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In part, this change in attitudes has led to patients' increasingly viewing healthcare as a 'preventative' process, rather than purely a 'curative' process. In some respects this empowers patients, making them responsible for their own health outcomes. However, it also shifts the dynamic towards a consumerist approach. The patient needs a service. In a preventative market the patient becomes consumer. The need for appointments that are not 'cure driven' means that we have to attract patients to use our service and we are in a 'buyers' market.'1 Even the term 'healthcare provider' is part of this shift. While empowering for patients they create a different attitude to our services.
Traditionally the 'practitioner knows best' (paternalism) or 'practitioner-centred' consultation has been the norm. Indeed, within optometry this is how most of us have been taught to examine patients. The patient attends for an eye examination with a particular problem, and the practitioner spends the rest of the consultation 'information gathering' through various tests in order to give the patient advice. This type of consultation has little reference to exploring patients' beliefs, expectations and fears.2 The practitioner is endowed with all the power and the patient is left as the supplicant. However, with changing patient attitudes this type of consultation becomes less appropriate. A practitioner-centred approach can lead to consultations that are both ineffective and dissatisfying to both patient and optometrist. Indeed, there is a growing need to adopt a more 'patient-centred' approach which allows the patient to have some power within the consultation. Unfortunately this change can lead to optometrists feeling helpless, frustrated and threatened by their lack of control.3
However, there are communicative techniques which the optometrist can use to achieve a more 'patient-centred' consultation without 'losing control' of the overall consultation. Therefore, the aim of this article to examine the balance of power between the patient and the optometrist within the optometric consultation. Furthermore, we will look at communicative techniques which can be used to achieve a more 'power-balanced' consultation ie patient-centred.
Background
Power in a relationship is a conceptual idea, it is neither inherently good nor bad and is not finite. One person's gain in power does not have to come from another's loss. The interaction can act to empower both parties. This is especially true when the source of power is knowledge and that knowledge is exchanged. However, true equality of power in a relationship is rare.
It is normal for the balance of power to change during any social encounter. At one moment one person is in control, at another they relinquish this and allow someone else control. I am sure we all know people who dominate conversations and will allow no digression from their agenda. In these situations the relationship can become dysfunctional, as there is a dominant power broker.
Transactional analysis (TA) has provided the tools and classification to describe and understand this.4 TA is complex, but simply put it considers that any person in a relationship, no matter how casual, is in one of three ego states parent, child or adult. The parent is our ingrained voice of authority it can be authoritative but can also be caring. The child reacts to emotions as a child would. The adult state is directed towards an objective appraisal of reality.
In a normal functioning relationship the other person will be in a complementary state. 'Parent to child' or 'adult to adult' which reflects the balance of power. These states are like a seesaw, they move up and down freely but remain balanced. Relationships become dysfunctional when the participants are not in complementary states eg 'parent to parent' or when the seesaw becomes locked in one position, as is the case in a paternalistic consultation where the optometrist is in the 'parent role' and the patient in the 'child role'. Interestingly, the child state is not a passive role. A person can choose to be seen as vulnerable, locking the other into the parent role against their wishes.
Power within the optometric consultation
At the beginning of the consultation there is already an imbalance in power. The optometrist holds the majority of the power within the relationship. The stereotypical view of a 'practitioner-' or 'optometrist-centred' consultation is one where the optometrist is authoritarian and overpowering. Being overly dependent on a biophysical approach (disease centred), cure fixated, can cause this to happen. However, the patient-centred approach redresses the balance of power within the patient-practitioner relationship by encouraging patient involvement. Indeed, patients report a strong preference for this type of consultation.5 It allows the patient to take ownership of their health and gives them input into the outcome.6
Figure 1 visually depicts the balance of power within practitioner- and patient-centred consultations.2 The practitioner-centred consultation is dominated by the practitioner's agenda (the right-hand side of the diagram), with only the presenting problem contributed by the patient. The practitioner retains most of the power and the patient's agenda is largely ignored. As we move towards the left hand-side of the diagram, the patient's agenda is increasingly acknowledged, increasing the amount of patient power. If a practitioner retains all the power throughout the consultation, the diagram shows that the patient is less likely to communicate important information, eg their beliefs, hopes, fears and expectations. This can result in a loss of effective communication and lead to patient dissatisfaction and non-compliance.7,8 In other words, communication and patient outcomes can be improved as the practitioner encourages the patient to share their agenda within the consultation. This includes encouraging patients to share their concerns or worries. For example, at the end of history and symptoms asking a patient, 'is there anything else worrying you about your eyes at the moment?'
Skills
Although we have seen that increasing patient empowerment can improve communication and outcomes, as an optometrist, relinquishing power can be a frightening prospect. There is the worry that you might be unable to re-establish that position and that it will potentially lead to a calamitous outcome - running over time on an appointment, not being able to complete an important task and so on. However, there are communicative skills which the optometrist can use to 'manage' the balance of power within the relationship. These will be described below.
Initially, it is important to note that the equitable balance of power in the professional relationship is just an illusion as the optometrist always holds the balance of power. Indeed there are a number of factors which bestow the balance of power and authority upon us:
- There is the power of our role: Whether we are seen as healers or retailers is another argument but regardless the patient has sought us out and chosen to see us
- Social power: We are a professional and as such have social standing and regard
- Our clothes and appearance: Either white coats or suits both denote power and authority
- The appointment structure: We see people when it is convenient to us rather than when it is convenient to them.
