The Doctor-Patient Relationship in its Social Context PDF

The doctor-patient relationship in its social context Dr Andy Guise Senior lecturer in Social Science and Health April 2024 Lecture After this session you should be able to: describe some key models of the doctor and patient relationship. critically evaluate ideas of patient centred care, em...

The doctor-patient relationship in its social context Dr Andy Guise Senior lecturer in Social Science and Health April 2024 Lecture After this session you should be able to: describe some key models of the doctor and patient relationship. critically evaluate ideas of patient centred care, empowerment and choice understand processes by which care interactions are shaped by specific contextual factors 1 Patient and doctor relationships Historical evolution of patient and professional relationships (in the UK/West) 1 bedside medicine (18th C) 3 Patient centred care (1970s) Person oriented, reliant on patient Biopsychosocial perspective reporting of experience Relationship as a therapeutic alliance Personal rapport and relationships Doctor reliant on fees 2 Hospital and laboratory medicine (19th C) Pathology reduced reliance on patient experience Growth of hospital as a focus for care Distance between patient and doctor Historical evolution, continuing spectrum? 1 Paternalism 2 Doctor as agent Bedside medicine Hospital and laboratory medicine Patient centred care 3 Consumer 4 Partnership 1 Paternalism High doctor control, low patient control consultations oriented to a biomedical disease model, closed questions Doctor chooses treatment Common for routine treatments, emergencies The sick role (Parsons, 1951) 2 Doctor as agent High doctor control, low patient control Variation on traditionalist paternalism Decision making stays with the doctor, but informed by knowledge of patients’ preferences and life world Aims to combine clinical evidence with knowledge of patient 3 Consumer low doctor control, high patient control information flow from doctor to patient, as much as patient to doctor Patient makes informed decisions Doctor allows for second opinions, referrals, sick notes Linked to where patients pay for services 4 Partnership High doctor, high patient control Recognising patient experience: understand personal meaning, and not patient as an object with disease Sharing control: responsibility and decision making Content: going beyond narrow biomedical focus, and addressing biopsychosocial needs Paternalism, doctor as agent, consumerism, partnership? Consider two scenarios: Regular check-up for diabetes Initial tests within hospital for cancer Which relationship format is most useful? 2 Patient and doctor relationships in their social context General practice Minor courtesies and macro structures Strong (1988): medical consultations are like ceremonies, rituals Following Goffman’s work on the ‘ceremonial order’ Tacit or implicit rules that structure and regulate interaction These rules are understood These ‘ceremonial orders’ – ie rituals – are then social structures that shape conduct in a consultation The particular nature of a ceremonial order is linked to ‘macro structures’ – broader social structures (e.g. policy, resources, culture) Minor courtesies and macro structures There are different rules of interaction depending on the context: ‘Private formats’ ‘Bureaucratic format’ Typical in fee paying health care, USA Typical of the NHS, UK Norms of polite conduct, linked to Doctor controls the encounter more doctor’s reliance on patient for their salary Doctors not so deferential to patients Doctors will explains and demonstrates No effort to explain or demonstrate their competence and expertise experience and qualifications Patients are allowed to criticise other Patients aren’t entitled to question a doctors doctors skill, or to ‘shop around’ Context of free market health care, and Context of patients having no control over insurance resources within health care (centrally tax payer funded system) Diabetes care and the empowered patient Empowerment and choice: the ‘expert patient’ as progress? A logic of care ‘Choice’ as a celebrated ideal (Mol, 2008) Western norms of autonomy, individualism With their own specific history and context But ‘choice’ is not how care happens: patients are active, but in interaction with providers; decisions are made over time through social networks and interactions with providers Need to consider the ‘logic of care’: care as emergent, dynamic, attentive, involving experimentation Opioid Substitution Therapy Health care as discipline? Health care practices as disciplining the supposedly immoral (Bourgois, 2003; Foucault) Seeking ‘moral’ discipline in people dependent on heroin Daily attendance and not using other drugs a way to control and shape behaviour Context of national and global discourses on drugs The ‘war on drugs’: drug use as criminal and immoral (and not a disease model or structural violence model or libertarian model of drug use and addiction) Summary Summary We can identify a historical change in doctor – patient relationships, and also a continuing spectrum: paternalism, doctor as agent, consumer, mutuality Patient centred care, empowerment and choice are important organising ideas for health care that respond to critiques of power, but we need care in our assumptions around them How doctor-patient relationships are organised is shaped by their social context (economic, political and cultural factors) and not just specific clinical imperatives Questions, comments [email protected]