Good Practice: Power and the Therapeutic Relationship
December 6, 2016
Leanne Loranger, PT, Practice Advisor
It seems to me that physiotherapists often perceive themselves as lacking power within the health system. In public practice physiotherapists are part of a larger health-care team, but the traditional physician and nursing dominated hierarchy still persists within many organizations. In private practice physiotherapists may perceive themselves to be “at the mercy” of third party payers who dictate contract fees and terms with little room for negotiation.
But what about the patient-provider relationship? Are we in a position of power and influence? How is that power dynamic changing as patients become more informed health-care “consumers?”
Power-sharing and patient-centered care
It is fair to say that we are living in the era of patient-centered care. For many years the trend has been to focus on the patient’s goals of treatment and shared decision making, to ensure that care provided and outcomes are consistent with patient values. We see this in the shift from “evidence-based practice” that focused on research findings, to “evidence-informed practice” which honors the patient perspective as having equal weight and importance as research evidence and clinician experience.
It is also fair to say that many patients are becoming better informed about health and health-care decision making. One key to this change is the democratization of health information that has been seen as a result of increasing use of social media and the internet to gain and share information. In many cases, patients have become sophisticated health consumers. Consumers that have many health-care options to choose from and the “power of the purse.”
In private environments, one could almost argue that it is the provider who is in the dependent position, as they are relying on patients to purchase their services.
Overall, the shift to patient-centered care and an increase in patient power has been a good thing, meaning that patients have been better able to use health-care services to meet their own goals and needs. But is that universally true? Are some patients more empowered than others? As a rule, do we do a good job of sharing power and empowering our patients in their own health-care decision making?
Are physiotherapists in a position of power?
Over the years, a great deal of information has been written about the power that health-care professionals have as a result of their unique knowledge of both health and the health system at large.1 That knowledge places physiotherapists in a position to be able to make more informed choices about their own health care, as compared with the general public. Among individuals with lower socio-economic status or lower levels of academic achievement, a physiotherapist’s extensive post-secondary education may confer them with special status and elevate them to a certain level of professional elitism.1 Indeed, among some sub-groups, it is not uncommon for patients to refer to physiotherapists with the honorific title “doctor.”
And indeed, physiotherapists are powerful. Patients come to us seeking a solution to a problem, illness or injury and by leveraging our skills and knowledge we help them to improve. What’s more, patients depend on us to do so. For many of us, whether we like to admit it or not, that feeling of being able to help someone is a motivator for why we practice.
Where this breaks down
Interestingly, even if health-care consumers are better informed and seem more empowered to make their own decisions, old behaviours are hard to change. Some research has shown that patients (including health-care providers themselves) continue to adopt the role of passive and compliant patient, rather than risking becoming labelled as a “bad patient.”2 In one study, patients reported the perception that “if they did not do as they were told, they might not get good care.”2 That fear was validated by direct researcher observations that when health-care providers perceived a patient as “difficult” “they tended to limit communication, withhold information, and provide only minimum care.”1
This is in stark contrast to the movement for patient-centered care, which requires health-care professionals to spend more time in discussion with patients about their health-care options and preferences.
Simultaneously, increasing workload demands placed on clinicians due to population demographic changes and difficulty attracting new health-care professionals result in clinicians who report having less and less time to provide patient care. It has been suggested that this results in health professionals who view patients “as objects or bodies” an attitude that “clearly places patients at a disadvantage because being perceived as a body detracts from seeing patients as human beings.”1 Thus, at a time when patients are ill and vulnerable, and in need of health-care providers who promote patient empowerment, they may be faced with health providers who are instead clinging to their position of authority and actively subverting efforts at patient empowerment1 in order to “get the job done and move on.”
