Who Has the Power?
September 2019 Issue
For a number of years, I provided O&P services to inmates in the largest medium security correctional institution in our state.
Entering and exiting the facility involved the expected security measures, but prisoners were allowed to move within the walls unescorted and would crowd into the narrow hallways of the healthcare unit with minimal supervision. As one of the nurses walked with me toward the front office after one of my monthly visits, I asked her if she was ever concerned for her safety, given the relative freedom the inmates had within the facility. She replied that prisoners preferred to remain in this prison rather than be transferred to one with more security, and in general they were careful to abide by the rules. Staff could report a prisoner simply for looking at them strangely, which would result in the inmate's actions being more forcibly controlled. Strict rules governed what O&P services could be provided, and decisions as simple as how many socks of each ply or what color shoes were provided were closely scrutinized to ensure consistency with institutional policies. Over time I began to notice a distinct pattern in how inmates communicated with me about their needs. Knowing that they could be penalized for being too assertive in their requests, they instead relied on less forceful persistence. Stripped of any formal power or authority, and under the threat of punishment if they were too demanding, these inmates adapted their style of persuasion to fit their low status in the institutional hierarchy.
Hostages in Healthcare
Berry et al.'s 2017 article in the Mayo Clinic Proceedings compared the dynamics that many patients and caretakers face in a complex and confusing healthcare system to a hostage situation. The authors state that patients and family members "are often reluctant to assert their interests in the presence of clinicians…. We refer to this phenomenon as ‘hostage bargaining syndrome' (HBS) because, in the presence of clinicians, patients and their families may behave like hostages negotiating, from a position of fear and confusion, for their health."1 This bargaining may take the form of compromising by "understating a concern or asking for less than what is desired or needed."1 Patients who fear jeopardizing their relationship with their providers or being labelled as difficult may hold back from questioning or expressing concerns about a decision their providers make, since it may affect the quality of their future care.1
The descriptions of HBS in this article were similar to what I observed among inmates. While it may seem extreme to compare patients to prisoners or hostages, consider the ways in which being a patient is different from being a customer. Customers have the power to decide whether to purchase an item or service based on their own appraisal of whether a want or need will be met as a result. Healthcare encounters involve serious needs, and patients typically lack the knowledge or expertise to fully assess that need or determine how to address it. The decision-making authority that comes with a provider's knowledge and skill invests them with considerable power and can put the patient in a passive position. (See "Patient, Client, or Customer: What Should We Call the People We Work With?," The O&P EDGE, April 2018, for a more in-depth discussion of these labels.) The decisions of healthcare providers significantly impact the quality of life of their patients. Their knowledge and skill can mean the difference between life and death, or, more likely in our profession, functional dependence or independence. Healthcare decisions often are complex enough that the patient must simply trust the provider to make decisions in his or her best interests, without completely understanding all the variables or the rationale behind the decisions.
In O&P this can involve recommending when treatment should begin or end, suggesting alternatives to surgical procedures, or selecting specific design features and components. Even if patients understand their own needs, they rely on the practitioner's official documentation to ensure third-party payment for high-cost components. Additionally, practitioners often interact with patients and caretakers during times of profound physical, emotional, and psychological vulnerability. Patients regularly give consent to be exposed, looked at, touched, and moved in ways that (out of necessity) invade their privacy, and would represent a serious infraction of social norms in any other context.2
Dani Filc, MD, PhD, says, "The communication process, the core of the medical encounter, is an asymmetric one. The meeting between a suffering person and somebody who has knowledge, which may alleviate the suffering, makes the relationship inherently asymmetric."3 He goes on to describe how providers can overpower their patients by managing information, including or excluding certain topics, using scientific jargon, not listening to the patient, and interrupting. "The very structure of the clinical interviews, modeled after the hospital's clinical history, limits patients' opportunities to tell the stories of their illnesses…."3 Simply by taking the lead during encounters, asking questions, and deciding what topics are discussed, practitioners demonstrate the power they have over patients.
