Tuesday, March 18, 2014

On Patient-Provider Relationship

Sarah Lawrence is known for its writing intensive education. In addition to weekly responses and conference papers, students also write papers and conduct projects. Unlike many schools in the U.S., SLC offers year-long classes. Throughout my sophomore year, I took four year-long classes. Health Policy/Activism was one of them. The relationship between healthcare providers and patients quickly became one of my primary focus in the class.

This is an essay that I wrote on the matter:


May 4, 2013
Essay 3: Doctor-Patient Relationship

The relationship between patients and physicians has experienced a crucial shift in the past few years. Through the discovery and implementation of new models, patients are gaining a much more active role in this relationship. However, the balance within the collaborative patient-doctor relationship should be maintained. Moreover, physicians should broaden their roles by offering a much more accessible and reliable source of medical information to patients.
A central interaction within the modern health care system, doctor-patient relationship is one essential step that usually entails some basic set of examinations and a conversation. The objective is to diagnose and treat; however, those goals may not always be achieved. In addition to depending on the type of illness or disease, the basic concept of a medical consultation is clouded with various social elements such as the hierarchical relationship between the patient and health provider; arguments or discussions when determining the most suitable treatment; ethical considerations such as administering the informed consent; as well as a level of professionalism. Furthermore, the understanding that each party has for each other’s culture, expertise and stake in the relationship influence the interaction.

Taken in Indonesia
Currently, numerous sectors: government, health care professionals, administration, patients, as well as activists have been in pursuit of the ideal doctor-patient relationship. What makes the ideal doctor-patient relationship? Is the conventional model too outdated for today’s society? And yet, is the collaborative model the best alternative?
The doctor-patient relationship could be classified into several models based on the social hierarchy within the relationship and the type of disease/illness/predicament at hand. The relationship between health professionals and patients could be separated based on the power dynamics: doctors as superior to patients, an equal stance within the relationship, as well as patients as superior to doctors, which rarely occurs (Badcott, 2005, 174).. On the other hand, the type of condition’s influence on the model may include acute and chronic conditions. For instance, chronic diseases require a long-term relationship within health care providers and patients, prompting the need to have a better relationship. In this essay, I will focus on the categories in doctor-patient relationship based on power dynamics.
In the past, most doctor-patient relationships placed the doctor superior to the patient. Doctors are viewed as credible based on their medical degrees, the perception of their higher level of intelligence and as experts. Many incidences have suggested that doctors have the autonomy and knowledge to determine the patient’s diagnosis and consequent treatment. The misplacement of authority in doctors has created a dynamic where patients are passive from chiming into the discussion and choosing their assigned treatment (Salmon and Hall, 2003, 1970). Patients are also often perceived as victims instead of active players in improving their own health. Surprisingly some patients prefer this model as it the responsibility is placed on the health care providers. Gathering information and finding a cure is not the patient’s obligation. This model undermines the information and added value that patients bring to the table.
Badcott proposed several models ranging from the expert patient who owns special knowledge and skills, autonomous patient who has the liberty to decide, emancipated patient who has freedom from legal or social constraint, and the empowered patient who is free to act (Badcott, 2005, 177). These modes are implicitly shown in the EPP.
            Various programs have involved a shift towards a more collaborative model of doctor-patient relationship. The Expert Patient Program (EPP), for instance, is a self-management program designed to support patients by elevating their confidence, improving their quality of life, and supporting them in managing their conditions in a more effective manner. Implemented in England, the program is particularly designed for those suffering from chronic illness and conditions, such as diabetes, hypertension, as well as physical disabilities.
            The model was founded on Bandura’s social cognitive theory of behavior, which stipulates, “Key predictors of successful behaviour changes are confidence (self efficacy) in the ability to carry out an action and expectation that a particular goal will be achieved (outcome expectancy). Self efficacy is seen as an early step in causal pathways of behaviour change in self management programmes; increasing self efficacy (confidence) is a prerequisite for behaviour change which, through improved self management may influence health and healthcare use” (Griffiths, et al., 2007, 1254). Later on the U.K. health department invested in a task force, which offered programs for patients with chronic diseases that were led by lay experts.
The EPP creates patients who are actively working together with the health care professionals, as well as independently gaining personal expertise regarding their own condition. Research has suggested that an increase in patient involvement during consultation might result in greater patient satisfaction, which perhaps could lead to better health. The basic assumption when adopting the EPP is that better health might be achieved through active participation determining their treatment. The U.K. NHS expects that these events would therefore culminate into the reduction of healthcare use and even mortality. Studies have suggested an increase in patients’ self-efficacy, which resulted in improved psychological health. Patient involvement modestly increases patients’ self-efficacy, increases psychological health and might be useful for ethnic minorities (Griffiths et al, 2007, 1255).
In addition to encouragement of the patient’s confidence, a collaborative model appears to be more effective as it actively includes the patient, who lives and therefore understands the condition from a different light. Although diseases, illnesses and conditions have general patterns, they are often presented differently in various people. A patient’s lifestyle, diet, and profession may contribute to the individual experience of a condition.
According to Salmon and Hall, having a better understanding of the individual and illness enables us to determine the shape and content of medical practice. Salmon and Hall mentioned the usage of the Bio Psycho Social (BPS) model, which allows medical professionals to expand their power into other areas of a patient’s life without blaming said patient for their lifestyle choices. With the BPS approach, patients take on the role of experts in each of their illness and disease (Salmon and Hall, 2003, 1972).

