Reflections on the doctor–patient relationship: from evidence and experience
a good doctor-patient relationship is determined by define medical information objectively (type of dis- ease, its stage .. Stewart and Roter  note that the. Stuart Goodman, MD, PhD is part of Stanford Profiles, official site for faculty, postdocs, Dr. Goodman is on the editorial board of the Journal of Orthopaedic. The doctor establishes a relationship with the patient. Phase II extremes, they described a graduation of styles from closed information-gathering to non-.
While Keith was working with Amanda, physical therapist Kay Crabb also worked with him in his home. To improve his swallowing and breathing, Keith saw a specialist who removed part of his windpipe and inserted a temporary balloon to stretch the organ.
Speech-language pathologists Rachel Judisch and Courtney Bostwick worked with Keith to assess and improve his ability to swallow. They also gave him diet recommendations and taught safe swallowing strategies.
After 8 weeks of intensive therapy in his home, Keith moved on to the next phase of his treatment. Able to drive himself to the Lake City hospital, he began working with occupational therapist Lisa Findley and OT student Marie Drey to improve the movement of his left arm and shoulder. His surgeries had left scar tissue which made moving his shoulder difficult and painful. After his rib surgery scar tissue built up and inhibited his range of motion. We stretched his muscles and ligaments and completed exercises to release the scar adhesion, increase his range of motion and strengthen his shoulder.
Therapy is hard work and work is therapy. I did the exercises at the hospital, and came home to help my sons with chores on the farm. I weed the gardens, take care of the livestock, power wash the hog units — anything the boys need me to do. I keep working and keep getting better all the time. All the people praying for me certainly helped in my recovery. An accident affects the rest of your life and the lives of your loved ones.
I was always greeted with a smile, and I got to know them quickly. They gave me the tools to work hard. Therapy hurts, it takes work. A new class is beginning for Medicare enrollees with information sessions on August 29th and September In a study from the American Medical Association and Centers for Disease Control, one in two people over the age of 60 has prediabetes, meaning blood sugar levels are higher than normal but not yet high enough to be classified as type 2 diabetes.
Without lifestyle changes, it is likely for people with prediabetes to progress to type 2 diabetes. When Sheri Hanks, a retired school teacher from Lake City, was told about a program being offered at SMCH that could help reduce her risk of developing type 2 diabetes, she jumped at the opportunity. This usually requires lifestyle changes like increased exercise and mindful eating. With my 50th class reunion coming up, I wanted to make some changes and become healthier. My overall goal was a seven percent weight loss.
Each session introduced new concepts, like reading labels, the benefits of different types of exercise, how to measure food, the glycemic index, and understanding triglycerides. NDPP has resulted in a 71 percent reduction in new cases of type 2 diabetes in people over the age of To be eligible for the program, you must be enrolled in Medicare Part B, have a body mass index of at least 25, have no previous diagnosis of type 1 or type 2 diabetes other than gestational diabetesnot have end-stage renal disease, and must meet one of the following three blood test requirements: A1c test with a value between 5.
Feigofsky began the program by explaining the risk factors for heart disease, which is the number one killer of women, which include family history, high cholesterol, tobacco use, obesity, and a sedentary lifestyle. For women waist circumference should be less than 35 inches, and for men the size should be less than 40 inches. She spoke to her audience about hypertension and how it impacts other health systems including kidneys, vision, and sexual dysfunction.
Feigofsky strongly urged her audience that was largely made up of women to be very clear when communicating with their medical providers. If you brush off your chest pain as something less urgent, your doctor may also.
Kelly Ferry is not afraid to try new things. The Gowrie resident was a paratrooper with the 82nd Airborne Division, an elite division of the U. Army specializing in air assault, for 21 years. During that time, he was seriously injured twice. The most severe injury was caused when his parachute was damaged and he fell too quickly.
The impact injured his spine and fractured a vertebrae. Kelly recovered and continued jumping out of airplanes and helicopters until A car accident in January resulted in injuries for which Kelly sought medical attention.
