On the remarkable persistence of asymmetry in doctor/patient interaction: A critical review
Highlights
► The medical profession has long been criticised for exerting professional dominance over patients. ► A variety of reforms have attempted to address this, notably the emphasis on patient-centred medicine. ► Analysis of empirical studies of consultations shows continued asymmetry. ► We argue that this is because this asymmetry has roots that are inaccessible to talk reform. ► We advocate for a different reform project.
Introduction
Doctor/patient interaction has been the object of various reform efforts in Western countries since the late1960s. Over the last forty years, it has consistently been depicted in these countries as a setting for the enactment of relationships of dominance, and even oppression, whether by age, class, gender, or other chosen variable. Numerous critics have suggested physicians should adopt more egalitarian styles of interaction and most younger practitioners will have experienced more or less sophisticated programmes of communication skills training during their basic medical education, designed to encourage desired forms of behaviour in consultations. Such training generally promotes the ideal of ‘patient-centred’ practice. However, the evidence for the positive impact of patient-centred practice on health outcomes, as opposed to patients’ perceptions of consultations, is at best mixed. At the same time, empirical studies point to the remarkable persistence of asymmetry: more recent recordings of consultations sound, in many ways, very much like those from the 1970s (see Heath, 1992, Perakyla, 2006). The resilience of this phenomenon suggests that it may have deeper roots than a mere reform of talking practices can affect. We suggest that asymmetry lies at the heart of the medical enterprise: it is, in short, founded in what doctors are there for. If this is correctly understood, then we can seek to disentangle what might be considered to be functional and dysfunctional asymmetry, and to proceed with rather better grounded reform programmes that acknowledge the inescapability of medical authority and patient deference. It may be possible to train doctors to exercise their dominance in more civil ways, but without some major shift in the social function of officially sanctioned medical practice, it is probably not possible to envisage a patient-led form of medical consultation in contemporary societies.
Section snippets
Power, dominance and medical interaction
Traditionally, researchers have treated doctor/patient interaction as a site where doctors exercise power over patients. This observation is conventionally attributed to Parsons (1951), drawing on his observations of medical practice in the late 1930s and 1940s (e.g. Heritage & Maynard, 2006a: 352), although, as we shall suggest, it may misrepresent Parsons’s own analysis. The assumption that the resulting asymmetry is problematic has underpinned the quest for ‘patient-centred’ medicine.
Conversation analytic research: asymmetry as co-construction
This challenge has traditionally been taken up through the application of conversation analysis to data from medical encounters, since CA research shifts the focus from assuming the problematic presence of asymmetry to understanding how it occurs in practice. Maynard (1991), for example, carefully illustrates how asymmetry is not automatically derivable from institutional processes: data from actual consultations show that both parties to the consultation constitute and enact asymmetry
Conclusion
The findings of interaction studies for the last thirty years are precisely what would be predicted from Parsons’s analysis, that the functional asymmetry of the encounter, a recurrent phenomenon of the local order∗, is embedded within a wider functionality of the institution of medicine in society. As such, we suggest that would-be reformers of doctor/patient interaction have crucially misunderstood the role and nature of medicine in their pursuit of projects for reform. We would also argue
Acknowledgements
We are grateful to our colleague, Ruth Parry, for her detailed reading and suggestions and to the participants in the sessions at the 2007 ASA Annual Meetings in New York and BSA Medical Sociology Group Annual Conference in Liverpool, where earlier versions of this paper were presented.
References (56)
- et al.
The roter interaction analysis system (rias): utility and flexibility for analysis of medical interactions
Patient Education and Counseling
(2002) Participating in decisions about treatment: overt parent pressure for antibiotic medication in pediatric encounters
Social Science & Medicine
(2002)Interaction process analysis
(1951)The doctor, his patient and the illness
(1957)Radicalism and the organization of radical movements
American Sociological Review
(1963)- et al.
Conflict and conflict resolution in doctor/patient interaction
A feminist critique of scientific ideology: an analysis of two doctor–patient encounters
- et al.
Doctors talking to patients: A study of the verbal behaviours of doctors in the consultation
(1976) Power under the microscope
(1988)- et al.
Four models of the physician–patient relationship
Journal of the American Medical Association
(1992)