turn, have raised questions about whether radically different relationships, with radically different providers of care, might be possible and preferable. Over-Specialization and the Decline of Primary Care One trend has been the rapid proliferation of specialization among American physicians.
Only one in ten American physicians are in "general practice" general or family practitioners, pediatricians and geriatricianswith a claim to a holistic approach to patients' concerns. Many researchers assume that increasing specialization will continue to "technologize" and "compartmentalize" doctor-patient interaction.
As patients see increasing numbers of poorly coordinated specialists for their myriad problems, the need for "case-managing" generalists becomes ever more acute. Declining Autonomy and Rise of the Organization Remaining independent of organizations, including insurance companies, unions and the government as well as hospitals, has been a consistent and explicit theme of physicians since the turn of the century.
Professional autonomy and independence is the most important factor in their satisfaction with their worklife.