Katie Cosby Health Communication 5115-001 October 2, 2014 Research Paper I. Introduction The purpose of this paper is to assess doctor-patient relationships and communication by evaluating a specific encounter. The manner in which the doctor operated, the patient’s behavior, and affects of both will be discussed. The specific encounter discussed will entail my personal visit to a general practitioner’s office in order to address a mild asthma attack. This paper will refer to the physician as “Dr. Hunt” and to myself as “the patient”. The patient was diagnosed at an early age with severe child-onset asthma which required daily treatment consisting of inhalers, oral medication, and breathing treatments (albuterol oral inhalation). The asthma went into “remission” for several years until one incident at the age of sixteen. The attack experienced was mild —characterized by labored, shallow breathing and wheezing. Because the attack was mild, the patient went to a general practitioner’s office instead of the emergency room. One factor to note is that the patient was a new resident of the town, and therefore did not have a previously established relationship with the practitioner. Another factor to note is Dr. Hunt’s practice was extremely small —thus the patient was seen immediately, and the doctor did not have any other scheduled appointments to tend to (as disclosed by the doctor to the patient). Physician-centered communication is characterized by the dominate role being taken on by the physician in the patient-physician relationship. The caregiver tends to operate from a position of authority, and the patient from a position of inferiority. Although this type of communication is dominated by the caregiver, it is important to observe that communication is collaborative by definition —hence the patient contributes to this power dynamic as well. In the specific encounter that will be discussed, I will seek to reveal Dr. Hunt’s practice of physician-centered communication by examining her domination of the conversation, depersonalization of the patient, and the implementation of a parent-child dynamic. II. Concept One Traditional practices of physician communication stem from the biomedical model. This model functions from a mechanistic perspective, in that ill health is viewed as exclusively physical. Physicians who work from the assumptions of the biomedical model tend to focus solely on the pathophysiology of the body —identifying where the dysfunction is occurring and what treatments will address said dysfunction. Although the biomedical model has many advantages such as its clear efficiency, many disadvantages are also associated with it, such as its acontextual nature and reductiveness. As a model that is not contextual, the biomedical model only considers biological aspects of the patient and disregards psychological, social, or mental aspects. Also, in being reductive, it diminishes a patient to their illness. The traditional practices of physician communication that originated from the biomedical model are largely similar to its functionality. These practices place emphasis on specificity, briefness, and precision. As such, this type of communication is catered toward the physician rather than the patient. “Patient-centered communication is based on a moral philosophy that calls for physicians to expand upon the biomedical approach to care by (1) helping patients feel understood through inquiry into patients’ needs, perspectives, and expectations; (2) attending to the psychosocial context; and (3) expanding patients’ involvement in understanding their illnesses and in decisions that affect their health” (Epstein, 415). This type of communication is largely preferred by patients, despite being a lesser used style by healthcare professionals. Ultimately, this approach is likely to produce better health outcomes, increase patient compliance, and reduce hospitalization and/or repeat visits by patients. Its clear benefits outweigh those of physician-centered communication that originates from the biomedical model. Physician-centered communication is usually characterized by the physician dominating the conversation. This occurs when the caregiver is directing or controlling the relationship with his or her patient. It is distinguished by multiple factors such as beginning and ending the conversation, utilizing leading questions, and being dismissive towards input from the patient. Dr. Hunt’s first inclination towards physician-centered communication was revealed when she began the conversation and asserted her power through doing so. The conversation was initiated without an introduction from the doctor, but instead began with a statement regarding the patient’s condition. By failing to introduce herself, Dr. Hunt was unsuccessful in progressing towards establishing a relationship with the patient. Forgoing an introduction also gave the impression that the physician was rushed and time for formalities was not available. In assessing the relationship between Dr. Hunt and the patient, it is necessary to observe the patient’s behavior as well. While scrutinizing the doctor’s omission of an introduction and seemingly rushed demeanor, it should be noted that the patient was presently struggling with her breath. The doctor’s rush could’ve been in consideration for the patient —so that treatment, and therefore relief, could more quickly be given. In proceeding with the conversation, Dr. Hunt then began to implement leading questions. Leading questions are often used by physicians to elicit specific, precise, and brief responses from the patient. By encouraging these types of answers, excess information is avoided and time is saved. However, leading questions can also result in the exclusion of pertinent information. The leading questions used by Dr. Hunt were relative of: “When did the attack start?” and “Has it been persistent or erratic?”