Transcript Why study the doctor-patient relationship?

Sociological approaches to the doctor-patient
relationship
Mary Dixon-Woods
Department of
Epidemiology and
Public Health
Objectives
• Describe sociological approaches to
understanding the doctor-patient
relationship
• Explain structural influences on the
consultation process
• Recognise issues of conflict and control in
medical encounters
Why study the doctor-patient relationship?
• Impact on outcomes of care
– dissatisfaction
– inaccurate diagnosis
– inappropriate treatment
– non-compliance
– poor physical and psychological outcomes
– lack of self-reliance
Sociological approaches
Why do we need theories?
To help
 explain what is going on
– analyse what happens when things go
wrong
Different theories
• Different sociologists come from different
theoretical backgrounds.
• Their theoretical backgrounds influence
their theories about the doctor-patient
relationship.
Sociological approaches
• 1. Functionalists emphasise
consensus and reciprocity.
• 2. Conflict theorists emphasise
conflict.
• 3. Interpretivists emphasise the
meanings that people give to actions
and words.
Functionalist (consensus) approaches
• Talcott Parsons - American sociologist
• Very influential in 1950s and 1960s.
• Saw doctor and patient as agreeing on their
respective roles.
Functionalist approaches see
relationship as consensual
Functionalist (consensus) approaches
• Patient assumes sick role:
– exempted from normal social obligations
(e.g. work)
– not blamed for his condition
– must try to get better includes seeking
medical help and obeying doctor’s
instructions
• Doctor controls access to sick role.
Parsons assumed competence gap between patient
and doctor
Patients
• have faith in doctor
• co-operate
because
• they are aware of the competence gap
• the doctor is a representative of the medical
profession
Functionalism
• Doctors’ rights:
- take a history, examine and treat patients
- professional autonomy; occupy a position of
authority
Doctors’ responsibilities:
- apply a high degree of skill and knowledge
- act for the welfare of the pt, not self-interest
- be objective and emotionally detached
Parsons assumed competence gap between patient
and doctor
Doctors
• have power, status and prestige
• belong to a beneficent profession
• need to be dominant partner in relationship.
Criticisms of the functionalist approach
• It is based on doctors’ ideas of what the
relationship should be like rather than
what it is like.
• assumes patients are incompetent.
• assumes rationality and beneficence of
medicine.
More criticisms of functionalist
approach
• assumes patients must have passive
role
• details of sick role not well thought out:
some patients cannot get better;
legitimate and illegitimate occupants of
the sick role
More criticisms of functionalist
approach
• Does not take gender or other structural
influences into account
• empirical evidence to show patients do not
agree with doctors
• Does not explain why things go wrong
2. Conflict approaches
• Friedson (1970) - another American
sociologist. Still very influential.
• Claim that doctor-patient relationship is
characterised by a clash of perspectives.
• Biomedical model vs lay model.
Conflict approaches emphasise
disharmony
Conflict approaches
• Doctor wants to retain monopoly on
defining medical reality.
• Doctors have a monopoly on defining
health and illness which they can exploit.
• Doctor wants to withhold information to
preserve his “aura of mystery”.
• Patient wants to pursue his agenda also.
More conflict theory
• Idea that doctors exert social control.
• Consultation is performing ideological
tasks.
• Eg Waitzkin’s work suggests that
biomedical explanations are offered for
problems that are really social in origin.
More conflict theory
• Particularly prominent in feminist theory e.g.
notion that doctor disempowers women.
• Doctor imposes his medical view and
discounts patient’s experientially derived
view.
Conflict theory and “medicalisation”
lay ideas are marginalised
and discounted
• medicine colonises
areas previously in
control of lay public
• “medicalisation” of
childbirth has resulted
in loss of control for
women
Medicalisation
• Pathologising of aspects of social life eg food
• Medicine engages in surveillance
• cultural iatrogenesis (Ivan Illich) - people
become dependent on medicine, lose selfreliance and become sick
Arguments against conflict theory and
medicalisation
• Portrayal of patients and doctors as inevitably
in conflict is inaccurate
• Patients are not passive e.g. non-compliance
• Patients may appear deferential in
consultation but assert themselves in lay
community
Arguments against conflict theory and
medicalisation
• Women are not (always) victims
• Conflict theory assumes patients’ views are
legitimate = very problematic
• Different doctors have different styles Comaroff ; Bryne and Long
• “Medicalisation” not always carried out by
medical profession
3. Interpretive approaches
• Do not see doctors or patients as being
fixed in positions of power  neither
conflict or consensus is inevitable
• Rejects notion of the “competence gap”
• Focus on dynamics of interaction and
RULES that govern these
Interpretive approaches
• Focus on the meanings that both parties
give to the encounter
• Emphasises negotiation between doctor
and patient
Rules of doctor-patient relationships
• Social rules are invisible, underlying codes
governing behaviour
• Rules often surface as complementary rights
and obligations
• Eg patient has to be polite to doctor, doctor has to be
polite to patient
• Eg patient has to bring only proper medical problems,
doctor has to take them seriously
The ceremonial order
• Each party to the encounter is presented in
an idealised light (Strong, 1979)
• The “appeal to gentility” can silence
patients, who may maintain a façade of
compliance and acquiescence
Power and control
• Interpretivists point out that the rules are
asymmetrical – patients don’t hold as much
power as doctors
• However, patients do have cards they can
play
• They can resist medicalisation and
surveillance using various strategies
Resisting health visitors (Bloor and
McIntosh, 1990)
• Individual ideological dissent – challenging
legitmacy of HV
• Non-cooperation – non-compliance
• Avoidance – not being in, not attending
• Concealment – hidden practices; avoided
confrontation
Reforming the doctor-patient
relationship
• Functionalists do not anticipate need for
reform
• Conflict theorists want to reduce the
power of the doctor
• Interpretivists want doctors to become
more sensitive to the meanings patients
give to health and illness and to how the
consultation is managed.
Aspirational models
• There are growing problems for the medical
profession. Great deal of interest in how to
address them.
• Tuckett et al (1985) = “meetings between experts”
• Charles et al (1999) = partnership between doctors
and patients
Key features of aspirational models
Try to get doctors to:
• recognise patients’ competence
• see the consultation as an opportunity
for co-operation
• emphasise partnership and participation
• Need for more evidence about whether this
can and should work.
Conclusions
• Diversity of explanatory approaches to the
doctor-patient relationship
• Diversity relates to different underlying
theoretical approaches
• Current trend is towards aspirational
models emphasising partnership