2.4 Healthcare interactions: Patient-practitioner relationships

Overview

In Chapter 2.2, we examined how people make sense of their subjective experiences of symptoms, and in Chapter 2.3, we considered what might motivate or hinder them from seeking healthcare. This chapter explores people’s interactions with healthcare professionals, including the quality of these interactions and the subsequent care they receive as patients.^[1] The latter can, of course, influence the former: bad experiences of treatment or health ‘care’ might colour future interactions with healthcare professionals.

Firstly, I critically consider how interactions and relationships between healthcare professionals and patients are shaped by power relations and prevailing sociocultural and political conditions. Within this section, I work towards a model of care known as patient-centred (or person-centred) care, which is an ideal approach to aim for in healthcare. Secondly, I discuss the various roles that healthcare professionals can play related to patients, and what functions these can serve in the healthcare professional-patient relationship. Finally, I draw on two case studies of research conducted on (1) sexual and reproductive health provision in South Africa and Aotearoa New Zealand, and (2) cisgender women’s experiences of fertility preservation in cancer treatment in Australia. Using these case studies, I examine the nuances and quality of such healthcare interactions, as well as the implications for those seeking or needing healthcare.

Healthcare interactions: from paternalism to partnership

In this section, I use a social constructionist lens to explore the sociocultural, political, and historical factors that have all shaped how healthcare professionals, patients, and healthcare provision have been variably understood over time.

Within the context of biomedical dominance (see Chapter 2.1), healthcare professionals have traditionally been placed (and continue to be) in greater positions of power relative to recipients of healthcare (Mishler, 1984; Parsons, 1951). This is particularly the case for medical doctors, who hold the most power in healthcare, compared to other healthcare professionals. This is primarily because of the prestige and authority attached to the (almost sole) ability of doctors to diagnose illness and disease and to prescribe medication (Britten, 2001; Freidson, 1970; Jutel, 2019), although this is slowly changing to include other healthcare professionals (e.g., nurse practitioners; pharmacists).

In this medicalised context, the term patient is most commonly used to refer to those who undergo some form of healthcare provision or treatment within a clinical context (e.g., doctor’s office, clinic, or hospital). Historically, in such contexts, patients have been expected to occupy a passive position, namely, the sick role (as discussed in Chapter 2.3) and required to accept the technical expertise of doctors to direct treatment decision making, with little to no prior consultation with them (Parsons, 1975). Part of taking up the sick role requires patient compliance or adherence by undertaking and completing treatment as directed (be it medical, surgical, or psychological).

Promoting or even enforcing treatment adherence has continued to pose an ongoing challenge to health service provision, owing to either intentional or non-intentional non-compliance on the part of patients (Foley et al., 2021; Stevenson, 2004; Treharne et al., 2006). At times, poor communication, lack of understanding, or other issues can cause patients to unintentionally not follow treatment regimens. At other times, patients choose not to comply (for a host of reasons). Given its central role in determining whether treatment is undertaken and completed, improving patient adherence has therefore long been the subject of medical and health services research (see Foley et al. (2021) for a comprehensive review). Arguments that are made for completing treatment include improving people’s health outcomes, increasing their overall quality of life, and decreasing long-term health costs (Foley et al., 2021; Sluijs et al., 2006; Treharne et al., 2006).

While this unbalanced dynamic remained undisputed for a considerable amount of time, the authority and power of doctors eventually started coming into question through several collective social movements, particularly in France, the UK, and the US, from the 1970s onwards. These included the anti-psychiatry movement (Crossley, 1998; 2005), the women’s health movement (Ehrenreich & English, 1978; Morgen, 2002), and the disability rights movement (Halpern, 2004), to name a few. Such disparate movements have shared common points of focus and political aspiration in terms of:

• empowering previously disenfranchised groups of people and promoting their access to equitable healthcare
• raising public awareness about the social and healthcare needs of these groups
• and lobbying for greater involvement and legal rights concerning healthcare provision.

These movements have also promoted a rhetoric of person-centred healthcare, involving partnership between healthcare professionals and patients, and the repositioning of people from “patients” to “health service users”, “clients”, or other terms that recognise their personhood (Rose & Lucas, 2007).

