I was on a conference call with my mentors a few weeks ago and the discussion of power dynamics between providers and patients came up.
They identified what I knew to be true but had never really thought much about: There is an inherent power dynamic in all provider-patient relationships and interactions.
This plays out in various ways, depending on the individuals. Historically, the entire health care system in the U.S. is based on power over the patient. How many times have you heard someone say, "Well, my doctor told me to take this pill, so I take it, but I'm not really sure what it's for or why I'm supposed to take it." How many times have you, as a patient, felt that warm wash of shame (Dr. Brené Brown's expression) at the doctor's office when you step on the scale, or when you haven't controlled your diabetes as you were told to, or when you haven't followed "doctor's orders." I, myself, have avoided health care because of the fear of disappointing my health care provider or for fear of getting the "lecture." And I know I'm not the only one.
I'm not trying to put down doctors or health care providers here, but I am wanting to open up a discussion about the inherent power dynamics and what it does (or doesn't do) for the health and well-being of the people we care for.
It is true that health care providers are specially trained to take care of the body and the overall health of a person. And, it's true that oftentimes they save lives and help eradicate disease.
It's also true that sometimes when a patient overrides their own internal knowing because they regard the health care provider as more powerful than they are, it can result in unhealthy, and sometimes devastating, results.
Dr. Dawn Doutrich and her colleagues recently did research around cultural safety and an article describing their work was published in 2012 in Trans Cultural Nursing (see citation below). The authors discovered 5 main themes in their research around providing and/or teaching with cultural safety. One of the themes was around the power dynamic and the practice of "Learning to Walk Alongside" our patients and students instead of participating in the traditional power dynamic. They discuss the importance of "standing beside or walking with the patient, family, colleague, or student, rather than “standing over” (p. 147).
How many times have you, as a patient, felt your health care provider "stand over" you? I have felt it. The worst time for me was when I was diagnosed with homosexuality without ever being talked to about it, finding out my doctor charted exams she never performed on me, and the several times I've generally felt the "ick" of being talked at, lectured to, or treated as unimportant. Or the times I've been lectured that I need to lose weight, exercise, and eat healthy. Bleh. Yeah, I knew that already.
How many times have you, as a health care provider, not recognized the power dynamic inherent in your relationship with your patient, and treated him or her as someone "less than," who should simply "follow doctor's orders?" How many times have you literally stood over your patient, with one hand on the door, as you give the not-so-subtle-hint that you are in a hurry?
Health care providers will be better providers and be better able to use their skills and knowledge if they allow themselves to identify the power dynamic and how they may be contributing to it. Health care would look a lot different if we, as providers, acknowledged that dynamic and worked to create healthy partnerships with our patients.
It's no secret that achieving and maintaining a healthy weight, exercising, and eating healthfully indeed contribute to being a healthy person. But giving "the lecture" as the "all-knowing" provider and actually engaging in partnership with your patient when approaching this makes this scenario play out drastically differently.
A Power Dynamic scenario might look like this:
Doctor swoops into your room 20 minutes late, gives a brief hello, and logs into his/her computer charting system. The provider never makes direct eye contact with you, goes through a few questions (all while staring at the computer), writes a few new prescriptions, and stands up to leave. With a hand on the door knob, he/she turns around and says to you, "You know, I also noticed your weight is up since your last visit. You really need to watch that or else you are going to have a heart attack and get diabetes. Start exercising 5-6 days a week and start eating healthy. I'll see you in 4 weeks." Then he/she leaves without any more interaction.
A Patient-Provider Partnership scenario might look like this:
Doctor walks in 20 minutes late. He/she apologizes to you for running late. (Let's be honest, good doctors and not-so-good doctors both tend to run late sometimes). Your doctor then greets you, asks you how you've been. Do you have any concerns today? What brings you in? He/she makes eye contact with you, sits with legs uncrossed, and leans toward you, engaged in listening. He/she asks some other questions and charts a few notes. Then your doctor shuts down the computer and turns back towards you. He/she says, "You know, I see that you've gained some weight since your last visit. Talk to me about that. Anything changed at home? How is your stress level? Do you have any goals around your health? How do you see me best assisting you to achieve these goals? What are things you would like to be doing for your health? Is there anything important going on that I haven't asked you about that you'd like to share?" After this back and forth dialogue, you and your doctor come up with a plan together to help improve your overall health. He/she asks to see you back in 2 weeks, and before standing up, asks, "Is there anything else I can do for you?"
I realize that the Partnership scenario takes probably four times as long as the Power Dynamic scenario. Some providers will simply not be willing to do this. And, yet, there are plenty that are willing. Most providers fall somewhere in the middle. I used these polar examples because I want you to start thinking about how this power dynamic shows up for you, as either a provider or a patient -- or both!
In her new book Mind Over Medicine, Lissa Rankin, M.D., talks extensively about the power of the mind.
She cites stories from actual research portraying how powerful the mind is over an individual's health outcomes and other aspects of life. For example, if a patient believes a treatment will help her, it usually does (regardless if it's a placebo or not). And if a patient believes she is dying, then she usually does.
Dr. Rankin then goes on to explain that how we, as providers, approach illness, is of utmost importance. Taking away hope from a patient or regarding a diagnosis as a death sentence are extreme (yet common) examples of how a provider uses their power, albeit unknowingly sometimes, to affect the outcome of the patient's health. Of course, honesty is important in health care. But if you approach a diagnosis or a health concern with a holistic approach, work to create partnerships instead of dictatorships, and do all you can to assist the patient in being the healthiest, most vibrant person he/she can be, the outcomes will probably be much different.
Will you share with me your stories or feelings around the Power Dynamic in health care? How has it affected your overall health? How have you, as a provider, learned to create partnerships with your patients?
I look forward to hearing from you!
Cultural Safety in New Zealand and the United States : Looking at a Way Forward Together. Dawn Doutrich, Kerri Arcus, Lida Dekker, Janet Spuck and Catherine Pollock-Robinson. J Transcult Nurs 2012 23: 143 originally published online 25 January 2012.