The power of the power differential

Everything looks so... small from up here.
[Jupiter Weighing the Fate of Man via wikimedia]

When we go to the doctor we are at our most vulnerable. We are vulnerable because we are sick and we are vulnerable because we are at a loss for medical domain knowledge. This gap between knowledge and helplessness is the power differential between doctors and patients. The more pain a patient is in, the larger the gap.

The emotional heart of power differential is fear. As a patient, I have a huge incentive to say things which make the doctor think well of me for fear I might jeopardize the care I need otherwise. If I worry about being judged, I won't feel safe. Some patients will respond to the power differential with deference, while others will be defensive. Either way, doctors who are willing to examine their own power dynamics will enhance security, honesty and shared understanding with their patients. So when I give feedback to students about communication skills, I frequently focus on things that reduce power differential.

This is a living list. Last updated June 29, 2014.

What increases power differential:

• Technical language: As a patient, if I can't understand the student, I will feel ashamed and stupid. In response I can attempt a reasonable guess, let it slide, or ask a question. Because patients often see doctors as authority figures, asking a question can feel confrontational. Comprehension (and the desire for confrontation) fails at a rate directly proportional to pain.
• Body language: Formal body language and sitting far away enhances the power differential between us. A clipboard can sometimes feel like a shield if the student has a death grip on it or spends more time looking at the notes than at me. Some students, in order to demonstrate active listening skills, lean forward too aggressively, making me feel scrutinized instead of supported.
• Taboo topics: when students assume they can ask sensitive questions without appropriate framing, they are taking advantage of the power differential. Topics include sex (cheating, STIs, abortion), alcoholism, depression, etc. For some patients, this can even include topics like urine and bowel movements. The more taboo the topic, the more important it is that the student doctor communicates safety and acceptance.
• Physical exam: The power differential is at its most obvious during the physical exam, especially if any part of my body is ungowned. Bodily autonomy is, in my opinion, a primary and absolute right. When students move me without asking me, or when they don't tell me what they are going to do before they do it, or when they give me unclear instructions (and then show surprise when I don't do what they expect), that makes me feel violated and frustrated. Compassion should not end when the physical exam begins.
• Command language: When students ask if I have been "compliant" with prior instructions during an encounter, I immediately feel judged and unworthy. Even in feedback, when I hear that my character was "non-compliant," I flinch. Compliance has power differential built into the word itself: the doctor gives orders, the patient obeys. Similarly, when a student doctor refers to my "complaint," the word implies a value judgement and I worry the student doctor isn't taking my concern seriously. The same is true if the student doctor at some point mentions "denies [pain, loss of consciousness, past medical history]." To hear that I have "denied" something sounds as if the student doctor doesn't believe me.
• Unbalanced speaking ratio: when the provider speaks much more than the patient does, that's a reflection of the power differential.
  
  
  

What decreases power differential:

• Empathy: When a student offers empathy at the pain I am currently experiencing, I can stop worrying about whether the student thinks my issue is serious enough to merit attention.
• Validation: When a student validates my choice to come in, I feel recognized and empowered.
• Normalization: When a student normalizes my concerns, I feel less alone and more accepted. Without empathy first, though, it can feel dismissive.
• Body language: open and relaxed postures help decrease the power differential, but being too familiar can have the opposite effect. A good rule of thumb is to sit close enough so that if we both reached out an arm we could touch.
• Rapport: when a student wants to know something about me that isn't medically necessary, that makes me feel like more of a person. When a student remarks on something we have in common, then I feel more connected. Being too familiar with a patient too quickly it can have the opposite effect, but a good rule of thumb is 1-2 remarks per case in which the patient is a new patient.
• Autonomy: When a student gives me a choice, I feel respected. Whenever a student specifically acknowledges that I am a person who might have her own needs, expectations and feelings, I am relieved and feel more in control.
• Manners: using "please" and "thank you," especially during the physical exam, makes me feel respected.
• Reflective language: When a student uses the same words and terms I use, I feel we are sharing the same reality.
• Summarization: When a student summarizes what s/he has heard at the end of the history and asks me to verify it, I feels as if my opinion about my own history matters. This sounds obvious, but as a patient it can too often feel as if my words fall into a black box and I have no idea if what I'm saying is actually what's being heard. Being specifically invited to correct the doctor is a very simple and elegant way for a doctor to redistribute power. Transparency also helps even the power dynamic, and summarization is one of the best ways to demonstrate it within the context of the encounter.
• Accommodation: whether the student doctor asks my preferred name or whether I want the lights dimmed when I have a headache, accommodation demonstrates a willingness to adapt to the patient's needs. Accommodation also means physical self-awareness: if it hurts to turn my neck, the student doctor should sit where I can see him or her comfortably. If I have to adjust myself to accommodate the doctor, that reinforces the power differential.
• Ownership: when I am allowed or expected to contribute to the treatment plan, I am able to more fully integrate it to fit my actual life, making it more likely I will follow the recommendations.
• Asking permission: when I am asked permission to be touched, especially in painful, vulnerable or private areas, I feel more respected and safe.

Basically, reducing power differential is a way to reduce vulnerability, fear and shame in patients. Reducing power differential enhances trust, confidence and respect.

Extra credit! 
Power is different than authority: discuss.