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The Doctor-Patient Relationship: A Review

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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.

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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.

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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.

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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.

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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.

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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. Susan Reycraft cousin Condolence: I have many fond and special childhood memories of cousin Burt, visiting with my parents and sister at the 'Farm'.

I was able to touch base again with my cousins Burt, Fraser and Bob a few years back when my husband, Ken, and I were in Selkirk for a friend's wedding. It was a great visit.

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My condolences to you all. It was with deep sadness that we heard of the death of our friend Burt. We enjoyed many fun times together in Winnipeg and out here in Nova Scotia. His smile and great friendship was special to us and his many friends. We are much better people for having known Burt. We extend our sympathy to his wife Lauri, his children and all his family, it is a great loss.

Sheldon Claman and Louise Claman Condolence: Dear Lauri, Cameron, Catherine, Kalynn and all the family: Burt was a gentle but strong man. While we were not always in sight of each other in the latter years we in "effect" grew up with him via our professional relationship and through the close ties our children had through SJR.

Burton was initially my student in dentistry and in my early years in practise he was a staunch supporter. It is not an exaggeration to say his patients loved him. More importantly he was a WELL respected and skilled practitioner of his proud profession.

Always quiet and private he was our close and valued friend. Picture a rural Caribbean health clinic. The mountainous community can seem remote based on the terrible conditions of the roads, but in fact as the crow flies there is only 10 miles to the capital city.

There is also fairly regular transport by bus to the city Mon — Sat, and a public run clinic in town which provides free STI testing and treatment all be it slow.

Community members, however, have very little disposable income and primarily lead subsistence lifestyles. Syndromic management, therefore, seemed the way to go… But the more I thought about syndromic management — STI management without any laboratory testing — the more negative implications I could think of: Contact tracing — this is still possible, but do you treat all sexual contacts even if symptom free?

This could expose numerous people to the risk of unnecessary medications when there is no guarantee that they have the disease.

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Missing concomitant STIs e. Treating syndromically without testing misses the opportunity to pick up some of the more serious infections that may be present simultaneously. Contributing to antibiotic resistance — as one of the biggest threats to modern medicine, antibiotic resistance cannot be ignored.

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Whilst syndromic management may be the pragmatic approach, the greater picture needs to be considered.