I called in my next patient, Jane and she sat down in front of me and we shook hands. Instead of letting go, our hands slipped back a little and our fingers interlocked, our thumbs raised …
“I’d like a referral to see a specialist”
She came out straight with it before I’d had a chance to ask her how she felt or how I could help. Her thumb twisted around the back of mine and pulled it down. One-nil.
“Ok” I replied, not being committed into an outright refusal or straightforward acceptance. Our thumbs circled, she pulled hers back defensively. “How did the FODMAP diet go?” I asked.
“I didn’t try it”, she replied brusquely, “You don’t even know what’s wrong with me and you said the blood tests were normal” Her thumb snapped down, but I pulled mine back just in time.
There was a sharp tug on my left arm, twisted behind my back. “Fill in the alcohol template,” a voice behind me hissed. A box in the corner of the computer screen listed the boxes I had to tick before Jane left the room.
“So, um, how much alcohol do you drink on an average week?” I asked and the grip on my left arm relaxed slightly.
“well …” Jane paused, I circled my thumb clockwise sensing she was getting off-guard. “I’ve been drinking a bit more lately, things have been pretty difficult at work and John and I have been arguing quite a lot since he did his back in and hasn’t been able to work”.
“I’m sorry to hear that”, I replied, genuinely sorry. “How bad has it been?” I could have beaten her then, thumbs-down, but it didn’t seem fair.
“You don’t know anything! She could have cancer!” several voices screamed through the window, a copy of the Daily Mail was pressed up against the glass. I jumped in fear and surprise and Jane nearly caught my thumb under hers again.
I quickly composed myself and tried to ignore the din outside and focus on Jane instead.
I tried to concentrate on her answer, but the door flew open, and several patients were stood outside, “I’ve been waiting for twenty minutes”, “You’ve got my prescription wrong”, “My sick-note’s run out”, “When are you going to visit my mum?”
I turned back to Jane, just as my left arm was yanked higher up my back. “She’s overdue a blood-pressure check, that’s £3k you’ll lose for the practice if you don’t hit the target for this year”, the voice behind me growled.
“Could I just check your blood pressure?” I asked. Patients rarely object to have their blood pressure checked even if it’s entirely irrelevant to their presenting complaint. We let go of each other’s hands briefly while I fitted the blood-pressure cuff.
“You’re only in it for the money! You don’t care about patients!” The taunts from outside had reached a hysterical pitch and copies of the Express and Telegraph were shoved through gap at the top of the window. “A nurse could do your job!”
I straightened up and tried to ignore them. “I guess you’ve read some stuff online about what might be causing your symptoms?” I suggested to Jane as I unwrapped the blood pressure cuff.
“Actually, I haven’t”, she confessed, “You know what it’s like, whatever you put into Google, before long you’ve come up with cancer, and that just gets you worrying. You must hate it when your patients look things up online”.
I laughed gently, it’s funny how often patients say that to me. I replied,
“No, no – really I don’t, but sometimes I think it’s like a law of the internet that whatever symptom you’ve got, you’re never more than six clicks away from cancer”
Our thumbs hovered, neither sure whether to strike.
Someone had pushed their way through the crowd of patients at the door, “You’re needed now, at the commissioning meeting” they barked angrily, pointing at the clock on my wall.
A pain shot through my shoulder as my arm was twisted even tighter, “You need to document their blood pressure and a five year follow-up on the other template and give them smoking cessation counselling”
“Thirty year old woman DIES from bowel cancer after seeing her GP THREE times!” Someone outside the window shouted.
I couldn’t think clearly. I looked at Jane and struggled to think of what next to say. Our thumbs hovered. “What do you think I should do?” She asked. Her thumb rested on my index finger in submission. “You know what I’m afraid of, I don’t want it to be cancer, I just want to feel better”.
Now is a good time to be thinking about power in the consulting room. Patients are learning to be assertive consumers, NHS England and commissioners are demanding evidence that we are ‘performing’, the government is devolving public health interventions from the state to the consulting room and the media is whipping up resentment towards professional power. It is easy for doctors to think of themselves as victims, but as John Launer warns,
Even in the era of shared decision making, the vast majority of consultations are led by the doctor’s beliefs about what it is right to investigate, how it is best to treat the patient, and when to make an onward referral. All of this power may be different to the kind of power exerted upon us by governments and managers. But it is still power, of a special and privileged kind. If we cannot recognise that it infuses most of the encounters we have during our working lives, we may be at risk of abusing it.
