5.1 A General Model of The Doctor-Patient Encounter

The physical setting of the doctor-patient encounter is invariably a ‘medical space’ — a hospital or consulting room with all the usual medical paraphernalia. The setting is completed by the subject positions, relations, and contents of the discourse type. Normally it is immediately and visibly apparent who is the doctor, the patient, the nurse etc. Fairclough comments: ‘There are requirements for modes of dress which reinforce properties of the setting in defining the encounter as medical’ (1989: 59). Fisher (1982) in her two-year study of women with abnormal Pap smears found a clearly established set of relations between doctor and patient:

Patients enter medical interactions in positions of relative weakness. They have an abnormal Pap smear and feel threatened by the possibility of a cancer-related medical problem. They enter unfamiliar surroundings in which all of the other participants seem to share a common language. This language is, for the most part, unintelligible and frightening to them. (p.59)

Doctors, however,

are in their ‘home courts’…They understand and have some control over the working of the hospital and clinic bureaucracies. The specialised jargon of medical talk is their professional lexicon. They have knowledge and skills which are basically mysterious to patients. It is from a position of relative strength that practioners greet patients and medical interview begins. (p.59)

Marsh (1981), who studied some of the social factors involved in medical encounters, would add that this power is further reinforced by the doctor’s class status. The patient, who has little control over the format of the encounter, is further weakened on many occasions by having a lesser social status. Additionally, the patient is in a position of vulnerability as it is his body and health that are subject to scrutiny (p.545).

Two forceful pieces of evidence for this asymmetrical power relationship come from Fairclough and Laing. Fairclough, whose data in this discourse type comes from Emerson’s (1970) study of gynaecological examinations, quotes from a resumé of what medical staff believe should be the correct behaviour of patients in such examinations: ‘Her role calls for passivity and self-effacement…The self must be eclipsed in order to sustain the definition that the doctor is working on a technical object and not a person’ (p.60). Laing (1961) remarks on some patient’s willing acceptance of the passive subject position in psychiatric encounters:

Some ‘psychotics’ look on psychoanalysis as a relatively safe place to tell someone what they really think. They are prepared to play at being a patient and even to keep up the charade by paying the analyst, providing he does not ‘cure’ them. They are even prepared to pretend to be cured if it will look bad for him if he is having a run of people who don’t seem to be getting better. (p.43)

Such a power differential is confirmed by the contents of this discourse type. “The sequence of events which constitute the examination is highly routinised, following a standard procedure, and this routine properly extends also to the verbal and nonverbal aspects of the ways in which medical staff relate to patients. (Fairclough p. 59). Thus the gaze of staff will be one of disengagement. They avoid using words which might embarrass patients, using euphemisms instead. Marsh’s study focused on how a degree of impersonalisation between doctor and patient is achieved through language. For example, the routine sentences,

Are you having pain?

Is your hand stiff?

can be replaced by the following impersonal alternates,
Is there any pain?

Is the hand stiff?
(p. 546)

Further, there are constraints on topic and who controls topic. Fairclough points out that in gynaecological examinations only questions and comments on medical-related matters were allowed (p.59). Marsh notes, with regard to general medical examinations, ‘verbal roles are asymmetrical with the physician being primarily the questioner and the patient primarily the respondent. Patients do of course ask questions. Yet the physician is in a position to define a question as irrelevant or unimportant’ (1981:545). Fisher found that while Questioning, Presentational, and Persuasional Strategies were used as interactive mechanisms to accomplish treatment decisions, “Only practitioners use Presentational and Persuasional Strategies’ (1982:60). Presentation Strategies provide information to a patient while suggesting how a patient should make sense of it. Persuasional Strategies provide information while specifying how it should be understood. Evidently, if one participant in a negotiation can suggest and even specify how meaning is to be interpreted, then power rests with her (p.60).

Thus, it is clear that in the general model of the doctor-patient relationship presented here, that in terms of power within the interaction, it is the doctor who is the more powerful participant in most respects.