How Physicians Handle Power
Laura Nimmon, PhD, a researcher in the Occupational Therapy Department at the University of British Columbia teamed up with Terese Stenfors-Hayes, a Swedish researcher, to investigate "how power is perceived and exerted in the physician-patient encounter from the perspective of experienced physicians."4 The researchers began interviews with 30 physicians by asking two questions: "Do you find that there are power relations in your interactions with patients?" and "How do you deal with these power relations if you experience that they are there?"4 They found that initially many of the physicians were so surprised by the question that they asked that it be restated. The responses the physicians eventually gave could be grouped into three categories. The first category of responses came from physicians who acknowledged that they hold the power in their interactions with patients. "This category of physicians believed that because of their medical training and credentials they were in position of power in the physician-patient encounter. This position of power was described as something which needs to be acknowledged and respected by physicians…."4 The second category of responses was from physicians who saw their power as waning due to increased emphasis on "patient rights, patients as consumers of healthcare, and informed patients."4 "Overall this group appeared to conceptualize the physician-patient encounter as a site of struggle, often describing how tensions emerge when patients make unreasonable demands on the physician."4 Interestingly, none of the physicians who had this view described any strategies they used to "strategically handle power" in their interactions with patients.4 A third category of responses came from physicians who "perceive that power dynamics are non-existent or irrelevant in the context of physician-patient interactions."4 For these physicians "power was not a meaningful or important concept in the context of delivering healthcare to patients, either because they perceived that it does not exist or because they perceived that power dissolves through a balanced empowering physician-patient power relationship."4
After analyzing the interviews, the researchers concluded that "sharing" was not the only way to describe the use of power by those physicians who acknowledge they have it. Instead, physicians "handled" power in different ways depending on the context of the encounter. "Rather than being ‘shared' uniformly, power appears to be moderated by a range of strategies (exerting, sharing, moderating, relinquishing) executed through language to meet physicians' purposes of cultivating an ethical therapeutic relationship with patients. In other words, physicians who are aware that they always hold power by virtue of their cultural and symbolic capital are deliberate in how they ethically handle power through language strategies to serve the patient's best interest."4 (See Figure 1, for information about how physicians handle power.)
One of the consequences of practitioners misusing power is that patients may become less engaged in their own care. According to Berry et al., HBS can lead to learned helplessness: "Perceiving repeated aversive events as beyond one's control can make a person expect future events to also be uncontrollable. The affected individual may overlook opportunities for relief, escape, or change, in effect simply giving up…. If clinicians' actions are (inadvertently) disempowering, that behavior can deepen the patients' sense that circumstances are beyond their control."1 Filc identifies ways in which patients can resist the power exerted by physicians, including requesting a second opinion or using other sources of medical knowledge. Other ways to resist that are less constructive, and potentially detrimental to patients' health and well-being, include refusing to talk or agree, withholding information, poor compliance, and abandoning treatment.3 If practitioners appropriately manage power in encounters by strategically ceding control, they may help patients avoid detrimental effects of fighting for it in unconstructive ways.
Shared decision-making involves partnering with patients by giving them a voice in their own care. This requires respecting their knowledge of themselves, and understanding their values and experiences.1 According to Berry et al., "Patients and families often hold back from openly engaging clinicians in the thorough discussions that true shared decision-making (SDM) requires."1 They suggest that "clinicians serve patients best when they frame available medical options in terms of the values and treatment goals that patients and their families articulate."1 (See Figure 2, for language that can be used to enhance shared decision-making.) This sort of alliance between practitioner and patient involves both parties contributing their expertise to the discussion, negotiating, and agreeing on the preferred treatment. Simply telling our patients what they should know and do maintains our power over them, but this strategy is not likely to improve their adherence to a treatment plan. "Doctors and other healthcare professionals are advised to understand better the ‘barriers' or ‘noise' inherent in communication processes in order to facilitate compliance: it is argued that they ‘should not only learn to listen and talk with their patients; they should also strive to avoid habitual or institutionally shaped communicative gaps and obstructions in their contacts with patients.'"5
Power is the "potential to exert influence."4 As trained and experienced clinicians, we have knowledge and skills that give us power over our patients and their caretakers. An important part of fulfilling our ethical obligations is to use that influence in our patients' best interest. It is more likely that we will use this power more effectively if we are aware we have it and understand how to manage it. "Part of the professional's expertise is in knowing how to fully bring the person he or she serves into the process; it's a core element of the job."1
Our patients deserve to be treated as individuals, not prisoners or hostages. Whether we care for them in our facility, a hospital, their home, or a prison, we can use the influence we have as practitioners to engage patients in their own care and improve their lives. This is the reason they came to see us and the reason that most of us decided to pursue this profession.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.
1. Berry, L. L., T. S. Danaher, D. Beckham, R. L. Awdish, K. S. Mate. 2017. When patients and their families feel like hostages to health care. Mayo Clinic Proceedings 92;9: 1373-1381. Elsevier.
2. Rajasoorya, C. 2018. Credat emptor–The sacrosanct doctor-patient relationship. Annals, Academy of Medicine, Singapore 47:275-7.
3. Filc, D. 2006. Power in the primary care medical encounter: Domination, resistance and alliances. Social Theory & Health 4(3):221-43.
4. Nimmon, L., and T. Stenfors-Hayes. 2016. The "Handling" of power in the physician-patient encounter: perceptions from experienced physicians. BMC Medical Education 16(1):114.
5. Lupton, D. 1995. Perspectives on power, communication and the medical encounter: implications for nursing theory and practice. Nursing Inquiry 2(3):157-63.