In the scene I described above the only battle the doctor could possibly win was with the patient. Unable to do anything about the bureaucratic burden imposed upon us, we may be at risk of venting our frustration on our patients.
Another reason we might blame our patients is because, as Richard Smith pointed out in 2001, we’re still hanging on to a bogus contract,
The bogus contract: the patient’s view
- Modern medicine can do remarkable things: it can solve many of my problems
- You, the doctor, can see inside me and know what’s wrong
- You know everything it’s necessary to know
- You can solve my problems, even my social problems
- So we give you high status and a good salary
The bogus contract: the doctor’s view
- Modern medicine has limited powers
- Worse, it’s dangerous
- We can’t begin to solve all problems, especially social ones
- I don’t know everything, but I do know how difficult many things are
- The balance between doing good and harm is very fine
- I’d better keep quiet about all this so as not to disappoint my patients and lose my status
The new contract
- Both patients and doctors know:
- Death, sickness, and pain are part of life
- Medicine has limited powers, particularly to solve social problems, and is risky
- Doctors don’t know everything: they need decision making and psychological support
- We’re in this together
- Patients can’t leave problems to doctors
- Doctors should be open about their limitations
- Politicians should refrain from extravagant promises and concentrate on reality
At last week’s inspired Imperial college GP training day, author and lugubrious self-confessed addict Will Self and I talked about doctors and power. If there was a ‘bottom line’ to Self’s presentation it was about this bogus contract. “Imagine”, he asked us, “if instead of billboards over the North Circular exclaiming, ‘We’re going to win the war on cancer!” we were more honest and said, “We’re all going to get cancer if we live long enough, and we’ve all got to die eventually!”
Part of the reason the bogus contract still exists is because of, as Self put it, the deep reverence with which many patients hold their doctor. Our earliest experiences of the medical profession are often as a frightened, febrile child bought by an anxious parent to a calm, authoritative figure who makes things better.
As Edward Ernst recently explained, a great deal of what makes patients feel better is to do with power and personality including the therapeutic relationship with the clinician (empathy, compassion etc.), and social desirability (patients tend to say they are better to please their friendly clinician)
The therapeutic relationship was described by psychoanalist Michael Balint, who used the term, ‘doctor as drug’. Like any drug there are indications (where it can be used), contra-indications (where it should not be used), risks (including tolerance and dependency) and side effects (including irritability and rejection or intoxication).
Used appropriately it is a potent force for good and as Foucault noted,
What makes power good, what makes it accepted, is simply the fact that it doesn’t weigh on us as a force that says no, but that it traverses and produces things, it induces pleasure, forms knowledge, produces discourse. It needs to be considered as a productive network that runs through the whole social body much more than a negative instance whose function is repression Foucault 1984: a 61. Quoted from DA Lupton
Physician Edvin Schei agrees,
The structural and symbolic power of doctors is what makes good and right healing actions possible.
Doctors know that without power, they will lose their potency as therapeutic agents. Self argued that patients might resent this just as they secretly desire for their doctors to retain their magic. There is an ambivalence between reverence and scepticism in their regard for the medical profession.
Most of us agree that power is unavoidable and inevitably stacked in the doctors’ favour, not only over patients, but also over nurses and other health professionals and far beyond. Unfortunately we don’t do enough to teach medical students and doctors about power and how it is used. As Kathryn Montgomery agues in her wonderful book, How Doctors Think, we don’t do encourage medical students to challenge the philosophical assumptions which underpin the practice of medicine. Medicine is neither art, nor science, but an interpretive practice that makes use of clinical reasoning, but we teach it as if it were science treating disease rather than people treating people.
Sara Donetto studied medical students’ conceptions of power in the doctor-patient relationship and discovered that they were severely limited, viewing the imbalance as a consequence of patient ignorance that could be solved by professionals educating them. It was striking that my second-year medical student’s learning objectives included ‘giving lifestyle advice to patients’, but didn’t include anything about understanding values or interpreting narratives, in other words making sense of other people and themselves. Many medical students, and for that matter, doctors, are stuck on the second of Emanuel and Emanuel‘s four models of the doctor-patient relationship, ‘Dr Informative.’ Dr Informative’s conceptual development is stranded, as the authors noted back in 1992 and Self concurred today, on a model where both doctors and patients are rational consumers. It’s a thinking that underpins much of the policy thinking that shaped and continues to drive the recent NHS reforms and is a source of despair to those patients and professionals who know that there are higher levels to which we should aspire.
