doctor patient relationship from sociological point of view

1. MEESUM KAZMI
BS SOCIOLOGY
(SUBJECT)
SOCIOLOGY OF HEALTH &
MEDICINE
BZU MULTAN, PAKISTAN

2. DOCTOR PATIENT
RELATIONSHIP
Topic

3. INTRODUCTION
• No other aspect of medicine has attracted more sociological analysis
than the medical professional patient relationship.
• From a classic view of the relation between doctor and patient "as a
pure person-to-person relation", the full range of psychosocial and
sociocultural influences has been studied.
• The world health organization has defined health promotion as the
process of enabling people to increase control over and to improve their
health (World Health Organization ,1984).
• Clearly the individual is seen to have an active rather than passive role
to play in the production and maintenance of health.

4. • McCarthy (1985) asserts that positive health is more likely to be
achieved by fostering a collaborative relationship between the patient
and the nurse, where by the patient is perceived as an active in, rather
than a passive recipient of, health care.
• As a result of these changes increasing attention has been given to the
nature of the relationship between patients and professional involved in
the provision of healthcare service.
• Sociological studies of this relationship have tended to focus primarily
on patient encounters with doctors.
• A possible explanation for this bias is that sociologists are interested in
the distribution and exercise of power in society and doctors represent
the most powerful profession within the health professionals within the
health system.

5. PERSPECTIVES ON THE
DOCTOR-PATIENT
RELATIONSHIP
•In looking at sociology approaches to the study of the doctor-
patient relationship a distinction can be made between those
theoretical models which examine medical practice within the
context of the wider social structure, and those which focus on
the dynamics of the day to day encounters between doctors and
patient.
•These approaches are sometimes labelled macro and micro
perspectives respectively.

6. FUNCTIONALISM
• Lawrence J. Henderson pioneered the application of an equilibrium model to the doctor–
patient relationship.
• Talcott parsons (1951) was one of the first Marco social theorists to explore the social
relationship between doctor and patient.
• He argued that human social relationships can be described as patterns rooted in cultural
expectation about the social roles of group members; that the fundamental process of
behaviour.
• Parsons conceived of the doctor–patient relationship as a social-role interaction in which
the sick role is voluntary; for instance, a person can be I’ll say, with a cold but choose
not to be "sick“.
• Writing from a functionalist perspective he sees doctors and patient acting out socially
prescribed roles. Doctors are expected to use their skills and expertise for the benefit of
their patients.

7. THREE TYPES OF THERAPEUTIC
RELATIONSHIP
• Activity/passivity:
Where the doctor plays the dominant role, as in the case of surgical procedures and
medical emergencies.
• Co operational/guidance:
Where are patient is compliant and cooperative and in accepting medical advice
plays a passive role.
• Mutual participation:
Where there is equality between doctor and patient as in cases of chronic illness
where a considerable amount of self-care is essential if the condition is to be
managed successfully.

8. CRITICISM
• Szasz and Hollender (1956) by criticizing Parson argue that, the
cooperation/guidance model comes the closest to the role of the sick
person as described by parsons whereas the activity/passivity and
mutual participation models represent an attempt to modify the
functionalist approach.
• Szasz and Hollender also note the importance of wider socio-cultural
factors. The idea that the relationship between doctor and patient is
reciprocal and based on a shared value system has attracted
considerable criticism.

9. STRUCTURAL CONFLICT
• Bloor and Horobin (1975) describe how conflict can stem from patients
being subject to conflicting sets of expectations, which places them in a
double bind situation.
• This occurs in the following way. On the one hand, individuals are expected
to be more knowledge about health matters so as to enable them to identify
those symptoms which require expert medical attention.
• They define the ideal patient as one who is capable of identifying which
health problems justify a visit to the doctor.
• Eliot Freidson is the major spokesman for the application of the structural
conflict theory. He sees conflict, not consensus, as a fundamental feature of
the doctor patient relationship.

10. • Unlike the traditional consensus theorists, who see patient as passive
and sub missive, Friedson sees them as being active and critical.
• As he asserts, the separate worlds of experience and reference of the
layman and the professional worker are always in potential conflict with
each other.
• A major potential for conflict in the doctor patient relationship is the
existence of a gulf between medical models of illness and lay
explanation of ill health.
• Doctor’s use a specialised language which patient do not always
comprehend. This gives rise to ‘competence gap’.
• Between doctor and patient, negotiation, not persuasion, occurs.
• The critical factor is structure, not function.

