Balancing Power in Patient Relationships

Kris English, Ph.D.Kris English, PhD

The University of Akron/NOAC

Here is a thought-provoking experiment. Ask audiology students to visualize the first moments of a typical appointment with a new patient.  The patient sits down, and the audiologist says, “So what brings you here today?”  Got the image? Now freeze that frame! And then ask, “In this scenario, who has power: the patient or the audiologist?”

Interestingly, students tend to say, “the patient.”  When asked why, the explanations tend to recognize the patient’s power of autonomy: ultimately, a patient can and will decide whether to follow to our recommendations (Calman, 2004). A reassuring answer! But remember, I was referring to the beginning of the appointment, not the end.  It seems possible that we could overlook a new patient’s vulnerability, and be unaware of an initial state of powerlessness. If we are blind to it, we are not likely to take active steps to start shifting the balance of power in the patient’s direction (Goodyear-Smith & Buetow, 2001).

Empathy 101 and Power.  To understand what powerlessness feels like from a patient’s point of view, let’s put ourselves in their shoes. Before and during our first appointment, we would have many questions, and experience some anxiety, worry and doubts. We would have absolutely no idea what to expect. We would see unfamiliar technology, framed diplomas and licenses hanging on the wall, and models of strange anatomy sitting on shelves. We would see brochures and posters about new hearing aid technology – something we have been avoided thinking about, and now it’s “in our face.” At this moment, we have little going for us – except for our unique story. This is a type of latent power: our story is valuable but it will have no impact if we are not given an opportunity to share it.  Is anyone interested?

Across from us is the audiologist, Dr. Somebody, with a white coat and specialized training and expertise. Dr. Somebody will determine how we start the appointment, what steps we take along the way, and how we conclude the appointment. It is reassuring to have an expert take the lead; it’s why we made this appointment in the first place. But it does means that we are still relatively powerless.  Will it always be that way?

balanceofpower

Initially, there is an inescapable power inequity in the patient-clinician relationship, a situation not unique to audiology. Palmer (1998) notes that “Virtually all professionals have been deformed by the myth that we serve our clients best by taking up all the space (i.e, holding all the power) with our hard-won omniscience…” (p. 132).

If this myth is part of our background, we need to expunge it. Patients prefer to take an active role in their health care; they want a voice in the process. In audiology, this means they want to tell us about their dilemmas, their barriers, their worries.  If we have been trained to “take up all the space” (be the only one with power), we need to reconsider this assumption and figure out how to take up less space and make room for the patient.

How to translate these issues into audiologic care?  Here is a simple solution: to recognize and work with the fact that talk is power.

The Person Who Talks Has Power. In our appointments, the person who is talking has the opportunity to make and interpret observations, establish expertise, and in general add his/her voice and insights to the understanding of a situation. This may sound like a role assigned only to the audiologist, and it wouldn’t be far from reality: the audiologist leads the interview, asks questions to fill in gaps, then gives test instructions, explains test results, and makes recommendations.  That could account for an estimated 90% of the “talk time.”

However, the patient has much to say, too, but may be given only the remaining 10% of the talk time.  Dominating the talk time may not be helpful in the long run. Goodyear-Smith and Buetow (2001) explains the impact of giving patients time to talk:

Through storytelling, patients place their problems and experiences in the context of their life histories and cultures. Their narratives give their lives meaning, offer a framework for interpreting events, order them into intelligible patterns, and provide an ongoing sequence in time and place – such is the basis of self-understanding that enables patients to decide what are health problems to them, and what to tell their doctors. Both factual (biomedical) and narrative (psychosocial) aspects of a patient’s story need to be taken into account in each interaction when considering the ethical use of power. Research indicates that patients who feel in control of their own lives and who are actively involved in decision-making about their health care have significantly improved health outcomes. (p. 453)

More Patient Talk Time = More Patient Power. Applying an old-fashioned scale as a metaphor for power, we can visualize how it initially tips heavily in the audiologist’s favor. How to shift the balance?

Make room for more “patient voice”

  1. Use self-assessments or self-reports to help a patient “go on record” with personal perspectives and life experiences, and serve as a springboard for more narrative.
  2. Develop active rehab assignments where patient participation is expected and valued (keeping a journal, emailing progress or questions, adding to a clinic’s wiki to teach other patients about unusual challenges, providing feedback about the clinic’s website on patient education)
  3. Monitor our listening efforts: was that routine question an opening to a more complicated subject?  Did we gloss over an issue that the patient would like to explore?

More patient voice means less “audiologist voice

  1. Use our talk time judiciously.  For example, although we may have been trained to explain the audiogram to every patient, it may not be necessary –  the patient may not be very interested. Why fill precious time with needless talk?
  2. Wait instead of immediately answering a question. The patient often has more to say. If we quickly answer the surface question, we may miss the real point. Is there a reason why the question was asked? Is there more to talk about?
  3. Monitor the conversational ball; is it mostly in our court? How can we bounce it back to the patient?

Conclusion. A new patient is in a vulnerable situation, and often looking for a reason to leave the appointment without accepting help.  However, the more patients talk, the more they establish power over their problem. The more they talk, the more they become invested in a help-seeking process.  The less we talk, the less space we take up and make room for patient growth.

The topic of power is just as challenging when we care for parents whose child was been diagnosed with a hearing loss.  This challenge will be addressed in a future article.

References

Calman, K.C. (2004). Evolutionary ethics: Can values change? Journal of Medical Ethics, 30, 366-370.

Goodyear-Smith, F., & Buetow, S. (2001). Power issues in the doctor-patient relationships. Health Care Analysis, 9. 449-462.

Palmer PJ. (1998). The courage to teach.  San Francisco: Jossey-Bass.