Patients and professionals as partners.
In 1998, GP Julian Tudor Hart wrote,
Progress in health care depends on developing professionals as sceptical producers of health gain rather than salesmen of process, and on developing patients as sceptical co-producers, rather than consumers searching for bargains. Productivity in health care depends on complex decisions about complex problems, involving innumerable unstable and unpredictable variables. These decisions require increasingly labour-intensive production methods, with ever deeper, more trusting and more continuous relationships between professionals and patients.
Doctors themselves have an ambiguous relationship with power. The reverence we enjoy can just as easily make us feel uncomfortable. Scepticism shared about, for example surgery for back pain, can be mutually reinforcing, but scepticism about the doctor’s clinical judgement is unsettling. My second year medical students described feeling uncomfortable with the trust and apparent reverence shown to them by a patient who revealed what it was like being severely depressed. They felt that they hadn’t earned the power that this trust conveyed. Bearing witness to intimate stories is a form of pastoral power. Handled sensitively and skilfully it can be enormously supportive and empowering for patients, but it can easily be abused.
Self raised the idea of the therapeutic state which is a form of Foucault’s idea of governmentality in which the state devolves responsibility for public health and action on the upstream social determinants of health like housing, education, nutrition and economic security down to individuals. Moral pressure is exerted on patients to behave in ways that fulfil public health objectives, so that obese individuals have to become thin in order to reduce the pressures on the NHS and contribute more to the economy. Pressure is exerted on patients who confess to their sins of being a burden, and then promise to repent by losing weight, returning to work and helping themselves.
It was interesting to watch the medical students reflexively slipping into role, most of them remembered their learning objective to give patients lifestyle advice at the same time as they interrupted their patients’ confessions. Like many more experienced healthcare professionals, they launched into this without exploring their patients’ priorities, or wandering too deeply about the efficacy of their advice, much less the philosophical basis of their practice.
Requiring the medical professional to put the needs of the state before the concerns of the patients in front of them undermines what could be an effective therapeutic relationship, but it’s not the only barrier to effective partnerships.
Because we don’t teach healthcare professionals to challenge the philosophical, political and economic foundations of their practice, they are insufficiently self-critical and sceptical about medicine’s role and purpose. This impedes their ability to be sceptical partners with their patients and makes them anxious and defensive when challenged, rather than interested and engaged. Insight is a teachable skill. Forced to act in an increasingly commercialised health-service patients are recast as consumers of health care rather than producers of health gain. The front line also becomes a battle-ground where clinicians are forced to protect limited NHS resources from demanding patients who want too much. Under conditions where patients pay for their care, they are encouraged to consume more medicine than they need. Commercial healthcare is incompatible with therapeutic alliances.
We have to live in a real world where both reverence and scepticism can co-exist. Without trust we will have nihilism and adversity; without scepticism we have ignorance and abuse of power. Trust and scepticism can flourish in partnerships which themselves depend on consultation times that allow doctors and patients to educate each other and continuity of care to allow them to get to know one another. Given more time, we could do a lot more to help patients and more to help patients help themselves.
The real question is, can contexts for clinical decision making be structured so that doctors’ interests coincide with those of patients individually and society collectively?
Julian Tudor Hart
Arm in Arm with Righteousness. Iona Heath http://www.peh-med.com/content/pdf/s13010-015-0024-y.pdf
Why are doctors unhappy? Richard Smith http://www.bmj.com/content/322/7294/1073?sso=
Doctors as victims. John Launer http://pmj.bmj.com/content/89/1049/182.full
Power and Powerlessness. John Launer http://pmj.bmj.com/content/85/1003/280.full
Unhappy doctors and what can be done. Nigel Edwards http://www.bmj.com/content/324/7341/835
Foucault on the case: The Pastoral and Judicial Foundation of medical power. http://www.ncbi.nlm.nih.gov/pubmed/15666081
The idea for the thumb-war between doctor and patient came from the play Who Cares at the Royal Court