A driver attempted to cross a highway in front of Kelly too closely for Kelly to apply the brakes. He was transported by ambulance to the nearest hospital, treated and released. He decided to seek help in recovering from his whiplash injuries from the Rehab Services department at Stewart Memorial Community Hospital. Kelly met with physical therapist Branden Roberts. He was able to turn his head 31 degrees one way and 40 degrees the other.
Normal range of motion is 60 degrees. His body had locked into a protective state after the accident to avoid further injury. He had me working hard! The therapist inserts the needle into trigger points, or bands of muscle within larger groups of muscle. The targeted trigger points are knotted or stiffened muscles.
Reflections on the doctor–patient relationship: from evidence and experience
The purpose is to release trigger points to relieve pain or improve range of motion. Using a pistoning, or up and down, motion with the needle to elicit the muscle twitch, the purpose is to pump out the pain and inflammatory mediators, or substances released from the cells, open blood vessels and allow more oxygen and healing nutrients to reach the tissue. Branden is so skilled he could tell how the muscle was feeling without me having to tell him.
The next day, though, I felt great! There is such positive energy in the whole department. By my second visit, the whole department greeted me by name. I felt comfortable with Branden right away.
He has a great sense of humor and is an accomplished conversationalist. He can talk about anything. I came away from the whole experience with a lot of respect for what physical therapists do. Kelly works overnights at Walmart as part of the mod crew. His work is very physical — resetting shelves with seasonal appropriate settings. He does a lot of lifting, reaching, and carrying for his job. Towards the end of his phyical therapy we did some workplace simulations to get him ready to return to work.
His range of motion is unrestricted, and his pain is vastly improved. The benefits are great! In my experience, dry needling is a tool that definitely benefits the patient. I strongly recommend it and the therapists at SMCH to anyone. The active 70 year old spends as much time as possible growing vegetables in his two large gardens and cooking, canning, and baking with the results. In the past, Mike struggled with back pain.
I was in the hospital for a week.
Transforming the Doctor-Patient Relationship
When I was released I had to return within a few hours because of the pain. His first consultation with certified registered nurse anesthetist Sarah Crilly, who co-directs the Pain Solutions Clinic with nurse anesthetist Jeremy Johnson, consisted of a long conversation. We talk about past injuries and other therapies that have been tried. We do a thorough physical assessment to identify where the pain is located. We talk about what activities cause it and how the patient has adjusted his lifestyle due to pain.
In Western society, Parsons saw four norms governing the functional sick role: For Parsons, the physician's role is to represent and communicate these norms to the patient to control their deviance.
Physicians exemplify for Parsons the shift to "affect-neutral" relationships in modern society, with physician and patient being protected by emotional distance.
Medical education and social role expectations impart normative socialization to physicians to act in the interests of the patient rather than their own material interests, and to be guided by an egalitarian universalism rather than a personalized particularism. Because physicians have mastered a body of technical knowledge, it is functional for the social order to allow physicians professional autonomy and authority, controlled by their socialization and role expectations.
While the basic notion that norms and social roles influence illness and doctoring has remained robust, there have been numerous qualifications to the particular elements that Parsons attributed to the patient-physician role relationship.
For instance, physicians and the public consider some illnesses in the West and in other societies to be the responsibility of the ill, such as lung cancer, AIDS and obesity, making it more difficult for them to be normatively reintegrated into society. Physicians and other providers react less favorably to patients who are held responsible for their illness than to "innocent" patients e.
Parsons has also been accused of having been overly optimistic about the success of physician socialization to universalism and affective-neutrality. Physicians often react negatively to dying patients, patients they do not like, and patients they believe are complainers Hafferty, Physicians also are subject to personal financial and personal interests in patient care.
Another weakness of Parsons' description is that it was specific to acute illness, and did not speak to the increasingly prevalent chronic illnesses and disabilities, a sick role which is permanent and not transitional Mechanic, Szasz and Hollender's work refined Parsons by elaborating different doctor-patient models arising around different types of illness.
