Academic literature on the topic 'Power asymmetry in the physician-patient relationship'

Argumentation theory has much to offer our understanding of the doctor-patient relationship as it plays out in the context of seeking and obtaining consent to treatment. In order to harness the power of argumentation theory in this regard, I argue, it is necessary to take into account insights from the legal and bioethical dimensions of informed consent, and in particular to account for features of the interaction that make it psychologically complex: that there is a fundamental asymmetry of authority, power and expertise between doctor and patient; that, given the potential for coercion, it is a challenge to preserve the interactive balance presumed by the requirement of informed consent; and finally that the necessary condition that patients be ‘competent to consent’ may undermine the requirement of respecting patient autonomy. I argue argumentation theory has the resources to deal with these challenges and expand our knowledge, and appreciation, of the informed consent interaction in health care.

There is a gap between the preferences of immigrant patients and their experiences with intercultural communication. This study aims to explore the experiences and perspectives of long-stay immigrants on intercultural communication in encounters with primary care (PC) nurses. Participants were selected by purposive sampling at the Maresme Primary Care Center. A focus group and five in-depth interviews with long-stay immigrants from eight countries were carried out. Data collection was guided by a script previously validated by a group of experts. We conducted a qualitative analysis following Charmaz’s approach, and data saturation was reached with 11 patients (one focus group and five interviews). Long-stay immigrants would like closer and more personalized communication exchanges with greater humanity, as well as polite and respectful manners as they perceive signs of an asymmetrical care relationship. Those who had negative communication experiences tried to justify some of the behaviors as a result of having free access to public health services. This is one of the few existing studies from the point of view of long-stay immigrants. Achieving effective intercultural communication requires a process of self-reflection, awareness-raising and commitment, both on a personal and institutional level, to eliminate the asymmetry in the nurse-patient relationship. Nurses should be trained in person-centered intercultural communication.

Background: Informal coercion, that is, situations where caregivers use subtle coercive measures to impose their will on patients, is common in adult psychiatric inpatient care. It has been described as ‘a necessary evil’, confronting nurses with an ethical dilemma where they need to balance between a wish to do good, and the risk of violating patients’ dignity and autonomy. Aim: To describe nurses’ experiences of being involved in informal coercion in adult psychiatric inpatient care. Research design: The study has a qualitative, inductive design. Participants and research context: Semi-structured interviews with 10 Swedish psychiatric nurses were analysed with qualitative content analysis. Ethical considerations: The study was performed in accordance with the Declaration of Helsinki. In line with the Swedish Ethical Review Act, it was also subject to ethical procedures at the university. Findings: Four domains comprise informal coercion as a process over time. These domains contain 11 categories focusing on different experiences involved in the process: Striving to connect, involving others, adjusting to the caring culture, dealing with laws, justifying coercion, waiting for the patient, persuading the patient, negotiating with the patient, using professional power, scrutinizing one’s actions and learning together. Discussion: Informal coercion is associated with moral stress as nurses might find themselves torn between a wish to do good for the patient, general practices and ‘house rules’ in the caring culture. In addition, nurses need to be aware of the asymmetry of the caring relationship, in order to avoid compliance becoming a consequence of patients subordinating to nurse power, rather than a result of mutual understanding. Reflections are thus necessary through the process to promote mutual learning and to avoid violations of patients’ dignity and autonomy. Conclusion: If there is a need for coercion, that is, if the coercion is found to be an ‘unpleasant good’, rather than ‘necessary evil’ considering the consequences for the patient, it should be subject to reflecting and learning together with the patient.

