Dr Patricia Cantley (@Trisha_the_doc) has written a blog post about the imbalances in the doctor-patient relationship. I like the blog, but I want to put a bit more of a context to it.
Dr Cantley says that there are three major imbalances in the clinical relationship – the knowledge gap, the power gap, and the arousal gap. Doctors know more, they have more power, and the patient is invested in the issue emotionally. The blog ends with some suggestions what clinicians could do help patients be more at ease in the relationship and they are sensible. I do appreciate the blog, I think doctors should reflect on their power, just as Dr Cantley does. But I would like to offer a comment or two to make it a bit fuller.
I want to focus on the power gap here and I’ll start by telling you a story. A few days before my father died, I visited him in the hospital. My father was already unconscious, my mother had been told to ‘prepare herself’ for his death (indeed, he died a few days later). As we were sitting in his room, a young doctor came in to check on him.
A little aside here. ‘Preparing yourself’ is an interesting euphemism. The doctor is not really saying anything about what will happen, but is telling the addressee to do something. In such a way, the medic assumes no responsibility for their communication. The imminence of death is implied, never stated. Just as with the medical ‘we’, which is a device for shirking responsibility, this time the clinician is trying hard not to take responsibility for their prediction. Anyway…
The doctor came in without a word, without even acknowledging our presence. My mother (already in her 60s) jumped to her feet and started beckoning me to get up. It took me a while to understand what she wanted me to do, so she whispered something like: ‘get up, the doctor has come in’ (in fact, she also used an honorific, ‘pani doktor’, which is something akin to ‘Madam Doctor’).
I got angry. Instead of getting up, I responded in a loudish, angry voice. I said something like: Or for pity’s sake, she’s coming in without a word, like we are not here, but she could be your daughter and my student. We both deserve some bloody basic respect, don’t we? At least a f…ing hello! The doctor looked at me shocked, immediately stopped doing what she was doing and left without a word.
My mother almost died. She thought all hell would break loose and we would be thrown out of the hospital immediately. She started shouting at me accusing me of causing my father to be sent home unconscious. She was both angry and desperate – after all, I seem to have offended a god. Yet, a few minutes later, another doctor came in, judging by appearances, about 10 years older. It also turned out that basic social graces were within the reach of a Polish medic.
But here comes the second part of the story. My mother and I heard that my father was in severe pain, but nothing could be done. Why, I asked. Why can’t you give him morphine? And here we heard:
- He might get addicted.
This time, I thought I would die. I opened my mouth in bewilderment, already getting up my hackles. The conversation went something like this.
- Me: He is dying, isn’t he?
- Dr: He is.
- Me: And you’re worried that he will get addicted to morphine.
- Dr: I am.
- Me: Are you for real (I started shouting), so, he will die bloody addicted!
The doctor started explaining that things were not so easy and said that relieving the pain was not an option, addiction was a real worry. I continued to shout, to no avail. My father died in pain, but, no, he did not get addicted to opiates. Whenever I think about this, and I often tell the story to students or doctors, I continue to be shocked by the idiocy of the argument. Yes, perhaps my father would have been an addict for his remaining two or three days. As he never regained consciousness, I don’t think he cared all that much.
Now, there are several points I want to make on the basis of this story. First is that power is not only doctors’. Those doctors who write about power, as Dr Cantley very usefully did, tend to forget that we, patients, are often grateful recipients of medical power. We actually help you on your powerful way.
As the young doctor went into my father’s hospital room, she was exercising her power the hard way. She blanked us; we were not worthy of a hello. But by getting up, playing submissiveness, my mother reinforced this. She co-constructed the doctor’s power. She not only showed that the doctor’s behaviour was acceptable, but she actually played someone eternally in awe of the god-like figure.
Yes, there is a question: why didn’t I go along with my mother? To be honest, I don’t know. At the time, I would have said that when I saw my despairing mother visiting her dying husband every bloody day, tired off her feet, jumping to attention and a woman 30 years her junior not even saying hello to her, I really got angry. I was livid. I was also aware of the power-play and how unacceptable it was. Today, I’d say that there was probably an additional context. I had already lived 10+ years in the UK where such behaviour was already much less likely to happen (I think), while my professional status and the fact I was probably about 10 years older than the doctor made me feel confident enough to challenge her.
The second part of the story is about medical power standing fast. They wouldn’t budge. Were they cruel? Were they nasty? I actually don’t think so. I think it was more about the training and the guidelines they had. The medical power they wielded had firm grounding both in the institution and in medicine. It wasn’t just an exercise of their power – it was an exercise of medicine’s power.
Dr Cantley is right when she is talking about ‘being in the system’ – that’s exactly the second part of the story. But it’s worth saying that that power is hardly yours, doctor. You actually become a tool dispensing medicine’s power. In other words, you are as much an object of it, as I am as a patient. You’re also in shackles, except you have someone powerless to take it out on. How you handle the shackles is on you.
The other power, social or interactional power, playing the powerful doctor is a very different kind of power. It serves not much more than putting the patient in their place. A GP whose surgery I attended, kept spreading in his comfortable swivelling armchair, sometimes putting his arms behind his neck, as I contorted my body to face him, perched on a basic hard chair. To my chagrin and regret, I never said a word. As so many of us, patients, I was fully complicit in making myself powerless and to doctor powerful.
These two kinds of powers are different because it’s hard to do something about medicine’s power. And so, as much as I disagree with the ‘addiction argument’, I find it stupid, to a considerable extent, I understand the person making it. It comes from being inculcated by training priorities and training assumptions. As I said, I do believe that the doctor had my father’s best interest at heart, however misguided she was.
What I don’t understand is playing power. I understand that you need a comfortable chair, could I have one (a bit comfortable) too? I understand that you don’t get up when I walk into the room but looking up would be nice. Just as talking to you and not to your side as you type on your keyboard would be. I even understand that you don’t know the level of my knowledge, but could we do away with being plain patronising?
However, I must admit that I don’t understand letting my father lie naked on his bed, because his hospital duvet had slipped onto the floor. In the same way, I don’t understand getting one hospital gown which I just could not make work and had I had to take my trousers off, my bare a.se (pardon!) would have been right on show. Just as the fellow patient’s sitting next to me. I really could go on and on, and on. This is, incidentally, why I thought the infamous hashtag was something for doctors to reflect on, rather than to get stroppy and all offended about (here is my earlier post on the #DoctorsAreDickheads hashtag).
And so, when doctors talk about the power gap, they tend to talk about clinical stuff, you know, the important things. Making sure the patient remembers, making sure you know who the patient is. And I would like them to wonder why their patients don’t ask them twice, or don’t bring a pen and paper to make notes (pen and paper seem to be only for efficient communication with the doctor). We are sometimes so complicity in helping you to be powerful that we prefer to say nothing, only to pretend how wonderful you are.
Whenever I had to go my local hospital in the UK, I saw people with their stethoscopes around their necks. They were the doctors with the stethoscope – a crucial attribute to make sure that no one is in any doubt who they are. I would (respectfully, of course) recommend losing it occasionally. Walk around without it. Try to ask questions, approach a medic. See how you do. Also, sit on the patient’s chair. See what your surgery looks like from their point of view, see what you need to do to face the doctor. You might end up re-arranging.
Every time you play a powerful doctor, every time you make me even more powerless, we lose the opportunity to have a meaningful relationship, you also become less and less of a doctor you ought to be.