Of course, this is assuming that the patient is an empowered and informed health-care consumer to begin with. What about patients with limited understanding of the health system? Individuals who are unable to discern the difference between high and low quality health-care information and advice? Individuals with limited education or health literacy, or those whose cultural background makes them less likely to challenge individuals who they perceive to be in authority positions? What about individuals who are told they must attend physiotherapy by their insurance company or WCB or they risk having their claim denied? Clearly, physiotherapists are in a position of power both due to their knowledge and due to the patient’s perception of his or her own situation. In these situations, it is imperative that physiotherapists and other health-care providers make intentional efforts to “level the playing field” and equalize the power imbalance with patients.
Can we assume that if a patient attends treatment they have agreed to that treatment? What if the patient perceives that they will be “cut off” from their insurance or WCB claim if they don’t attend, but really doesn’t agree with the plan? In such a situation, the physiotherapist is clearly in a precarious position if they haven’t taken the time to understand the patient, their values and preferences and if they haven’t taken the opportunity to share power with the patient.
Keep in mind that the effort to share power may require a significant amount of effort on the part of the health-care provider. As one author noted, “health-care systems have invested substantial efforts in trying to shift the attitudes of clinicians but have not invested the same efforts in preparing patients for these new types of social interaction.”2 The implication being that even if the provider is intentional in attempting to gain the patient’s input and share decision-making, the patient may not be prepared to do so. Health-care providers should be careful with assumptions that the patient is “not interested” in providing input, it may simply be that we have not taught them how to become engaged in that process, nor explained that we need and want them to be.2
How to create a power-sharing therapeutic relationship
First and foremost, pay attention! Spend some time trying to get a sense of your patient,1,3 their level of health literacy and their cultural background. Think about the importance of power sharing in the therapeutic relationship and be intentional in your approach.
Take steps to minimize the power imbalance
Share and give information to patients readily, not just when asked.3 Your education and experience mean that you know the information patients “should” be asking for, things you would want to know, things other patients with similar problems have asked. Offer it!
Share information neutrally. You may have an opinion about the best approach to care, and if asked you can give it, but when giving information about treatment options, risks and benefits, best practice is to provide the information in as neutral a manner possible, to avoid swaying the patient’s decisions to what you would choose and away from the choice that best fits their own values.
Encourage the patient to participate by demonstrating that there are two experts in the therapeutic relationship, the patient and the provider.1,2
Employ open communication strategies: use plain language,4 and open ended questions to ensure understanding and patient engagement and to elicit what matters to the patient.1
Note the patient’s individual needs and concerns.1 While you may be able to anticipate some of the information that patients will want to receive but don’t know to ask, you won’t know what matters to the patient. Try asking “what matters?” rather than “what’s the matter?”
Most importantly: accept the patient’s decisions1
As one researcher noted, “Although health professionals have changed language so that it appears less judgmental, they still imply that patients have a responsibility to defer to the so-called expert knowledge of health professionals.”1 Whether you refer to patient compliance or adherence, or use some other term, is your underlying assumption that the patient should “do what you tell them?”
Next time a patient doesn’t “comply” with the treatment you have suggested, ask yourself if compliance was the goal. Is the patient just exerting their own power over their health? Do we really know what’s best for someone else?
Henderson S. Power imbalance between nurses and patients: A potential inhibitor of partnership in care. Journal of Clinical Nursing 2003; 12:501-508.
Joseph-Williams N, Edwards A, Elwyn G. Power imbalance prevents shared decision making: Providing information is not enough to enable shared decision making, argue Natalie Joseph-Williams and colleagues. Action is required to change the attitudes of both patients and doctors. BMJ 2014; 348: g3178 doi: 10.1136/bmj.g3178
Schachter CL, Stalker CA, Teram E, Lasiuk GC, Danilkewich A. Handbook on sensitive practice for health care practitioner: lessons from adult survivors of childhood sexual abuse. Ottawa: Public Health Agency of Canada.
Wizowski L, Harper T, Hutchings T. Writing health information for patients and families: A guide to developing educational materials that promote health literacy. (4th Ed.). Hamilton: Hamilton Health Sciences, 2014. Available at: http://www.hamiltonhealthsciences.ca/workfiles/PATIENT_ED/Writing_HI_Edition4.pdf. Accessed on January 7, 2016.