Abstract In contrast to medical care, which is focused on the individual patient, public health is focused on collective health. This article argues that, in order to better protect the individual, discussions of public health would benefit from incorporating the insights of virtue ethics. There are three reasons to for this. First, the collective focus may cause neglect of the effects of public health policy on the interests and rights of individuals and minorities. Second, whereas the one-on-one encounters in medical care facilitate a compassionate and caring attitude, public health involves a distance between professionals and the public. Therefore, public health professionals must use imagination and care to evaluate the effects of policies on individuals. Third, the relationship between public health professionals and the people who are affected by the policies they design is characterized by power asymmetry, demanding a high level of responsibility from those who wield them. Against this background, it is argued that public health professionals should develop the virtues of responsibility, compassion and humility. The examples provided, i.e. breastfeeding information and vaccination policy, illustrate the importance of these virtues, which needed for normative as well as instrumental reasons, i.e. as a way to restore trust.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) outcomes include pain reduction and improved gait speed. Ankle push off power, which requires gastroc-soleus muscle strength, is a critical aspect of healthy gait and increases as gait speed increases. It appears that improvements in pain translate to improved ankle muscle performance. However, ankle power after TAA is surprisingly low. It is possible years of arthritis and latent muscle memory result in reduced gastroc-soleus muscle strength and a gait pattern reliant on proximal joints for power. Evaluating these hypotheses will drive postoperative care. The purpose of this ongoing prospective study is to be the first to evaluate the interplay of pain, gait speed, and ankle muscle performance (strength and power) in people following TAA for end-stage ankle arthritis. Methods: Twelve people [Mean (SD): Age 61 (14.3) years; BMI 30.0 (5.4) Kg/m2; 83% male] with end-stage ankle arthritis who were candidates for TAA participated (12 preoperative and 9 six-month postoperative visits). Performance of adjunct soft tissue procedures and postoperative care were patient specific. A twenty point numeric pain rating scale was used to measure worst pain in the past week. Three dimensional multi-segment foot motion analysis was performed while participants walked barefoot on level ground over a force plate. Ankle peak push-off power (joint torque x segmental velocity) was calculated. Ankle peak isokinetic plantarflexion strength (torque at 60 degrees / second) and ankle sagittal plane passive range of motion were measured with a dynamometer. Participants also completed the six minute walk test. Wilcoxon Signed Rank tests were used to evaluate preoperative to postoperative changes and between limb differences postoperatively. Results: Pain decreased (postoperative mean = 2.8; p = 0.01) and gait speed increased following TAA (p = 0.02). Ankle plantarflexion strength and ankle power during walking were preserved following TAA (both p > 0.8) (Figure 1). Postoperative group mean dorsiflexion was 25.1 degrees and plantarflexion was 18.9 degrees, suggesting sufficient ankle motion was present for plantarflexor muscle performance. However, between limb differences were significant for both strength and power (both p < 0.05) postoperatively. The involved ankle produced 36% less strength and generated 45% less power during walking in comparison to the uninvolved limb. This asymmetry demonstrates that involved limb ankle muscle performance was not normalized at six-month follow up, despite improvements in pain. Conclusion: Study findings provide preliminary evidence that improved pain and gait speed are disconnected from ankle muscle performance following TAA. Postoperative improvements in gait speed were likely driven by more proximal joints (i.e. hip). Without additional targeted postoperative plantarflexion strengthening and gait training to improve ankle muscle involvement, gains in ankle power, a symmetrical gait pattern, and patient tolerance to higher level activity (i.e. stairs) are unlikely to occur long-term. The underpinning mechanisms limiting the necessary strength to drive power generation (i.e. length-tension relationship, atrophy), and the possible cumulative effect of how abnormal gait may influence implant survivorship deserve further attention.

Healing power in the doctor-patient relationship is addressed to physicians in physical health care and to medical students but is of equal importance to dentists, social workers, nurses, and teachers in the field of physical health care. The presentation points up that in the relationship between physician and patient certain phenomena occur that are comparable to responses in the relationship between the psychoanalyst and analysand, such as transference and countertransference. This indicates that the physician in physical health care in effect is involved in some kind of psychotherapy. Aspects of the art of medicine are described. Emphasis is on the potential for patients' physical health improvement—placebo effect—when the providers' perception extends beyond focus on physical symptoms and disorders and includes attention to the patients' psychological and emotional needs.

The following paper deals with the issues of doctor’s image in the doctor-patient relationship in the Internet era and the influence of Internet on patient’s compliance. Both positive and negative standpoints have been discussed briefly, followed by a description of a research model proposed by Laugesen, Hassanein and Yufei (2015) applicable for this type of study. The study examines the impact of patients’ use of Internet health information on various elements of patient-doctor relation (including compliance) through a theoretical model based on principal-agent theory as well as the information asymmetry perspective. A pilot survey and interview study performed on one Polish doctor and a group of his patients, a specialist in Family Medicine has been described. The study carried out by three coworkers: Laugesen, Hassanein and Yufei (2015) revealed that patient-doctor concordance and perceived information asymmetry have relevant effects on patient’s compliance while patient-doctor concordance reveals a stronger relationship. The final conclusions were such that only doctor’s quality had a significant influence on the information asymmetry; the Internet health information gathered by a patient had no impact on perceived information asymmetry; the pilot study performed on the Polish physician confirms the theses presented in this paper but further investigations concerning the formerly discussed issues should be done.

