Four Models of the Physician-Patient Relationship — Northwestern Scholars
Structure of health-care dyad leadership: an organization's experience . In the four models of the “physician-patient relationship” outlined by Emanuel .. If physicians were expecting rather negative behavior from patients. We identified four models of physician–patient relationships that vary in their sumer behaviors as responses to modeling in advertising. Associations between . Interview data organization, management, and analysis were facilitated by the . The physician–patient relationship is the cornerstone of care quality. The implications of this model and directions for future research are presented. .. ( ) report on four clinical trials examining the effect of communication behaviors on patient outcomes. .. "Professional burnout in human services organizations".
The physician may not have intended her to read this information; though it may be of interest to the open-minded patient. Although healthcare providers may suggest to patients that they acquire information from specific sources, patients will likely obtain a "second opinion" on the Internet.
In this case, the potential benefit of the Internet prescription may arise from a patient viewing suggested information first and giving it preference because his or her physician provided it. Furthermore, patients who find additional sources of information on the Internet have the option of obtaining another opinion through their physicians. In this case, the woman in our example could provide her physician with the Web address or printed information that addresses the dangers of traditional exercises.
This step may promote discussion between her and her physician about its interpretation. Whereas it is difficult to teach "evidence-based medicine" to the layperson, it is more feasible to discuss articles with patients using related concepts that physicians have learned. There is great concern about the accuracy and validity of medical information found on the Internet [ 3 - 5 ]. For the physician prescribing Web sites, there is the persistent challenge of ensuring quality in online content.
Both physician and patient must become aware of what information is available, the source of information, and the intended audience [ 24 ]. Online information that differs significantly from that prescribed by the physician may result in unanticipated consequences. The additional strength and reinforcement of referenced consumer information requires the physician to carefully review what patients will read and to recognize that such information may be periodically updated.
In the instance of a major medical illness, some sites may soothe an individual's anxiety whereas others may raise false hopes [ 25 ]. The physician's traditional reluctance to offer more information than is necessary may be well intended.
However, with the Internet, patients may opt to pursue stories and anecdotal literature evoking strong emotions for an example, see ConquerCancer. To combat online misinformation, healthcare providers must positively influence patient selection of online materials. The presentation of awards on medical Web pages may not have a significant impact on patients' assessment of credibility [ 27 ]. However, approximately 3 out of 4 Internet users seeking health information feel that a doctor recommendation would make them more likely to trust a health Web site [ 28 ].
Physicians need to take an active role in this regard. For example, physicians can link their own Web sites to various known Web sites that provide quality content. This idea appears to be increasing in popularity as physician practice Web sites continue to grow in number.
As an alternative, medical journals and professional health organizations may represent even more valuable sources, for they offer assessment and dissemination of the best evidence for clinical problems. Referenced Web sites may be explicitly recommended to patients during clinical encounters or by electronic mail. It then becomes important for physicians to know where high caliber information is located in cyberspace rather than merely know what the specific information is itself [ 24 ].
Given how difficult it is for health professionals to keep track of the ever-changing Web, it becomes equally important to know about quality repositories of medical links. The "healthfinder" Web site selects links to health information from sources that include government agencies, nonprofit and professional organizations serving the public interest, universities and other educational institutions, libraries, and so on [ 30 ]. This site was developed by the US Department of Health and Human Services to provide up-to-date resources beyond what physicians have time to prepare on their own.
Physicians may feel more comfortable recommending information from MEDLINE plus rather than a "dot-com" source of medical information, which often endorses products or companies. Despite the existence of quality repositories of health information, there is still significant resistance to online physician activity. Many have a "fight or flight" response to these technical communicative innovations, creating a challenge in implementation [ 33 ].
The Research Agenda Though there have been previous studies analyzing the patient-physician relationship, research must be directed toward evaluating the impact of electronically obtained knowledge on this relationship.
Further analysis of the current models for the patient-physician relationship may reveal that new, emerging trends are taking place. Efficiency, patient satisfaction, and clinical encounter time may vary when Internet-acquired information is considered in decision-making. Variability in patient types and in physician personalities compounds the dynamics of decision-making analysis. Additional focus must be placed on studies that include the impact of electronically obtained knowledge on the patient-physician relationship.
Another issue that should be addressed is the extent of responsibility that a patient is willing to accept. In one pilot study, individuals have been given access to their medical records and have been provided with online communication with their physicians derived from Web-based methods of sharing clinical content [ 34 ].
