Patient perceptions of power dynamics are a root cause of our healthcare woes

When asked, “If a clinician makes a medical diagnosis and/or tells me what I should do to treat a condition, I believe that I can tell the clinician that I disagree or will not follow what they have asked me to do”, 51% of patients I surveyed in the U.S. and U.K. responded that they were undecided or disagreed.

This reported lack of patient confidence in the ability to openly disagree with or question a clinician’s decision making is alarming and is a serious barrier to both providing and receiving high quality healthcare services.

In this article, part two in a series studying the clinician-patient relationship, we will take a closer look at patient perceptions of power dynamics.
Why don’t patients feel empowered?

To better understand why 51% of the aforementioned patients I surveyed reported they were undecided or disagreed, I analyzed responses and was able to find some common themes:

  • Patients perceive a culture of clinician superiority: many patients shared feelings of “being less than” (e.g. being spoken over, patronized, etc.) clinicians because of pre-conceived notions, assumptions or past experiences. Some patients detailed:

“I have done this (disagreed with clinicians’ guidance) before and I was simply spoken over and given the method of treatment they suggested”

“They never believe that I know more about my conditions than they do. They have very little idea how to treat me”

  • Patients fear disagreeing with clinicians due to perceived negative consequences: patient reported fear ranges in severity. While this fear is applicable to all patients, it is often felt most deeply by patients of marginalized communities. Some patients expressed:

“I can tell them (clinicians) more information about myself, but then I risk them (clinicians) washing their hands of me and telling me that if I don’t follow their advice then any problems I have are my own fault and why did I bother coming to the doctor if I am not willing to follow the treatment they have decided on”

“I’d like to feel comfortable telling my clinician but I’m also afraid they’ll (clinicians) do something to sabotage my health if they know”

“There is still a lot of stigma around “these things” (e.g. my sexual orientation, race, ethnicity, beliefs, values, religious preference, disability status, etc.) – and not just stigma, but actual institutional injustice.”

“It (disagreeing with a clinician) would depend on how that might impact me upon entitlement to further care (e.g. specialist referral)”

What’s the impact?

An interesting phenomenon that surfaced as a result of this analysis was that even if patients will not openly disagree with or express their concerns to clinicians, they will take matters into their own hands: disagreeing quietly but “going their own way”, finding a new clinician, and/or not following the prescribed treatment plan, to name a few.

This notion of a patient taking matters into their own hands has an inextricable link to many of the major issues that health focused organizations (e.g. health insurers, health systems, etc.) face.

For instance, patient adherence is a hot topic in healthcare (meaning to what extent is the patient following the recommended, documented treatment plan prescribed by the clinician which could include tasks like: filling a prescription, taking the correct dosage of a prescription for the appropriate length of time, etc.). Significant financial investments have been made by veteran companies and startups alike to develop tools and technologies to improve patient adherence, but it’s still difficult to change patients’ behaviors.

Don’t get me wrong, investment in health tech is key, but why aren’t we trying to uncover the root cause of why patients aren’t filling their prescription drugs or missing their primary care follow up appointments, for example? I hypothesize that redefining the clinician-patient relationship is critical to solving many of our grievances in healthcare.

What can we do to change this patient perception of powerlessness?

First, we need to accept that this change will not happen overnight and innovative tools and technologies are critical to support but not replace the human-human nature of the clinician-patient relationship. By accepting that redefining the way clinicians and patients interact will not happen overnight, we can devote the time and attention that is needed to work towards solutions to this complex issue and not look for a quick fix or “silver bullet”. For example, starting with a ground level, systematic approach to gaining awareness of and education about the problem is a logical first step to reform.

Second, we need to acknowledge that the clinician-patient relationship is not intuitive and we shouldn’t expect it to come about organically. For instance, vulnerability, humility and empathy, three values that I consider to be integral in delivering high quality healthcare services, must be learned and embedded in education and training approaches. Also, for many clinicians, establishing deep, emotional connections with patients can be difficult for many reasons. For example, not every clinician naturally possesses the interpersonal skills to navigate complicated discussions with patients especially when those conversations aren’t directly related to physical ailments. In addition, in medical school curriculum, many clinicians have disclosed that they are taught not to get too emotionally invested as it could cloud their judgement and medical decision making.

The stakes are high if we don’t adjust our approach to the clinician-patient relationship. For clinicians, an improved clinician-patient relationship is not only an ethical imperative but also important to financial incentives aligned with the value-based care movement. Conversely, without an improved clinician-patient relationship, patients will continue to fall victim to health disparities and be at risk for medical misdiagnoses or be on the receiving end of an inappropriate treatment plan based on their needs.

Accountability and education for both clinicians and patients must take place before any significant change can be realized.

Agree? Disagree? Tell me why! I’d love to hear from you.

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