This study focusing on physician-patient interactions aimed to find out whetherphysicians’ gender and experience influence Persian doctor-patient interactions. Sopower strategies in physician-patient interactions were extracted and categorized toexplore the relationship between physicians’ gender and experience and power strategies.Fieldwork was conducted in clinics and hospitals of Rafsanjan city in Iran. One hundredphysician-patient consultations were audiotaped and transcribed during 2011-2012.Woods’ (2006) view was used to examine four strategies of power and knowledge ontheir talk. The findings pointed out the importance of investigating discourse of medicinein order to improve medical consultations, especially physician-patient interactions.Our study confirmed some previous assertions that physician-patient interactionswere asymmetrical. Physicians controlled and dominated the medical consultations byquestioning, interruptions, directive statements and tag questions. The analysis of the datarevealed that all power strategies were applied in Iranian physician-patient interactions.The results of Chi-Square tests indicated that there was a significant relationship betweenpower strategies and physicians’ experience and gender. It was concluded that the femaleand inexperienced physicians tended to control consultations by questioning, interruption,directives and tag questions more than the male and experienced physicians.

Thesis (M.A.)--University of Stellenbosch, 2000.
ENGLISH ABSTRACT: This paper examines aspects of power within the physicianpatient relationship. The historical development of the physician-patient relationship is briefly reviewed and some of the complexities of the relationship highlighted. It is shown that, historically, there is no imperative for the physician to consider only the interests of the patient and it has always been acceptable to consider the interests of a third party, such as the State or an employer - essentially the interests of whoever is paying the physician. The classical sources of power are then considered. These sources include legitimate power, coercive power, information power, reward power, expert power, referent power, economic power, indirect power, associative power, group power, resource power and gender power. Other approaches to power are also considered such as principle-centred power as described by Covey, power relationships as explained by Foucault, the power experience as described by McClelland and an analysis of power as expounded by Morriss. The various sources of power are then considered specifically within the physician-patient relationship to determine: if this particular type of power is operative in the physicianpatient relationship, and if so if it operates primarily to the advantage of the physician or the advantage of the patient. A simple method of quantifying power is proposed. Each form of power operative in the physician-patient relationship is then considered and graphically depicted in the form of a bar chart. Each form of power is shown as a bar and bars are added to the chart to 'build up' an argument which demonstrates the extent of the power disparity between physician and patient. It is clearly demonstrated that all forms of power operate to the advantage of the physician and in those rare circumstances where the patient is able to mobilize power to his/her advantage, the physician quickly calls on other sources of power to re-establish the usual, comfortable, power distance. Forms of abuse of power are mentioned. Finally, the ethical consequences of the power disparity are briefly considered. Concern is expressed that the power disparity exists at all but this is offset by the apparent need for society to empower physicians. Conversely, consideration is given to various societal developments which are intended to disempower physicians, particularly at the level of the general practitioner. Various suggestions are made as to how the power relationships will develop in future with or without conscious effort by the profession to change the relationship.
AFRIKAANSE OPSOMMING: Hierdie voordrag ondersoek aspekte van mag in die verwantskap tussen pasiënt en geneesheer. Die historiese ontwikkeling van die verwantskap word kortliks hersien en 'n kort beskrywing van die ingewikkeldheid van die verwantskap word uitgelig. Vanuit 'n historiese oogpunt, word 'n geneesheer nie verplig om alleenlik na die belange van die pasiënt om te sien nie en was dit nog altyd aanvaarbaar om die belange van 'n derde party soos die Staat of 'n werkgewer se belange to oorweeg - hoofsaaklik die belange van wie ookal die geneesheer moet betaal. Die tradisionele bronne van mag word oorweeg. Hierdie bronne sluit in: wetlike mag of 'gesag', die mag om te kan dwing, inligtingsmag, vergoedingsmag, deskundigheidsmag, verwysingsmag, ekonomiesemag, indirektemag, vereeningingsmag, groepsmag, bronnemag en gelslagsmag. Alternatiewe benaderings word ook voorgelê, naamlik die beginsel van etiese mag soos deur Covey beskryf, krag in menslike verhoudings soos deur Foucault, die ondervinding van krag soos beskryf deur McClelland en 'n ontleding van krag soos deur Morriss verduidelik. Hierdie verskillende mag/gesagsbronne word spesifiek met betrekking tot die geneesheer-pasiënt verhouding uiteengesit om te besluit: of hierdie tipe mag aktief is tussen geneesheer en pasiënt, en indien wel, werk dit tot die voordeel van die geneesheer of die pasiënt. 'n Eenvoudige sisteem vir die meting van mag/gesag word voorgestel. Die bronne word individueeloorweeg en gemeet en die resultaat in 'n grafiese voorstelling voorgelê op so 'n wyse dat 'n argument daardeur 'opgebou' word om die verskille van van mag/gesag tussen geneesheer en pasiënt uit te wys. Dit word duidelik uiteengesit dat alle vorms van mag/gesag ten gunste van die geneesheer werk. Kommer is getoon dat hierdie magsverskil werklik bestaan, asook die snaakse teenstelling dat die gemeenskap wil eintlik die geneesheer in "n magsposiesie plaas. Die etiese gevolge van hierdie ongebalanseerde verwantskap, asook die moontlikheid van wangebruik van hierdie mag word ook genoem. Verskillende gemeenskaplike ontwikkelinge wat die mag van die geneesheer wil wegneem word geidentifiseer, meestalop die vlak van die algmene praktisyn. Verskeie voorstelle vir toekomstige ontwikkeling van die verwantskap word voorgelê, met of sonder spesifieke pogings van die professie om die verwantskap te verbeter.