Patient interest, as well as physician acceptance, has been evaluated. In another pilot project, patients are being provided with consumer health information in waiting and exam rooms [ 35 ]. The resulting patient-physician communication and level of satisfaction will be measured. When patients assume a greater role in acquiring medical knowledge, there must be a corresponding change in the physician's role as treatment decision-maker.
Additional dynamics are likely to result from different physician behaviors, including embracing, avoiding, or disregarding Internet-derived information. To better define this variable, surveys and observational studies are needed that will elicit physician attitudes toward Internet health information and their corresponding patient-physician relationships.
In addition, research is needed to evaluate the barriers to physician implementation of information technology. In Canada, researchers have administered a new survey instrument to stratify primary care physicians into different levels of information technology usage [ 36 ].
This approach may allow for specifically tailored strategies to be used in implementation. Although many individuals have the potential to gain medical knowledge easily through on-line information, others do not.
Few studies have examined the benefit of computers in patient education within economically depressed urban areas [ 37 ]. There is also little evidence that describes how individuals lacking the latest technology including high-speed Internet Service Providers cannot access resource-intensive Web sites, including those requiring audio or video streaming. The long-term effects and potential benefits of computer technology for vulnerable populations have yet to be determined.
Although there is a considerable amount of data that demonstrate limited access, there still is overwhelming interest in computer education by all segments of the public.
Additional research is necessary to define how patients of different cultural or socio-economic backgrounds utilize computers and the Internet for information, and how this has an impact on their relationship with healthcare providers.
Most patients using a home computer have access to medical information on the Internet. This circumstance will likely reflect a select, educated patient population with income levels that support the equipment. Yet there was significant interest expressed in on-line health information. If minority patient populations are to become active participants in the Internet age, it is necessary to continue to devote greater resources to improving easy access of electronic information.
There is a definite need for interventions that empower ethnic minority patients and help them become informed and active healthcare consumers [ 39 ]. Patients with poor literacy skills are less likely to take advantage of the Internet in order to acquire additional medical knowledge, whether they have access or not.
Unfortunately, because these individuals are more likely to have worse health, their needs for health education are greater, especially for those with chronic illnesses [ 40 ]. This issue affects their relationship with physicians; studies have shown that patients' acceptance of diagnoses and treatment plans depends on education [ 41 ]. Hence, additional efforts are required to assist persons with lower literacy skills. With adaptive technologies supplying touch-screen input and audio output, kiosks can be made available for patients motivated to learn, independent of their literacy or education level [ 4243 ].
Physician offices with health information kiosks may be an alternative method for browsing health-related information, being temporally linked to clinician interactions. However, additional issues, such as cost, complexity of use, and potential for misinformation, then arise [ 44 ].
Still, additional research is necessary to determine the possible benefits and effects on the patient-physician relationship. In sum, the research agenda on on-line information and the patient-physician relationship includes: Conclusions The Internet Age is altering the patient-physician relationship. If physicians actively assist patients in the information-gathering process, an improved relationship may result.
Through the understanding of evolving professional roles, the decision-making process between physicians and patients may improve with efforts to share the burden of responsibility for knowledge.
This change could usher in a new era of the patient-physician relationship, with a potential gain for all collaborative parties. However, there is no assurance that implementation will occur smoothly or in a desirable fashion. Thus, there is a compelling need for prospective research in this area. Methods of bridging the Digital Divide are also important considerations for future research, for this disparity in technology use still exists today [ 45 ].
It is essential that large segments of the population not be left behind as strides are made in information technology and healthcare decision-making. Acknowledgments We are indebted to Paul Heckerling, M. Towards quality management of medical information on the internet: BMJ Nov 28; An evidence-based approach to interactive health communication: Science Panel on Interactive Communication and Health. JAMA Oct 14; The next transformation in the delivery of health care. N Engl J Med Jan 5; 1: Rating health information on the Internet: JAMA Feb 25; 8: Assessing, controlling, and assuring the quality of medical information on the Internet: Caveant lector et viewor--Let the reader and viewer beware.
JAMA Apr 16; Health Information on the Internet: Let the Viewer Beware Caveat Viewor. MD Computing Jul: Patients, gastroenterologists, and the World Wide Web. Gastroenterology Jan; 1: BMJ Jun 28; Four models of the physician-patient relationship. JAMA Apr; Shared decision-making in the medical encounter: Soc Sci Med Mar;44 5: Measuring patients' desire for autonomy: J Gen Intern Med Feb;4 1: Characteristics of physicians with participatory decision-making styles. Ann Intern Med Mar 1; 5: Szasz and Hollender's work refined Parsons by elaborating different doctor-patient models arising around different types of illness.