In other words, the patient has sought your opinion, it is your territory, you facilitate the process and you are the time keeper. Throughout the consultation the optometrist has ultimate authority over the 'power balance'. To aid us in managing this balance of power we can use 'maintenance tasks' or 'facilitator elements' during the consultation:
- We provide structure to the consultation.
- We control the transition between phases of the consultation eg between history and symptoms and physical examination
- We offer the agenda for discussion - We sum up and provide an action plan. The patient can choose to reject this but it is the outcome of the consultation and signals a closing phase to the consultation.
However, even with these 'facilitator elements' in place, there are times when the patient can forcefully seize power during a consultation. Examples include: what the patient chooses to disclose and what not to disclose, when they request inappropriate treatment or tests, when they behave in an inappropriately dependent manner, when they choose to ignore your advice or do not return for follow-up. In this situation the optometrist can start to feel powerless. When patients seize power in this way it can feel threatening and can lead to 'heartsink' episode.9 However, in these situations there are a number of techniques that the optometrist can use to gain a more even power balance in the relationship. These are as follows:
- Not maintaining eye contact and writing notes when the patient is talking
- Relative positions and height - either raising their stool or standing to look down on the patient
Less usefully
- Using jargon or technical terms
- Asking closed questions
- Performing tests without fully explaining what you are going to do or what they are for.
Although these are communicative techniques which are generally discouraged within patient-practitioner communication, they are sometimes necessary. In other words, although we want to encourage the patient to be actively involved in the consultation, that does not mean that we adopt a 'powerless' or 'child' role. Indeed, patients are unlikely to consult a healthcare professional who they perceive as powerless. Patients ultimately expect their practitioner to give them advice and expect them to be the professional.
Misuse of power
Having identified ways in which to manage the balance of power within the patient-optometrist relationship, it is also important to note that within any relationship power can be misused - by either party. It is important to identify the potential pitfalls which can occur within the patient-optometrist relationship so that we can seek to avoid them.
Firstly, some patients commonly abuse their power. Obvious examples are patients that fail to keep their appointments. Patients will often seek to manipulate their optometrist. There are patients whose goal is not to 'get well' but to receive confirmation that they are special, that they have a condition unlike anyone else's. Other patients will fail to follow treatment regimes until they are given one that they like. Suggesting a lid scrub intervention when the patient wants a 'magic bullet tablet' rather than making lifestyle changes can be likened to patient requests for inappropriate antibiotics. In other words, these patients place an unfair burden on the optometrist as resolution of the problem is entirely in their hands. Being aware of these patient characteristics can help the optometrist to educate and change patient attitudes.
Secondly, power in a relationship can be misused by healthcare practitioners. For instance, an optometrist may recommend an inappropriate, unnecessary or more expensive treatment option for financial gain. They may delay referral to other agencies when their skills and knowledge mean that the patient is receiving minimum standards of care rather than excellence. The motivation may be a misguided feeling that you are helping the patient, for instance avoiding the pain of referral or the hassle of travel to another practice for an elderly patient.
Withholding medical information is another way of maintaining superiority over a patient. We can also slip into the trap of punishing patients for not doing what we want them to, eg withholding contact lenses from non-compliant patients making follow up appointments difficult for patients who have missed an appointment only offering times that suit us rather than times that are mutually beneficial or even making decisions based on our own beliefs and values rather than the patient's. We need to achieve a level of self-awareness that allows us to recognise and avoid this happening.
Summary
Negotiating power within any relationship can be difficult. However, within the patient-optometrist relationship we have seen that encouraging patient empowerment can result in improved communication and patient outcomes. The communicative skills outlined in this article can help to achieve this and also to avoid the pitfalls associated with misuse of power. ?
References
- Roter DL and JA Hall. Doctors talking with patients/patients talking with doctors : improving communication in medical visits 2nd ed. 2006: Greenwood Publishing Group.
- Tate P, The Doctor's Communication Handbook. Third ed. 2001, Oxon: Radcliffe Medical Press Ltd.
- Eggly, S and A Tzelepis. Relational control in difficult physician-patient encounters: negotiating treatment for pain. Journal of health communication, 2001. 6(4): p. 323-333.
- Harris, TA. I'm OK, You're OK 1995, USA: Arrow Books Ltd.
- Little P, et al. Preferences of patients for patient centred approach to consultation in primary care: observational study. British Medical Journal, 2001. 322(7284): p. 468-472.
- Botelho, RJ, A Negotiation Model for the Doctor-Patient Relationship Family Practice, 1992. 9(2): p 210-218.
- Harrington J, LM Noble, and SP Newman. Improving patients' communication with doctors: a systematic review of intervention studies. Patient Education and Counseling, 2004. 52(1): p. 7-16.
- Stewart MA. Effective Physician-Patient Communication and Health Outcomes a Review. Canadian Medical Association Journal, 1995. 152(9): p. 1423-1433.
- Millington A. How to survive the heartsink patient, in Optician. 2008.
? Andrew Millington is an independent practitioner in Chepstow. Helen Court is a lecturer at Cardiff School of Optometry & Vision Sciences