. The patient was enabled to precisely answer these questions in few words —thus allowing Dr. Hunt to continue to control the conversation. Again, the state of the patient must be addressed. When a patient is struggling to breathe, questions that allow for uncomplicated responses may be to the benefit of that patient so as not to expend themselves further. One defining event within the encounter occurred when the patient asserted herself beyond the encouraged, precise amount. The patient felt it necessary to inform Dr. Hunt of her medical history due to the fact that she was a new patient, and the doctor did not have a working knowledge of her past. After notifying the doctor of her child-onset asthma diagnosis, Dr. Hunt responded dismissively: “That’s just what doctors diagnose kids with when they don’t really know what the problem is. It makes the parents feel better to have a concrete explanation.” This statement from the doctor blatantly revealed her disregard for the patient’s input in the conversation. Furthermore, it suggests that the physician believes her knowledge surpasses empirical evidence and the knowledge of the patient’s previous doctors. Discounting the patient’s previous experiences is indicative of the biomedical model and ultimately, physician-centered communication. Dr. Hunt asserted her status over the patient’s and continued to operate from a position of power —rather than collaboration. The communication between the physician and the patient was initially established as physician-centered as demonstrated through Dr. Hunt’s initiation of the conversation sans introduction, use of leading questions, and dismissal of the patient’s input and previous history. III. Concept Two Depersonalization is a technique used by many physicians that also appeals to their needs above the patient’s. This method involves the physician’s detachment from the patient, which can be used for a multitude of reasons. Some reasons involve attempting to refrain from involving emotions in decision-making while others involve a lack of compassion for patients and their conditions. Depersonalization is considered to be physician-centered because its benefits are geared towards the physician as opposed to the patient. While it may allow the physician to more efficiently diagnose and treat, it often leaves patients feeling isolated or dehumanized. Depersonalization is also a facet of the biomedical model because it permits the physician to focus on the biological functions of the patient —rather than outlying factors such as psychology or social characteristics. However, this approach is often discounted as neutral rather than invested, and gives the patient a perception of minimal empathy. “Rather than solely focusing on scientific advancements or prognosis of the patient, he [Dr. Flexner] encouraged physicians to invest in patients’ lives long-term in order to see improved interactions and ease patient’s concerns” (Marshall, 17). Depersonalization ignores the existence of the patient outside of the doctor’s office or hospital and allows the caregiver to view them as a case or illness as opposed to a human. Dr. Hunt demonstrated a degree of depersonalization by refraining from inquiring about situations surrounding the asthma attack beyond simply what it consisted of. As noted previously, the patient recently relocated. In having this knowledge, Dr. Hunt could’ve deduced that stress was a current factor in the patient’s life, and thus considered it as a trigger for asthma. Beyond this, Dr. Hunt did not solicit information about the patient’s current activity level —although exercise notoriously induces asthma attacks. By not showing interest in other aspects of the patient’s life, and instead only considering the empirical evidence presented, Dr. Hunt was not enabled to accurately assess the situation. The patient was depersonalized and treated as a “case” rather than a valuable source of input, and was therefore subjected to the doctor’s opinions. Another means of depersonalizing a patient is patronizing them —by whatever means. A patient can often be viewed as an obstacle as opposed to a human. Doctors can perceive the situation this way because of depersonalization —each patient becomes a problem to be solved rather than a human to be helped. Dr. Hunt, consciously or not, participated in patronizing behavior towards the patient which furthered the depersonalization in the relationship. Her first method of “treatment” was to provide the patient with a brown paper bag to breathe into. Because the labored and shallow breathing persisted in the patient throughout the conversation, the doctor provided the paper bag in an attempt to restore normal breathing. Breathing into a brown paper bag is a common solution for persons suffering from hyperventilation. However, as asthma is characterized by the swelling and inflammation of the airways to the lungs, a brown paper bag has no benefit in such a situation. The patient, who suffered from asthma for a large portion of her life, was keen to the fact that a brown paper bag had no benefit for her situation and was actually a common fix for hyperventilation. Knowing this, the patient perceived that the doctor was diagnosing her with hyperventilation and discounting her history of asthma. Dr. Hunt’s aim was to solve the problem presented to her, so she assessed the current problem (labored breathing) and treated it as such without accounting for surrounding factors. Treating the problem rather than the patient, and reducing a serious condition to a common