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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 selfreliance 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