Szasz and Hollender proposed that patient passivity and physician assertiveness are the most common reactions to acute illness; less acute illness is characterized by physician guidance and patient cooperation; and chronic illness is characterized by physicians participating in a treatment plan where patients had the bulk of the responsibility to help themselves.
Critics have also shown that there is a great deal of inter-cultural, and inter-personal variation in sick roles and norms.
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The "American" sick role is not as useful a concept as the more specific "white, Midwestern, Scandinavian, male" sick role. There is also cross-class variation.
Some of the poor adapt to their lack of access to medical care by becoming fatalistic, rejecting the necessity of medical treatment, and coming to see illness and death as inevitable. On the other hand, the educated classes have become more assertive in the relationship, rejecting the norm of passivity in favor of self-diagnosis or negotiated diagnosis. Parsons also based his model of the doctor role on the assumption of a long-term relationship with a family physician.
Growing medical specialization and the decline of the solo family practitioner makes this dyadic role model incomplete. Increasingly, several doctors attend various of a patient's ailments, each with a somewhat different set of role expectations and interpretations of the patient's role performance.
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Professionalization and Socialization There is also inter-cultural variation in physician roles, and variation among physicians in the success of their role socialization. While Parsons' model of doctors' affective neutrality, collective-orientation, and egalitarianism towards patients did express the professional ideal, some physicians are more affectively neutral than others. Following Parsons' lead, sociologists began to focus on the socialization of physicians and the factors in medical school and residency that facilitated or discouraged optimal role socialization to doctor-patient relationships Merton, Reader, and Kendall, ; Becker, Geer, Hughes and Strauss, This work generally took the division of labor in medicine for granted, and painted a more or less heroic picture of medical self-sacrifice.
A few writers began to focus on aspects of the physician role and medical education that themselves militated against humanistic patient care. Critics suggested that medical schools and residencies socialized physicians into "dehumanization," and to place professional identity and camaraderie before patient advocacy and social idealism Eron, ; Lief and Fox, ; and more recently Anspach, ; Hafferty, ; Sudit, ; Conrad, Professional Power and Autonomy The most important weakness of Parsons' functionalist account of the doctor-patient relationship, however, arose from his poor understanding of the ecological concepts of dysfunction and niche width.
Social structures cannot be assumed to be functional for the social system simply because they exist, any more than an organic structure, such as an appendix, can be assumed to be functional for its organism.
All that can be said about a structure, or in this case a role relationship, is that it has not yet pushed the organism outside its niche, causing its extinction. In other words, the study of doctor-patient relationships in one society does not indicate how much the particular structures and norms of the provider-patient relationship are simply the result of historical chance, rather than necessitated by the nature of illness and healing in industrial society.
And second, such a study does not indicate whether the particular practices and norms are leading in a dysfunctional direction. A critical sociology of the doctor-patient relationship thus arose to challenge the internal contradictions of the Parsonsian biological metaphor: To the more critical 60's generation of social scientists, inspired by growing resistance to unjust claims to power, physicians' defense of professional power and autonomy appeared to be merely self-interested authoritarianism.
Physicians' battle-cry of the sacred nature of the doctor-patient relationship sounded hollow in their struggles against universal health insurance. Physicians' high incomes and defense of autonomy appeared to result in both bad medicine and bad health policy, and physician's unaccountable power appeared all the more nefarious because of medicine's intimate invasion of the body, In this context, Eliot Freidson's work,crystallized the notion that professional power was more self-interested than "collectivity-oriented.
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Freidson's approach to the sick role was influenced by labeling theory Szasz, ; Scheff,and went beyond Parsons to assert that doctors create the legitimate categories of illness. Professionalization grants physicians a monopoly on the definition of health and illness, and they use this power over diagnosis to extend their control. This control extends beyond the claim to technical proficiency in medicine, to claims of authority over the organization and financing of health care, areas which have little to do with their training.
There are now many studies of the way that professional power has been institutionalized in the structure and language of the doctor-patient relationship. For instance, a recent study of medical students' presentation of cases demonstrated that physicians were being trained to talk about their patients in a way that portrayed the physician as merely the vehicle of an impersonal medicine acting on malfunctioning organs, rather than a potentially fallible human being interacting with another human being.
The more highly regarded presenters were found to 1 separate biological processes from the patient, 2 use the passive voice in describing interventions, 3 treat medical technology as the agent, and 4 mark patients' accounts as subjective the patient "states," "reports," "denies,".
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.
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. 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.
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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.
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. 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.
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.