one ultimately patronized the patient. Dr. Hunt’s last act of depersonalization was withholding information. By withholding information, Dr. Hunt insinuated that the patient was a “case” and not a person to be informed of important information. Examples of the withheld information include: refraining from explanation of why hyperventilation would occur, how to prevent it from happening in the future (assuming that was the issue), and not telling the patient what would occur at the follow-up visit. Depersonalization of a patient caters to the physicians needs because it is a mechanism used in order to enhance their efficiency or successfully abstain from being affected by their patients —among others. III. Concept Three A patient-child dynamic between the physician and patient can result from physician-centered communication. In this type of relationship, the physician is viewed as a figure of authority whereas the patient is viewed as one who is expected to follow the orders of said authority figure. This dynamic comes about through contribution from both the physician and the patient. If the physician is assertive and directive and the patient is in turn passive, a patient-child relationship is likely to develop. Physicians and patients also have differing orientations when it comes to assessing an illness. The caregiver is formally trained to diagnose and treat symptoms, whereas the the patient is more largely focused on the contextual aspects of that illness. These orientations can predispose both parties to be inclined towards a relationship in which the physician takes the leading role. A patient-child relation can be encouraged and heightened when the caregiver gives direct orders to the patient and attempts to dictate their future actions. Although Dr. Hunt did not prescribe any treatments, she required the patient to promptly return to her office if an “episode” ever occurred again. Not providing medicinal treatment and ordering the patient to return to the office were both directives that were decided upon solely by the doctor —without consultation from the patient. In any medical situation in which a treatment plan is being decided upon for a sane and reasonable patient, input from that patient should be considered as a function of respect for autonomy. Autonomy is deliberated self rule —“if we have autonomy we can make our own decisions on the basis of deliberation” (Gillon, 185). In health care, respect for autonomy implies that physicians acknowledge the intellectualism of their patients and implement them into conversations and decision-making on the basis of such. In Dr. Hunt’s refrain from disclosing all relevant information, she discounted the patient’s autonomy and thus further solidified her expected “patient” (child) role. Even though physician-centered communication is what the name implies, it does require collaboration from the patient. In this encounter, the patient contributed to the patient-child dynamic by taking on a passive role and refraining from any assertion. This can be evaluated from the disclosure decision-making model which states that people decide to reveal information based on three considerations: the predicted outcome, the anticipated reaction, and confidence and skills. Particularly, the patient most likely refrained from disclosing information based on the predicted outcome. When attempting to share relevant information about her medical history, the patient was dismissed by Dr. Hunt. Following this, the patient could perceive the negative predicted outcome of disclosing further information, and therefore refrained. After this point, the patient became passive and ultimately supported the parent-child relationship. IV. Conclusion Physician-centered communication is a function of the biomedical model and is characterized by domination of the conversation by the physician, depersonalization of the patient, and the presence of a patient-child dynamic between the caregiver and patient. This style of communication is beneficial in facilitating precise and specific conversations, yet has significant disadvantages in reducing a patient to their illness and disregarding aspects of the patient’s life beyond biology. The implications of this model are revealed through negative provider-patient relationships, downtrending health outcomes, and increased hospitalization. “Increasing trust or connectivity statistically suggests the patient will have better health” (Marshall, 17). Physician-centered communication fails to establish these essential qualities of a positive relationship, to the detriment of the patient. Medical school reform has worked to curb the emphasis on the biomedical model by integrating the biopsychosocial model —which promotes an encompassing view of the patient’s biological, psychological, and social characteristics. Greater importance is increasingly being given to communication and interrelationships because of empirical evidence that suggests its effectiveness in the healthcare realm. Communication between patient and physician that allows the patient to have input, fully express their concerns, and receive comprehensible information has been proven to increase patient satisfaction and overall positive health outcomes. Works Cited Epstein, Ronald M. "Patient-Centered Communication and Diagnostic Testing." Annals of Family Medicine 3.5 (2005): 415-21. Academic Search Premiere. Web. 27 Sept. 2014. Gillon, Raanan. "Medical Ethics: Four Principles plus Attention to Scope." British Medical Journal 309.6948 (1994): 184-88. Journal Storage. Web. 27 Sept. 2014. Marshall, Mayme. "Placing the Patient at the Center of Care." Penn Bioethics Journal 6.2 (2010): 16-20. Academic Search Premier. Web. 27 Sept. 2014.