Doctor-Patient Interactions
Power imbalances, trust, relationship/partnership building
The inherent power imbalance in doctor-patient interactions exists largely because the patient comes to the physician for help, immediately placing the physician in a position of power. Physicians expect patients to relay the most intimate details of their lives as well as surrender their modesty during the physical exam. While the intense and specialized education required by the physician produces the necessary expertise for diagnosis and treatment, it also sets up potential imbalances with patients based on knowledge, language, comprehension, and socio-economic status. In addition, physicians typically wear or carry markers of status that may be intimidating, such as the white coat and the stethoscope. Awareness of this power imbalance is important.
The power endowed to healthcare providers by patients can be helpful in the diagnosis and management of illness, but it can also work to a doctor’s disadvantage if a patient feels too intimidated to divulge information, ask questions, or disagree. Occasionally, intimidation and distrust of physicians develops because of previous interactions with physicians who have abused their power and adversely affects interactions with all physicians, even those who make efforts to avoid abuse of power. Additionally, in some cultures deference to the physician is expected, and asking questions or disagreeing with a doctor is viewed as rude and disrespectful. Whether intimidated or deferential, patients who cannot communicate freely or effectively with a physician are at risk for suboptimal health care outcomes.
Improving the balance of power can help to build trust between a patient and a doctor and create a successful healthcare relationship. The Program for Multicultural Health at The University of Michigan Health System [http://www.med.umich.edu/Multicultural/ccp/approaches.htm#clinicians] suggests the following characteristics of culturally competent clinicians that enhance trust:
Understanding: acknowledging that there can be differences between our western and other cultures’ health care values and practices.
Empathy: being sensitive to the feeling of being different.
Patience: understanding the potential differences between our western and other cultures’ concept of time and immediacy.
Respect: the importance of culture as a determinant of health; the existence of other worldviews regarding health/illness. The adaptability and survival skills of our patients; the influence of religious beliefs on health; the role of bilingual/bicultural staff.
Ability: to laugh with oneself and others.
Trust: investment in building a relationship with patients, which conveys a commitment to safeguard their well-being.
The following are ideas of how to shift the balance of power back to the patient to create more equal footing. As always, awareness of your patients and yourself is key. For more on self awareness, the Self-awareness tool box.
Language:
- Use short, simple, declarative sentences
- Avoid jargon and modify your vocabulary; for example, say “red,” rather than erythematous; “swollen” rather than edematous
- Avoid language that imputes motives. For example, say “does not have” rather than “denies;” use “has abdominal pain” rather than “complains of abdominal pain.”
- Emphasize cooperation: “adherence” to a medical plan implies a jointly developed plan, while “compliance” implies a physician-directed plan.
- Know the reading level of your pamphlets and handouts. The average reading level of parents of young children in the US was approximately 7th-8th grade in 1994.
- For more on comprehension, reading level and language, see http://www.informatics-review.com/FAQ/reading.html ---- look up!
Attire:
- Modify your dress for your patient population; for example, if you work in a poorer community, wearing large amounts of expensive jewelry may be inappropriate
- Consider whether the white coat serves to enhanced the patient-physician interaction or cause intimidatation
Positioning:
- Conduct interviews at the patient’s eye level; if two people are in a room and one is standing and the other is sitting, the one who is standing has more power
- Eye contact – appropriate eye contact varies between cultures, In much of Western culture, direct eye contact is appropriate and indicates attention and interest, but prolonged eye contact may be intimidating. People in many non-Western cultures avoid direct eye contact.
Resource:
The Informatics Review. Comprehension and Reading Level.
http://www.informatics-review.com/FAQ/reading.html
University of Michigan Health System, Program for Multicultural Health. Approaches for Cross-Cultural Relationships.
http://www.med.umich.edu/Multicultural/index.html