Szasz and Hollender proposed that patient passivity and physician assertiveness are the most common reactions to acute illness; less acute illness is characterized by physician guidance and patient cooperation; and chronic illness is characterized by physicians participating in a treatment plan where patients had the bulk of the responsibility to help themselves.
Critics have also shown that there is a great deal of inter-cultural, and inter-personal variation in sick roles and norms. The "American" sick role is not as useful a concept as the more specific "white, Midwestern, Scandinavian, male" sick role.
There is also cross-class variation. Some of the poor adapt to their lack of access to medical care by becoming fatalistic, rejecting the necessity of medical treatment, and coming to see illness and death as inevitable. On the other hand, the educated classes have become more assertive in the relationship, rejecting the norm of passivity in favor of self-diagnosis or negotiated diagnosis.
Transforming the Doctor-Patient Relationship – STUART PIMSLER DANCE & THEATER
Parsons also based his model of the doctor role on the assumption of a long-term relationship with a family physician. Growing medical specialization and the decline of the solo family practitioner makes this dyadic role model incomplete. Increasingly, several doctors attend various of a patient's ailments, each with a somewhat different set of role expectations and interpretations of the patient's role performance.
Professionalization and Socialization There is also inter-cultural variation in physician roles, and variation among physicians in the success of their role socialization.
The Doctor-Patient Relationship: A Review
While Parsons' model of doctors' affective neutrality, collective-orientation, and egalitarianism towards patients did express the professional ideal, some physicians are more affectively neutral than others.
Following Parsons' lead, sociologists began to focus on the socialization of physicians and the factors in medical school and residency that facilitated or discouraged optimal role socialization to doctor-patient relationships Merton, Reader, and Kendall, ; Becker, Geer, Hughes and Strauss, This work generally took the division of labor in medicine for granted, and painted a more or less heroic picture of medical self-sacrifice.
A few writers began to focus on aspects of the physician role and medical education that themselves militated against humanistic patient care. Critics suggested that medical schools and residencies socialized physicians into "dehumanization," and to place professional identity and camaraderie before patient advocacy and social idealism Eron, ; Lief and Fox, ; and more recently Anspach, ; Hafferty, ; Sudit, ; Conrad, Professional Power and Autonomy The most important weakness of Parsons' functionalist account of the doctor-patient relationship, however, arose from his poor understanding of the ecological concepts of dysfunction and niche width.
Social structures cannot be assumed to be functional for the social system simply because they exist, any more than an organic structure, such as an appendix, can be assumed to be functional for its organism. All that can be said about a structure, or in this case a role relationship, is that it has not yet pushed the organism outside its niche, causing its extinction. In other words, the study of doctor-patient relationships in one society does not indicate how much the particular structures and norms of the provider-patient relationship are simply the result of historical chance, rather than necessitated by the nature of illness and healing in industrial society.
And second, such a study does not indicate whether the particular practices and norms are leading in a dysfunctional direction. A critical sociology of the doctor-patient relationship thus arose to challenge the internal contradictions of the Parsonsian biological metaphor: To the more critical 60's generation of social scientists, inspired by growing resistance to unjust claims to power, physicians' defense of professional power and autonomy appeared to be merely self-interested authoritarianism.
Physicians' battle-cry of the sacred nature of the doctor-patient relationship sounded hollow in their struggles against universal health insurance. Physicians' high incomes and defense of autonomy appeared to result in both bad medicine and bad health policy, and physician's unaccountable power appeared all the more nefarious because of medicine's intimate invasion of the body, In this context, Eliot Freidson's work,crystallized the notion that professional power was more self-interested than "collectivity-oriented.
Freidson's approach to the sick role was influenced by labeling theory Szasz, ; Scheff,and went beyond Parsons to assert that doctors create the legitimate categories of illness. Professionalization grants physicians a monopoly on the definition of health and illness, and they use this power over diagnosis to extend their control.
This control extends beyond the claim to technical proficiency in medicine, to claims of authority over the organization and financing of health care, areas which have little to do with their training. There are now many studies of the way that professional power has been institutionalized in the structure and language of the doctor-patient relationship. For instance, a recent study of medical students' presentation of cases demonstrated that physicians were being trained to talk about their patients in a way that portrayed the physician as merely the vehicle of an impersonal medicine acting on malfunctioning organs, rather than a potentially fallible human being interacting with another human being.
