Imbalance of power between patients and doctors
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7485 (Published 15 December 2014) Cite this as: BMJ 2014;349:g7485
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I was very moved by your article. I am just starting my long journey in the medical profession. Five months in, I have struggled to put a label on what I have been feeling, but it is something like a shadow; certainly a huge fear of failure, of doing harm, of being weak.
But aside from the fears of front-line clinical practice, I was interested in your argument that 'treatment decisions should be reached co-creatively between experts'. Having had patient-centered training at medical school, one of my major aims in clinical interactions is to elicit the patient’s ideas and agendas, and let this inform and influence their management. What I have been surprised by is the aggressiveness of patient expectation. I have had tears, anger, and seen verbal and physical abuse because patients and their families have unrealistic expectations of us. We cannot diagnose every cause of abdominal pain, we cannot save every great-grandmother, we cannot fix a lifetime of problems in 24-hours. By attempting to understanding my patients and their needs better, I seem to spend ever-more time apologising for the inadequacy not of our service, but of medicine as a whole and the limits of our power.
Whilst the power modern medicine wields is both inspiring and formidable, the power the population believes we have often far surpasses reality. For truly co-creative management decisions to be made, we need patients and their loved ones to understand the constraints of our medical world, as much as we must try and understand their personal sphere. Otherwise with each patient or relative who stares in disbelief that we haven’t solved their problem, we are further reminded of our inadequacy, and get pushed deeper into shadow.
Competing interests: No competing interests
Re: Imbalance of power between patients and doctors
The author has written a complicated article. Dr Conti-Ramsden has naturally got lost.
I, a Simple Man, believe:
The patient will always be less powerful than the doctor.
The patient will almost always know less of medicine than the doctor.
The doctor's job is first to appraise the whole patient, second to formulate a plan of action, thirdly formulate one or more alternative plans, fourthly to apprise the patient of the merits and demerits of each plan, fourth to discuss the foregoing in language the patient can understand.
Next the doctor should ask the patient what he feels he would choose. If the patient's and the doctor's views coincide, then there is no problem.
The doctor still retains the power. So he should.
My question to the doctor would be: what would YOU want to be done for you in similar circumstances?
Doctor has too little time, I hear you say.
Doctor! Tell your employer to give you more time.
Quit your employment if the employer refuses.
Earlier I spoke about language the patient can understand. The Bavarian peasant might not understand the Viennese brand of German. Queen's English may not be adequate for the old man born within the sounds of Bow bells, who had only been away for the years of WW2.
( In the mid1960s, living and working in the East End, a board-certificated surgeon was attached to my unit as an honorary senior registrar. After he had moved to the next bed, the patient having nodded and said yes to everything, the patient stopped me, the registrar, and said, " Doctor, what did the Yank say?)
When the patient is anxious, he may find it hard to absorb what the doctor says. In such a case, please do not be hard on us, the patients.
Competing interests: Old man. No longer practising medicine.