Thesis (LLD (Public Law))--University of Stellenbosch, 2010.
ENGLISH ABSTRACT: The unique and intimate relationship that exists between a medical practitioner and his/her client is possibly one of the most important relationships that can come into being between any two people. This relationship is characterised and influenced by the qualities and attributes specific to the nature and historical development of medical care, as well as medical science in general. The doctor-patient relationship is also influenced by the social dynamics of a particular community, environmental factors, technological advances and the general social and commercial evolution of the human race. With regard to medical care and health service delivery, the doctor-patient relationship is furthermore vital to the quality of the care provided, as well as to the outcomes and relative success of the specific medical intervention or treatment. One of the distinct characteristics of the doctor-patient relationship is the power imbalance inherent in this relationship. The medical practitioner has expert knowledge and skill, while the patient finds himself or herself in an unusually dependent and vulnerable position. It is because of this important role that the doctor-patient relationship still plays in health service delivery today; the susceptibility of the relationship to a variety of influences, and the characteristic power imbalances inherent in this relationship, that a study of the doctor-patient relationship in South African medical- and health law is necessary. The characteristic power imbalances will be considered from a legal perspective in this dissertation. This study provides a comprehensive source of the doctor-patient relationship from a legal perspective. Where relevant, references are made to theories and principles from other disciplines, including sociology, economy and medical ethnomethodology. The prevalence and consequences of power imbalances in the doctor-patient relationship are identified and discussed with the aim of bringing these to the attention of both the legal fraternity, and medical practitioners. Specific problem areas are identified and solutions are offered, including the following: • The adverse consequences of power imbalances inherent in the doctor-patient relationship on the medical decision-making process are considered from various perspectives. With regard to these adverse consequences, the doctrine of informed consent is analysed and evaluated in great detail. • The influence of paternalistic notions in health service delivery; the business model of health service delivery and the effects of managed care and consumer-directed health care on the doctor-patient relationship and health service delivery in general are also analysed from a legal perspective, and specifically with regard to the power imbalances inherent in this relationship. • The role of autonomy, self-determination and dignity, as well as the principles of beneficence in medical practice, are reconsidered in an attempt to provide a solution for redressing the power imbalances inherent in the doctor-patient relationship. • The fiduciary nature of the doctor-patient relationship and the special role of trust in the relationship are emphasised throughout the dissertation as the focal point of departure in the doctor-patient relationship and the main constituent in any legal endeavor to redress the power imbalances inherent in it.
AFRIKAANS OPSOMMING: Die unieke en intieme verhouding wat bestaan tussen ‘n mediese praktisyn en ‘n pasiënt is wêreldwyd waarskynlik een van die belangrikste verhoudings wat tussen twee persone tot stand kan kom. Hierdie verhouding word gekenmerk en beïnvloed deur kwaliteite en eienskappe eie aan die besonderse aard en historiese ontwikkeling van gesondheidsorg, sowel as die mediese wetenskap in die algemeen. Die dokter-pasiënt verhouding word verder beïnvloed deur die sosiale dinamika van ‘n bepaalde gemeenskap, omgewingsfaktore, tegnologiese vooruitgang en die algemene sosiale en kommersiële ontwikkeling van die mensdom. Op die terrein van gesondheidsorg en mediese dienslewering is die dokter-pasiënt verhouding voorts ook sentraal tot die kwaliteit van die mediese sorg wat verskaf word, sowel as die uitkomste en relatiewe sukses van die spesifieke mediese behandeling. Een van die kenmerkende eienskappe van die dokter-pasiënt verhouding is die magswanbalans wat daar tussen dokter en pasiënt bestaan. Die mediese praktisyn beskik oor deskundige kennis en vaardighede, terwyl die pasiënt hom- of haarself in ‘n ongewone, afhanklike en kwesbare posisie bevind. Dit is dan veral weens die besondere rol wat hierdie verhouding steeds in hedendaagse gesondheidsorg speel, die beïnvloedbaarheid van hierdie verhouding deur ‘n verskeidenheid faktore, sowel as die kenmerkende magswanbalans inherent in die verhouding, dat ‘n ondersoek na die dokter-pasiënt verhouding in die Suid-Afrikaanse mediese reg noodsaaklik is. Hierdie kenmerkende magswanbalans sal vanuit ‘n regsperspektief verder in hierdie proefskrif ondersoek word. Hierdie studie bied ‘n omvattende bron van die dokter-pasiënt verhouding benader vanuit ‘n regsperspektief, terwyl verwysings na teorieë en beginsels van ander dissiplines soos die sosiologie, ekonomie en mediese etnometodologie ook waar nodig ingesluit word. Die voorkoms en gevolge van ‘n magswanbalans in die dokter-pasiënt verhouding word verder geïdentifiseer en bespreek ten einde dit onder die aandag te bring van beide regslui en medici. Spesifieke probleemareas wat geïdentifiseer is en die oplossings wat daarvoor aan die hand gedoen is sluit die volgende in: • Die nadelige gevolge van die bestaan van ‘n magswanbalans in die dokter-pasiënt verhouding op die mediese-besluitnemingsproses word bespreek vanuit verskillende persepktiewe. Met betrekking tot hierdie nadelige gevolge, word die leerstuk van ingeligte toestemming in besonder geanaliseer en geëvalueer. • Die invloed van ‘n paternalistiese benadering tot gesondheidsorg, die besigheids-model van gesondheidsorg, en die effek van bestuurde- en verbruikersgedrewe gesondheidsorg inisiatiewe op die dokter-pasiënt verhouding en die verskaffing van gesondheidsdienste in die algemeen word ook vanuit ‘n regsperspektief ge-analiseer. Spesifieke aandag word in dié verband gegee aan die invloede van hierdie benaderings en perspektiewe op die magswanbalans inherent aan die dokter-pasiënt verhouding. • Die besondere rol van autonomie, selfbeskikking en menswaardigheid, asook die beginsels van weldadigheid in gesondheidsorg, word heroorweeg in ‘n poging om ‘n meer gelyke distribusie van mag in die dokter-pasiënt verhouding te verseker. • Die fidusiêre aard van die dokter-pasiënt verhouding en die besondere rol wat vertroue in hierdie verhouding speel, word in hierdie proefskrif beklemtoon en word voorts as die basis van die dokter-pasiënt verhouding beskou. Vertroue, as ‘n kenmerk van die dokter-pasiënt verhouding, behoort ook die fokuspunt te wees van enige poging om die magswanbalans in die dokter-pasiënt verhouding aan te spreek.