11. FREIDSON'S CRITIQUE OF PARSONS
• Parsons model does not pay attention to the varying expectations of all
members of the "role-set," including the patients (or, more inclusively,
their lay associates as well) and the nurses and other persons involved
in the process of treatment.
• Expectations are presented by Parsons as though they are the primary
influence on actual behaviour; they are only an ideal standard against
which actual behaviour is judged.
• Only from the structure of the situation and the limits imposed by it can
one weigh the possibility of an expectation's being met.
• The functional model ignores the necessity of conflict in human
relationships.

12. NEO-MARXISM,
BUREAUCRACY, AND THE
POLITICS OF HEALTH
• Marxist critiques followed by Howard Waitzkin and Barbara Waterman in 1974
and by Vicente Navarro in 1975.
• The new Marxism built its argument on the classic conception that social
behaviour is essentially organized according to principles of social stratification or
social class, based on materialistic determinants, and inevitably dominated by one
class.
• Leading to monopolistic control of resources and markets by the dominant class
and to the exploitation of subordinate groups for profit or gain of the more
powerful class.
• Waitzkin illustrated what he called the "Micropolitics" of the doctor–patient
relationship.

13. •What neo-Marxists like Waitzkin added to forecast subsequent
trends was the analysis of how both doctor and patient have
become captives of monopolistic trends in the healthcare
industries.
•Examples:
•A young worker with occupationally caused sterility.
•Neonatal death attributable to neglect caused by poverty and
racial discrimination.
•An elderly man burdened by costs of technically oriented
medicine.

14. MEDICAL CONSULTATIONS
AS SOCIAL ENCOUNTERS
• Social theorists working at the micro level of analysis are also concerned with
aspects of conflict and consensus in encounters between doctors and patient.
• Research shows that the professional dominance of the doctor not only is
maintained in these encounters but in certain circumstance it is in fact enhanced.
• There is ample evidence that doctor maintain a tight control over the consultation
process.
• Their primary aim is to elicit from the patient the information necessary to reach
an accurate medical diagnosis.
• In order to achieve this goal, many doctors are inclined to adopt what has been
termed a ‘Bureaucratic, task oriented’ interviewing style.

15. •The medical consultation is another form of social encounter
and as such will be influenced by the class, gender and ethnic
background of the participants.
•The amount of information given to the patient is not simply
determined by the nature of the presenting symptoms but
depends on an array of factors including the expectations and
attitudes of the parties involved, and the level of
communication skills of the participants.
•Doctors tend to be middle class and research shows that middle-
class patients, in comparison with their working-class
counterparts, tend to be given more information either
voluntarily or in response to direct questioning.

16. • Doctors may find it easier to communicate with patients of a similar cultural and
social background to themselves.
• As regards gender, there is some evidence to suggest that doctors are less
responsive to questions from female patients and are more readily inclined to offer
their male patients a fuller and more technical explanation of their medical
condition.
• A characteristic feature of this style is the tendency for the doctor to concentrate
on asking the patient a series of highly specific factual questions in such a way as
to discourage the patient from playing a more active part in the encounter.
• Byrne and long (1976) discovered that the majority of interviews followed a
doctor centred pattern as opposed to a patient centred approach.
• Patients do not openly challenge their doctors when apparently dissatisfied with
some aspect of their treatment.

17. INTERVIEW
STRATEGIES
• Coma off (1976), in a study, found that, some doctors withheld information from
their patient in order to prevent them worrying, some gave as little information as
possible and others saw the provision of information as an important aspect of
their job.
• Coma off identified two broad communication strategies, the unelaborated and
elaborated.
• The former was favoured by those doctors who felt the need to preserve their
professional autonomy they adopted a doctor centred interview style.
• In elaborated strategy doctors placed less emphasis on their professional status,
and recognized the importance of sharing information with patient.

18. INTERVIEW PHASES
The four phase of the interview have been identified by Fisher (1984).
1. The opening
2. Medical history
3. Physical examination
4. Closing phase
From the doctor’s perspective the consultation ideally should take the form of a highly structured
interview.
In the opening phase the patient is encouraged to tell his or her story, The second and third phases
are when the doctor gathers the information necessary to reach a diagnosis. In the final phase of
the interview the doctor offers a diagnosis and recommends an appropriate course of treatment.
The doctor is clearly in control of the interview process.