The Hospital
The BPS has garnered some backlash as it implies the extension of medical power. Where does the health care professional’s influence begin and end? Even though this model seems to encourage a more equal relationship between patient and health care provider, it also galvanizes the doctors’ control on the patients’ lives. For example, when using this model doctors have the right to determine the patient’s diet, exercise routine, living environment, as well as day-to-day activities. This model includes both collaboration between doctors and patient while implementing a restrictive measures to improve health. 
Another argument for an equal power distribution between patient and health provider is the concept that patient’s own validation will boost his/her recovery. To attain these goals, Badcott suggested that patients are entitled to learn more about their illness, especially through the increase in health information available on-line. This situation will result in the possibility for anyone who chooses and is capable in digest the information to become better informed and to participate in decisions relating to his/her illness (Badcott, 2005, 174).
Alongside the programs involving lay led experts is the informed patient model, that is said to be reflexive, informed, requires highly specified information, as well as having highly developed skills and tactics for acquiring information. This discourse implies that individuals are inclined to receive more responsibility for their own health (Adams and DeBont, 2007, 274). Placing the patients as consumers, this model benefits from the heightened availability of and access to medical information on the Internet. However, in order to fully use this information and avoid incorrect information, and dangerous consequences, a patient needs the right skills, such as being able to verify the information based on its quality and sources. This discourse led to a shift in the role of health professionals to include providing support, advise, and help patients in broadening the latter’s medical knowledge via reliable sources. In contrast, medical professionals aren’t as obligated to provide superfluous amounts of information to the patient as they can recommend a list of reliable medical websites.
The collaborative doctor-patient relationship model is glorified as the solution to many health care problems. However, changes need to be made in order to improve the circumstances in which information is presented. General policing is required to ensure that information available online are credible, safe and trustworthy. Policing should be designed to be a simple and effortless task, such as the ability to verify information with one mouse click (Adams and DeBont, 2007, 279).
Yet, how beneficial is a collaborative doctor-patient relationship? Three of four studies, listed by Griffiths et al., showed no change in generic measures of self rated health and use of health care. Perhaps these results were due to the possibility that lay led programs both increased and reduced consultation; even though unscheduled care may decrease, scheduled care may have experienced some increase; and it is possible that the program may not be as effective in countries with universal health coverage and primary care, such as UK (Griffiths, et al., 2007, 1255).
With the technological advances available various patient groups continue to rely on their physicians to provide information and advise them on a certain treatment, indicating that some patients are still unwilling to take on the responsibility that accommodates the informed patient program. This phenomenon maintains that much of the responsibility and power are within the doctors’ hands.
Even though paternalism by doctors and other health providers will continue to limit patients’ freedom the power to diagnose; choose the remedy; and decide a treatment plan should lie in both patient and medical providers, as health professionals are experts in the general patterns of a condition, however the patient is an expert in his/her own condition (Badcott, 2005, 177). Having additional and more specific knowledge will help in the diagnosis as well as treatment. Studies have clearly shown the EPP’s and Informed Patient Program’s positive influences on the patient. With patients playing a much more active role in determining treatment, a partnership between the patient and health care professional is still needed to ensure that a balanced, collaborative relationship in health care is created. This should not stop the availability and accessibility of medical information to patients who choose to broaden their knowledge.  The role of the physician will extend to offering and policing online information, as well as train patients to use and evaluate the information in a safe and useful manner.


*The author owns rights to the photos above

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