The more highly regarded presenters were found to 1 separate biological processes from the patient, 2 use the passive voice in describing interventions, 3 treat medical technology as the agent, and 4 mark patients' accounts as subjective the patient "states," "reports," "denies,". These devices make the physician more powerful by emphasizing technology and eliminating the agency of both physician and patient Anspach, Since its publication, Starr's The Social Transformation of American Medicine has quickly become the canonical history of the institutionalization of professional power, its effect on the organization of health care, and the profession's metastasized influence in the political sphere.
Though Starr draws on many theoretical sources, he paints a picture of the American doctor-patient relationship as a successful "collective mobility project" Parry and Parry,whose contours were not at all determined by the functional prerequisites of society. While Starr does not goes so far as to say that we do not need "doctors" at all, he argues that there are a range of possible structures that medicine could have taken in industrial society, and that American physicians are an extreme within that range.
Marxist and Feminist Approaches Drawing on, and extending the professional power analysts, the growing school of Marxist sociologists interpreted the doctor-patient relationship within the context of capitalism. In the Marxist analysis, the American doctor-patient relationship is conditioned by the "medical-industrial complex" Ehrenreich and Ehrenreich, ; Waitzkin and Waterman, ; McKinlay, ; Waitzkin, ; profit-maximization drives the innovation of technologies and drugs and constrains physician decision-making.
The most orthodox advocate of this analysis, Vincente Navarro,rejects the analyses of those such as IllichFreidson and Starr who see professional power as having some autonomy from, and sometimes being in direct conflict with, capitalism and corporate prerogatives. For Navarro, physicians are both agents and victims of capitalist exploitation, engineers required to fix up the workers and send them back into community and work environments made dangerous and toxic by capitalism.
But the professions are anomalous for traditional Marxist theory; only those who own the means of production are supposed to accrue occupational autonomy and great wealth. Theorists of physician proletarianization point to the rising numbers of salaried physicians, the deskilling of some medical tasks, and the shifting of some tasks from physicians to less skilled technical personnel.
Parallel to, and often included in the Marxist account, has been the growing feminist literature on medicine. In particular, feminists have focused on the patriarchal nature of the male physician-female patient relationship, documenting the history of medical pseudo-science that has portrayed women as congenitally weak and in need of dubious treatments Ehrenreich and English, ; Arms, ; Scully, ; Mendelsohn, ; Shorter, ; Corea, ; Fisher, ; Martin, ; Todd, There is also extensive work done on the history of exclusion of women from medicine Walsh, ; Levitt, ; Achterberg,and the effects of the growing numbers of female doctors on the doctor-patient relationship.
Women physicians tend to choose poorly paid primary care fields over the more lucrative, male-oriented surgical specialties, are more likely to be employed as opposed to in private practice, and are less likely to be in positions of authority Martin, Women providers are also better communicators Weisman and Teitelbaum, ; Shapiro, Economic Approaches The growth of studies on cost-containment, and the economistic trend of 's social science, led to the rise of methodologically individualistic "rational choice" studies of the doctor-patient relationship.
These studies usually ignored the functionalists' interest in norms and roles, as well as the critical theorists' interest in power and exploitation. Instead, the economists' model starts from the assumption of a mutual "utility-maximizing" agency contract between the doctor and patient Dranove and White, ; Buchanan, The patient is interested in maximizing consumption of health, and the physician is interested in maximizing income.
The studies then focus on the effects of insurance, reimbursement and utilization control structures on doctor behavior, the doctor-patient relationship and the success of medical agency Eisenberg, ; Salmon and Feinglass, For instance, a number of studies have documented that patients without health insurance have less access to doctors, and receive less care from them when they have access Hadley, Steinberg and Feder, ; Kerr and Siu, Research has also demonstrated that different payment structures affect physician behavior Moreno, ; Rodwin,