Alongside such movements was a growing political turn to neoliberalism in Western society (as discussed in Chapter 1.4 and Chapter 2.1), involving governments rationalising and minimising public spending on areas such as healthcare, and further shifting responsibility to individuals (Crawford, 1980). Such a turn to consumerism has been further fuelled by the increasing corporatisation and privatisation of medicine (Lee, 2015). Despite conflicting sociopolitical values, the coalescing of social rights movements with neoliberalism repositioned people needing healthcare within greater positions of power as “service users”, “clients” or “consumers”, and to varying degrees of partnership with medical doctors. This shift enabled—even required—lay people to educate and empower themselves about their health, to ask questions of doctors, to be more involved in decision making, and to exercise a “freedom of choice” (Lee, 2015, p. 137), such as “shopping around” for doctors should they be dissatisfied with the healthcare they receive. Although this consumer-focused approach overlaps with values of person-centred care, it often involves an oversight of the broader structural factors that make health and healthcare more accessible to some than others (Lupton, 2012).

Nevertheless, such a move (towards health service user-/consumer-/person-centred care) signals a major departure from previous doctor/patient relationships and interactions, and has had significant implications for the provision, delivery, and receipt of healthcare since.

Textbox 2: Shared decision making and person-centred care

Shared decision making is integral to person-centred care because it ensures that healthcare decisions are made collaboratively, taking into account the patient’s individual values, needs, and preferences alongside clinical evidence.

 

As Charles, Gafni, and Whelan (1997, p. 687) succinctly describe, shared decision-making involves professionals:

1. establishing a conducive atmosphere so that the patient feels that her views about various treatment options are valued and needed;
2. eliciting patient preferences so that treatment options discussed are compatible with the patient’s lifestyle and values;
3. transferring technical information to the patient on treatment options, risks and their probable benefits;
4. helping the patient conceptualise the weighing process of risks versus benefits; and
5. sharing [their] treatment recommendation with the patient, and/or affirming the patient’s treatment preference.

What Charles et al. (1997) describe above ties to the notion of concordance, which gained attention in the UK in the early 1990s, serving as an alternative to the concepts of patient adherence or compliance (Marinker et al., 1997) discussed further above. Focus on medical adherence or compliance, in scholarship and practice, has tended to reinforce a binary between doctors as powerful and patients as disempowered—with decision-making power as something to be wrestled with between doctor and patient. The notion of concordance offers a different perspective, as Stevenson (2004) explains:

The introduction of concordance marks a shift in the thinking in this area as it embraces the notion that the patient perspective should be an integral part of any consultation. As such, concordance reflects a shift from paternalistic practice, and in relation to models of medicine-taking strategies of patient blaming, to a model based on patient-centred medicine and shared decision making, and in relation to the issue of medicine taking, and more generally, the notion of health care practitioners and patients working in partnership (p. 184).

In an editorial to a medical audience, Treharne et al. (2006) demonstrate the utility of the concept of concordance using the example of patients with rheumatic disease—an illness that requires taking ongoing medication to promote patients’ longevity and symptom control. This case study is particularly applicable to understanding concordance, given that it is an illness that can be treated in several similar ways, with relatively similar chances of success. Treatment is also likely to offer a range of side-effects (or risk/benefit ratio) for patients. With no clear preferred option, rheumatology physicians are in a good position, Treharne et al. (2006) argue, to work with patients in a collaborative way to reach a point of agreement, or concordance, by weighing up the costs and benefits for each patient, with each patient. Nevertheless, they acknowledge that the degree to which a patient might want to be involved in this process might vary across individuals. Concordance thus involves the patient’s buy-in to be involved in this decision making process.

Each of these approaches to treatment, therefore, involves varying degrees of power held between the patient and the healthcare professional. Patients (and healthcare professionals) might hold very different opinions about what degree of involvement (thus, power) they want to have, or should have, within this decision-making process.

It is worth noting that, as an interpersonal interaction, the process of achieving successful treatment-taking is further influenced by the broader sociocultural context in which the interaction takes place. This is evidenced in a study conducted by Hikaka et al. (2020) in Aotearoa New Zealand, where older Māori relayed the cultural beliefs and social dynamics that impact whether or not they take the medication they are prescribed. Dr Hikaka gives a brief overview of her research in the following video.

Notably, scholars are shifting away from focusing on a dichotomy of power (as something that is held or not held by patients or healthcare professionals) and are instead drawing attention to the nuances of doctor-patient relationships and the roles that healthcare professionals can play (MacArtney et al., 2020), as we explore below.

