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 self-reliance 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