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AUSTRALIAN MEDICAL ASSOCIATION (WA)
Many would argue that the practice of medicine has changed with the progress of consumer empowerment and ready access to Dr Google.
Respectfully, however, some things even in that context are still underpinned by the interaction and relationship between the doctor and the patient. Whether it is in a face-to-face consultation or examination, by telephone or telemedicine, by snail mail or email, or even by SMS – it
has long been recognised that the interaction between doctor and patient is one where the doctor is in a position of power.
Even the patient most empowered with knowledge and consumer confidence must still be respected in their position as ‘patient’ – the differential lies in their ‘need’ for the physician. A sharp example to remind us of this is when we ourselves – doctors – fall into the need to be cared for by colleagues.
We often minimise our symptoms and fears, make presumptive diagnoses, mistrust ourselves and our colleagues, fail to conform to advice and put ourselves at greater risk of poorer outcomes. It is difficult to yield ourselves to the hands of someone else’s care, and we are challenging to treat.
Every patient is vulnerable due to the very fact that they have a need to see a physician – they may feel unwell, weak, confused, frightened, anxious or stressed. These are the ‘emotional’ and ‘subjective’ overlays that are part of the physical that we must interrogate, examine and manage.
In addition of course, there are many other factors that come into play including age, sex, socio-economic status, past history, education, religious and cultural origins etc. The patient suffering with mental illness is another example of complex vulnerability.
In addition, there is a knowledge differential between patient and doctor as to how the consultation will be conducted and the path that the taking of a history, examination and management of presenting or other problems will take.
We hear of the obvious examples of where difficulties can arise in the context of male doctors seeing young women. The position of power by the doctor in this circumstance is seen to be potentially greater by society and by virtue of gender, and sometimes age must be recognised as an interaction that may need more caution or even a chaperone.
As in any instance, the appropriate conduct of the doctor is essential to protect the patient from even feeling at risk or vulnerable. This is presented in language, communication and explanation, body position and space, touch and examination technique.
A patient can feel abused in the professional relationship just through the tone and body language of the clinician. This vulnerability places responsibility and onus on the physician to respect the patient, not take advantage, to explain carefully what is happening, and to obtain consent for any examination, investigation or treatment.
The doctor is not to misrepresent themselves or what they are doing to a patient. The doctor is expected to be honest and transparent at all times.
Similarly, the doctor should not foster a relationship with a patient to create a false relationship to increase the vulnerability of a patient in order to then exploit them.
An example of this might be where the doctor describes himself as ‘special’ at particular care. Creating anxiety or a false confidence in a patient in order to get them to commit to that treating doctor and then in that vulnerability, accept over investigation, over servicing, sale of product and a false belief that the treatment they are receiving is ‘better’ than elsewhere. This is an abuse of the doctor-patient relationship.
There are a variety of ways that a doctor can manipulate a patient and these are founded in that innate ‘position of power’. We must be aware, and always practise with high ethical and moral principles.
Flattery, inducement, withholding of prescriptions, job offers – these are all extreme situations and fortunately, very rare examples of abuse of the doctor-patient relationship to obtain some kind of gratification (usually sexual) for the doctor. These are the obvious – less obvious are the ones we must all actively consider every time we have a patient encounter.