Roles of healthcare professionals

Regarding people seeking or using healthcare, healthcare professionals (and the care or ‘services’ they provide) can take up various positions or play one of several roles, and often more than just one of these at one time. These roles are not limited to doctors but rather identified across healthcare professions to varying degrees, depending upon a healthcare professional’s discipline, seniority, and relationship to a particular patient.

Firstly, I present a typology of these roles below. I also critically explore how these roles operate within patient-practitioner interactions, and when they might be accepted, contested, or modified depending on different contextual factors.

Knowledge-provider

As discussed above, healthcare professionals have historically been positioned as experts in treating illness and disease and continue to hold this role in Western society (Freidson, 1970; Jutel, 2019; Lupton, 2012). They are socially recognised as possessing specialised forms of knowledge, primarily gained from professional training, their practical experience, and with oversight through registration with professional boards (see Freidson (1970); although this can vary amongst complementary and alternative medicines.

It is this professional knowledge and social standing that enables healthcare professionals to be in a position to provide explanations to patients regarding what they might be experiencing subjectively. Medical doctors (amongst other healthcare professionals) additionally have the moral and legal right to diagnose conditions based on these symptoms. This knowledge is given further credence and legitimacy based on physical or psychological assessments they can conduct with patients (with their consent) (Britten, 2001; LaFrance & McKenzie-Mohr, 2013).

The role of “knowledge-provider” can serve a comforting function to patients, who might be seeking reassurance and support for what they are subjectively experiencing. Similarly, as discussed in the preceding chapter, diagnoses themselves can have a legitimising effect for patients, in giving a name to any peculiar or unusual symptoms (LaFrance & McKenzie-Mohr, 2013). Indeed, healthcare professionals might even detect signs (e.g., elevated heart rate, blood test results) that give support to a patient’s felt symptoms, to support their sense they are not “making it up” (although see LaFrance & McKenzie-Mohr, 2013 for a discussion of stigmatising labels). This need for legitimacy is, furthermore, strongly tied to the broader social capital attached to diagnostic labels (Jutel, 2010a).

There are, however, also limitations to the knowledge and ability of healthcare professionals, as well as to any assessment measures, not to mention any differences in opinion, or invisible or undetectable symptoms that could be at play. Dealing with uncertainty can be a challenging experience for healthcare professionals, as it contradicts the role of knowledge-provider, as being seen to be experts or diagnosticians (Fox, 2000; Parsons, 1951). Likewise, the experience of invisible symptoms can be littered with tensions between a patient and healthcare professional, when they are not recognised and legitimised by the healthcare professional, or discounted as “psychosomatic”, “undifferentiated”, or “not otherwise classified” (Jutel, 2010a). This can have a damaging function for people seeking help, leaving them feeling silenced or stigmatised (Armentor, 2017).

Treatment-provider

Subsequently, as knowledge-providers, healthcare professionals are in a position to offer patients options (where applicable) or instructions for treatment to consider. Healthcare professionals can thus also play a role as “treatment-providers”.

This role is traditionally characterised by healthcare professionals taking up a relatively directive approach, acting in a position of power in relation to patients, while patients are expected to take up a position of compliance or adherence, as discussed above (Parsons, 1951; Stevenson, 2004). Taking medicine as directed, changing one’s behaviour, undergoing surgical treatment, and so on, all require a patient accepting and adhering to such instructions in an ongoing way. As acknowledged earlier, this uneven power dynamic is frequently justified from a medical or health services perspective as being necessary for achieving successful health outcomes for patients and healthcare services (Lutfey, 2005; Sluijs et al., 2006; Treharne et al., 2006). Medical (and psychological) treatment—especially curative treatment—also holds the promise of relieving a patient’s suffering (Cassell, 1983), and therefore serves as further justification for the directive function of treatment-provision. Indeed, patients and their families can be seen to accept or take up the role of following treatment directives in the hope of surviving, or even out of a sense of moral responsibility to do everything possible to get better (Tate & Stivers, 2025).

More nuanced analyses of patient-healthcare professional interactions are starting to demonstrate how treatment provision involves a complex negotiation between healthcare professionals and patients to achieve concordance. Drawing on interviews with cancer patients, MacArtney et al. (2020), for example, illustrate the way patients can position themselves ambiguously relative to their doctors, as seemingly having less power than their doctors while still presenting themselves as feeling “cared for” or having a positive relationship with them. This complicated power dynamic is well illustrated in one of their participants’ comments:

I think once you put yourself into the hands of the experts, let them get on with it and follow their advice. [er] That’s what I have [erm] learned all my life and certainly in medical terms [erm] it, it seems absolutely clear to me that [erm] they know what they are doing… And they are at pains to [er] at the end of each discussion so when “Have you got any questions at all?” They are at pains to have their brains picked, so there was absolutely, there was no problem whatever about not being kept informed. At no point did I feel I was being somehow not taken notice of. People were very concerned to make sure that I knew exactly what was going on at every stage (MacArtney et al., 2020, p. 850).