Professional boundaries refer to the “edge” or limit of appropriate behavior in the clinical setting. The fundamental ethical principal involved is respect for the patient’s dignity and autonomy. Because there is a potential for exploitation of the patient due to the power differential and asymmetry between psychiatrist and patient, the following dimensions of the treatment frame must be considered: location, time, behavior, language, dress, confidentiality, self-disclosure, money and gifts, dual relationships, and physical/sexual contact. Context is crucially important in assessing professional boundaries. Hence, relatively benign boundary crossings must be differentiated from exploitative boundary violations. Preventive strategies, such as education, self-monitoring, and regular consultation should be part of the practice of all clinicians. The domain of the Internet is a recent context that has emerged, and psychiatrists must now be attuned to boundary issues in cyberspace.

The increase in the availability of mental health services in primary care settings in large health systems is a positive development for suicide prevention, but challenges remain. Unhelpful power asymmetries in the patient–primary care physician (PCP) relationship, supply-side economic factors, and the disease-centered (biomedical) model make it difficult for PCPs to elicit patient priorities. Thus many of the drivers of suicide risk are marginalized if not ignored in the patient–PCP encounter. Drawing from self-determination theory and systems theory, this chapter offers a person-centered vision of suicide prevention in primary care. It calls for policy initiatives to that accommodate PCPs’ needs for self-determination and outfit primary care settings with the technological and human resources needed to improve the way PCPs and patients communicate about difficult issues. These initiatives are expected to mitigate suicide risk and improve other patient outcomes as well as PCP job satisfaction.