19. PROFESSIONAL-PATIENT INTERACTION
IN PREGNANCY AND CHILDBIRTH
• Feminist sociologists have made a significant contribution to the
understanding of the way in which pregnancy and childbirth have been
subjected to increasing medical intervention.
• A major consequence of this development is that mother hood has
become a medicalized domain' .
• The management and control of labour and childbirth are now firmly in
the hands of the medical profession.
• Historical studies reveal how doctors gradually came to dominate this
area of medicine by restricting the activities of female midwives.

20. • The potential for conflict in doctor-patient relationships in this area is
evident when it is realised that doctors and mothers have different
perspectives on the nature of childbearing.
• Medically oriented approach, which sees pregnancy as a problematic
event, is contrasted with the mothers' view, which sees it as a natural
biological process.
• Graham and Oakley sees the difference is of a much more fundamental
nature and is explained by using the concept of a 'frame of reference:
• Two frames of reference are labelled medical and maternal. From a
medical frame of reference pregnancy is treated as an isolated episode.
• Viewed from a woman's frame of reference having a baby is a major life
event which leads to significant role changes.

21. NURSE PATIENT
RELATIONSHIP
• Firstly, there are similarities between some of the tasks performed by doctors and
other health workers.
• Secondly, knowledge of how doctors perceive patient expect from their doctors
can provide nurses with better understanding of patient behaviour.
• Thirdly, an insight into how social class background, ethnicity and gender affect
the doctor patient relationship will encourage nurses to reflect on their own
practice.
• Armstrong remarks on how the role of the nurse changed radically during the
1960s and 1970s. With the introduction of the ‘nursing process’ and the growing
acceptance of the ideology of individualized care, nurses were encouraged to
adopt an active rather than a passive role.

22. FOUR TYPES OF MUTUAL
RELATIONSHIP
1.Clinical
2.Therapeutic
3.Connected
4.Over-interview
• While receiving treatment for a minor condition. The encounter is brief with the nurse carrying
out the required procedures in an efficient and perfunctory manner.
• The therapeutic relationship is the one most commonly found. Again this applies to short-term
cases.
• The third type of mutual relationship identified by Morse, and termed the connected
relationship, develops when nurse and patient have been in prolonged contact .
• However, in the over-involved relationship the nurse and patient develop a close personal
relationship.

23. • For the general practitioner the 'good' patient is the one who knows when a
medical consultation is appropriate and does not bother the doctor.
• As regards nurses, ideal patients are those who readily co-operate in their
treatment, willingly conform to hospital rules, do not disrupt the ward routine and
communicate well with staff.
• Stockwell (1972) observed that nurses were selective in their interaction with
patients and would spend more time with, and undertake small favours for those
patients who behaved in accordance with the nurses' role expectations of the ideal
patient.
• Stockwell found that nurses used sanctions against patients who complained and
who expressed more suffering than nurses believed was warranted by their
condition.
• "Bad' patients are also problem' patients, that is who by their behaviour make it
difficult for nurses to carry out their work.

24. CONCLUSION
• The doctor-patient relationship can be examined from a functionalist or consensus perspective. The nature of the doctor patient
relationship may vary according to the type of illness and the situational context of the medical encounter.
• Conflict theorists offer a radical critique of professional power. The existence of a gulf between formal medical models of
illness and informal lay explanations of ill health can be one source of conflict.
• Medical consultations can be 'doctor-centred' or 'patient-centred'. In the asymmetrical nature of the doctor-patient relationship it
is important to take social class, gender and ethnicity into account.
• Morse (1991) identifies four basic types of mutual relationship in nurse patient interactions: clinical, therapeutic, connected and
over-involved.
• Research shows how nurses distinguish between 'good' and 'bad' patients.
• Feminist researchers have drawn attention to the medicalisation of reproduction whereby pregnancy and childbirth have become
increasingly subject to medical control.
• Gender inequalities are apparent in the division of labour in healthcare. Given that nursing is a predominantly female
occupation, women are under-represented in senior managerial posts.
• Gender stereotypes feature largely in the traditional model. When it comes to making decisions about the care of patients, nurses
make a more overt contribution.

25. ANY
QUESTIONS?
THANK YOU!