Elsevier

Social Science & Medicine

Volume 72, Issue 8, April 2011, Pages 1374-1382
Social Science & Medicine

On the remarkable persistence of asymmetry in doctor/patient interaction: A critical review

https://doi.org/10.1016/j.socscimed.2011.02.033Get rights and content

Abstract

Doctor/patient interaction has been the object of various reform efforts in Western countries since the 1960s. It has consistently been depicted as enacting relationships of dominance or oppression. Most younger medical practitioners have received interaction skills training during their professional education, intended to encourage more equal forms of consultation behaviour. However, the evidence that ‘patient-centredness’ has a positive impact on health outcomes is at best mixed. At the same time, empirical studies of consultations point to the remarkable persistence of asymmetry. These two factors together suggest that asymmetry may have roots that are inaccessible to training programmes in talking practices. Illustrating our argument with findings from conversation analytic studies of doctor/patient interaction, we suggest that asymmetry lies at the heart of the medical enterprise: it is founded in what doctors are there for. As such, we argue that both critical and consumerist analysts and reformers have crucially misunderstood the role and nature of medicine.

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.

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