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.