MacArtney et al. (2020) argue that patients’ interactions with their doctors—and what they want from their doctors—depend on the interpersonal and contextual factors of any interaction (which can change over time and place). For example, participants in their study indicated they wanted doctors to exercise good interpersonal skills, to demonstrate care and respect toward them, and to hold space for their questions or emotional responses to the diagnosis or treatment (much like what is suggested in The Guardian article). This did not necessarily equate to doctors giving them equal partnership. Instead, patients positioned doctors as still responsible for gauging the appropriateness of information sharing (when it was too much/too little), and of directive behaviour (of needing to “nanny” or to share decision making), and to act on their expertise and make—or even direct—decisions when appropriate (MacArtney et al., 2020). As they conclude:

To be cared for was not understood as an imposition upon a person’s freedom when it was part of a healthcare process in which the patient feels engaged as a human in the right way. Moreover, being affected, but not directed, by their doctors was often desired by the patient as a way to lessen the emotional and practical burdens of the process of a cancer diagnosis (MacArtney et al., 2020, p. 856, emphasis added).

This study demonstrates the need to move away from understanding the patient-healthcare professional relationship as a dichotomy of power, and rather explore the way both parties might experience this as a negotiated, complex process of interaction.

Gatekeeper

Healthcare systems are complex in the stratified levels of the disciplines and seniority of healthcare professionals of which they are made up. Most typically, however, they are structured in terms of primary and secondary care through a process of gatekeeping. Members of the public are (only) able to access primary care by directly making an appointment, for example, with a clinic or health service. Primary care is usually made up of general practitioners (GPs), psychologists, nurses, nurse practitioners, midwives, health improvement practitioners, and other allied healthcare professionals (e.g., physiotherapists). Healthcare professionals working in this space are required to have relatively generalised knowledge to be able to assess, diagnose (where applicable), and/or treat a host of problems that people can experience in relation to their health.

Because of the scarcity of specialists in healthcare systems, healthcare professionals within primary care (most often GPs) are positioned to act as gatekeepers (Loudon, 2008), determining which patients present as severe or concerning enough to require a referral to secondary care, or who might require referrals to specialist tests or screening. The arguments for this gatekeeping role are most often made based on promoting lower hospital use, ensuring lower healthcare spending, and better quality of care—although this has been found to occur to varying degrees of success (Sripa et al., 2019).

At both primary and secondary levels of healthcare, healthcare professionals also act as gatekeepers to medicine or treatment of some kind. It is only through the recognition of a patient’s symptoms (through diagnosis) that a patient can ordinarily receive pharmaceutical, medical, or surgical treatment (Jutel, 2010b). Furthermore, as Jutel (2010b) points out, it is through diagnosis that doctors (and other relevant healthcare professionals) can grant patients certain allowances, such as sick leave, disability parking permits, and so on (p. 6). Having access to these allowances, however, requires recognition that a person needs—or even (in neoliberal terms) “deserves”—them.

Broker

Central to the role and values of being a healthcare professional is the sense of being a patient advocate (Schwartz, 2002). Healthcare professionals are often in a position to act on behalf of patients, to advocate for them, but borrowing the term from Broom et al. (2016), I use the term “broker” to capture the dynamic negotiation this role requires. As Stovel and Shaw (2012) originally put forward:

…people situated between distinct social worlds collect and channel scarce information in ways that make things happen. When people—and occasionally organizations—make introductions, help us find jobs, advocate on our behalf, or make sense of the world for us, they act as brokers (p. 139, emphasis added).

In other words, it is not always simply a case of a healthcare professional putting the needs of a patient forward, but sometimes actively working to negotiate towards a deal, an outcome that works in the interests of their patient. Stovel and Shaw (2012) explain:

The crucial characteristics of brokers are that (a) they bridge a gap in social structure [where something is wrong or missing] and (b) they help goods, information, opportunities, or knowledge flow across that gap (p. 141, words added).

In their Australian study of antibiotic use in hospitals, Broom et al. (2016), for example, examined the role that nurses play in challenging or re-directing physicians’ antibiotic decisions to start, continue, or stop their use. This is discussed by nurses as occurring all within the context of new guidelines to rationalise antibiotic prescribing, the professional hierarchy within the hospital setting, and their sense of advocacy for patient wellbeing.

The work of MacArtney et al. (2020) similarly demonstrates moments of brokerage—where healthcare professionals are seen to broker access to secondary care (seeing a specialist, having further testing) at the request—or persistence—of patients. This is demonstrated in this extract from MacArtney et al. (2020):

The participant was a hospital doctor, whose story started with a description of the difficulty that she had getting a referral for further investigation from her GP. She had seen the GP twice, who had suggested the bleeding she was experiencing was due to constipation. Frustrated, and facing a third appointment with her GP, the participant spoke to a surgical colleague when at work, who was able to help her,

So then he takes – exactly what one loves – he takes over… So he took me and we went straight out to the nurse who you make appointments with, and so I got the [laboratory] referrals and so I got the appointments – everything I needed (p. 854).

In this example, it is evident there is a sense of breakdown within the interactional process of referral, between the participant (as patient) and her GP, of feeling discounted and frustrated, to the point of circumnavigating the usual referral pathway, resulting in a colleague reportedly brokering this access to further testing on her behalf.

Another example is provided by a GP in the US, who describes himself as acting as a “quarterback” for his patient, a woman who was highly anxious and unfamiliar with accessing the healthcare system but required it for assessing a breast lump.

In this example, the GP notably presents himself as going above and beyond to allay a woman’s fears, primarily by continuing to advocate for her access to secondary care services and to follow her through the process, rather than losing contact after the point of primary care. Earlier, the referral made between primary and secondary care was discussed in terms of healthcare professionals acting as gatekeepers. Here we can see the term gatekeeper is not always appropriate, nor meaningfully captures what occurs between patients and healthcare professionals in the pursuit of healthcare.

The role of broker also brings up questions of power and who holds it within the healthcare professional-patient relationship. As evidenced in the example drawn from the study by MacArtney et al. (2020), this is not always simply doctors using their positions of power to benefit patients. What we saw in that example was the way the patient presented herself as actively playing a role in acquiring the support (a hospital physician) to broker the gap between her experience and the healthcare service she needed. Of course, like any interaction, any examples of such interaction need to be examined within the particular social context in which they play out. In this case, the patient could be seen to already hold significant social capital, as a doctor herself, with contacts (colleagues in the hospital) to benefit from such brokerage. This opens up interesting opportunities to explore how patients and healthcare professionals might negotiate decision making in the pursuit of improving a patient’s health and access to healthcare.

Negotiating decision making in healthcare

For the rest of this chapter, I explore the relationships and interactions between healthcare professionals and people seeking healthcare, using the example of sexual and reproductive health framed through a lens of reproductive justice.

I now turn to reproductive decision making in another healthcare setting, oncology treatment in Australia. The case study has been adapted from an article by Rowlands et al. (2024), highlighting key arguments they make concerning women’s experiences of treatment decision making for gynaecological cancer in Australia.

In the following interactive section, I explore the tensions that women can find themselves experiencing: between the value and critical timing that is placed on fertility decision making and on cancer treatment, the active negotiation (reported) between women and their oncologists in this process, and the difficulties of trying to manage competing priorities within a particular sociocultural context that values both survivorship and motherhood.

Conclusion

In this chapter, I have explored the issue of healthcare professional-patient relationships and how these are shaped, not only by one-on-one interactions within a particular moment but also by broader and deeper sociocultural, historical, and economic contexts. I discussed how this plays out within a power dynamic between patients and healthcare professionals. This dynamic has historically occurred in a hierarchical, patronising way, with healthcare professionals (particularly doctors) holding all decision-making power. However, with broader sociocultural forces at play, patients have progressively been able to take on more engaged roles concerning their healthcare. Healthcare professionals can also be seen to perform varying roles when interacting with patients, which can involve differing degrees of power and negotiation. I have drawn on several case studies throughout the chapter to illustrate how these interactions can occur. I have also drawn on theoretical contributions in health psychology and related disciplines to help understand their complexity. As I have argued throughout, taking a critical lens to these interactions entails looking beyond individual factors to consider the deeper, underlying context in which they occur, and the implications they might have for people from a variety of sociocultural locations.

Acknowledgement

Thanks to Tracy Morison for her assistance with formatting the interactive exercises and the chapter layout, and for helping to source additional content.

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