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Review Article Pol J Public Health 2017;127(4): 176-181

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Review Article Pol J Public Health 2017;127(4): 176-181 Review Article Pol J Public Health 2017;127(4): 176-181 Michał Skrzypek The social and clinical determinants of proportions between paternalism and partnership in therapeutic relationships in medicine Abstract The subject of the article are the contextual determinants of the formula of the therapeutic relationship in medicine with regard to the proportions between paternalism and partnership. The article was inspired by the results of two recent editions of the Organisation for Economic Co-operation and Development (OECD) “Health at a Glance” studies of 2015 and 2017; in their light, Poland ranks at the bottom of ratings concerning patient satisfaction with communication with doctors. According to these studies, the therapeutic relationship in medicine in Polish society appears to be petrified in the paternalist formula, not suffi- ciently taking into account the autonomy and agency of patients. Based on the analysis of the determinants of a broader tendency, described in Western studies, consisting in the wider development of partnership relationships between doctors and patients, the study will show individual barriers, social ones, including structural and institutional, as well as clinical barriers to implementa- tion in medical practice of the partnership model of therapeutic relationships in medicine, which assumes the active involvement of patients in clinical decision-making as well as in the processes of medical treatment. Keywords: physician-patient interaction, empowerment, socioeconomic status, social health inequalities, paternalism and partnership in medicine, medical sociology. DOI: 10.1515/pjph-2017-0038 INTRODUCTION and, as a result, Poland is placed at the bottom of the ranking of the level of patients’ satisfaction with communication with The article focuses on the problem of the determinants of doctors [5,6]. proportions between paternalism and partnership in medicine Let us examine particular results of the studies. The dura- and also on the related issues of the empowerment of patients tion of a visit in the edition of 2017 was evaluated as satisfac- in the therapeutic relationship which will be shown as a ne- tory only by 59.6% of Polish patients; (only Japan was worse cessary condition for the active participation of patients in the – 39% of unsatisfied patients), the average for OECD-18 be- process of medical treatment. Investigation of these problems, ing 81.3% of satisfied patients. In this aspect of studies, in the not only in the field of social sciences (included by the author previous edition of the “Health at a Glance” studies of 2015, of the present study in the earlier publications) [1-4] but also in Poland ranked as the last (the average for OECD 19 countries the field of medicine and public health, is justified in the con- was then 84.9%). In the case of countries with the highest notes, text of the results of two recent editions of the OECD “Health the percentage of satisfied patients was, for example, 97.5% at a Glance” studies of 2015 and 2017, whose aim was to as- in Belgium, or 97.2% in the Czech Republic. In the category sess the quality of communication with doctors in outpatient concerning the explanation of medical problems in a clear and care. The studies included, inter alia, the following aspects of intelligible way (the patients were asked about their experien- the doctor-patient relationship: devoting enough time to the ces with their regular doctor), the highest scores were achieved patient, explaining the medical issues to the patient in a clear in 2015 by Belgian doctors (97.8%) and Luxembourgian doc- and intelligible way, and involving the patient in the decision- tors (97.5%), the average for OECD-19 being 87.9%; accord- making process. The results concerning each of the aspects ing to Polish respondents, only 69.5% of doctors fulfilled the of the doctor-patient relationship assessed in the project in criteria (it was then the bottom ranking in this category). In both editions of the program were unfavorable for Poland. 2017 Poland also came last (with the average for OECD 17 They suggest that the therapeutic relationship in medicine in being 88.9%). The next aspect of the studies concerned the the realities of Polish society is petrified in a paternalistic for- involvement of patients in the decision-making process: mula and does not sufficiently take the agency of patients into in 2015 only 47.9% of patients in Poland had such an experi- consideration. The Poles, in comparison with citizens of other ence. The average for OECD-19 countries was 81.3% in the OECD countries, do not very highly evaluate the state of reali- same year; the best evaluated were doctors working in Lux- zation/implementation of the partnership model of the thera- embourg (95.5% of satisfied patients) and Belgium (95.1% of peutic relationship in the Polish system of health protection, satisfied patients) [5]. In 2017, Poland also came last in this Dept Clinical Dietetics, Medical University of Lublin, Poland © 2018 Medical University of Lublin. This is an open access article distributed under the Creative Commons Attribution-NonComercial-No Derivs licence (http://creativecommons.org/licenses/by-nc-nd/3.0/) Pol J Public Health 2017;127(4) 177 ranking (the average for studied OECD countries was 83% of power which enables him/her to undertake active measures satisfied patients). Thus, the position of Poland at the bottom regarding health and treatment issues. In the course of further of the ranking did not change in 2017 in comparison with the analysis, the social determinants of the patient’s empowerment results of the previous edition of studies. In the earlier analy- on health issues will be specified. sis conducted by A. Ostrowska, who based her studies on the Historical changes in the doctor-patient relationship from results of European Health Survey (EHS) of 2004, Poland also the sociomedical perspective occupied the last position in the group of 17 European coun- tries on the scale of cooperation between doctors and patients, The doctor-patient relationship is a sine qua non condition which meant that therapeutic relationships were at that time for medical practice (excluding special situations e.g. when evaluated by Poles as paternalistic [2]. Taking the presented the patient is unconscious) and the quality and formula of this OECD results into consideration, one can state that the situa- relationship, including the proportion between paternalism tion diagnosed as part of the EHS did not change significantly and a partnership, influences the effectiveness of treatment and [5,6]. the level of patient’s and doctor’s satisfaction. Sociomedical analyses with such characteristics are located within a branch The patient’s agency regarding health issues as a factor of the sub-discipline called “sociology of medicine” by Ro- determining the degree of retained autonomy in the thera- bert Straus [9]. They were initiated by an American sociolo- peutic relationship gist Talcott Parsons who, in the 1950s, described the model In view of the quoted results, the analysis of determinants of doctor-patient relationship as a model of compliance or of proportions between paternalism and partnership in the a model of complementary social roles [10]. He then suggested doctor-patient relationship, and particularly the search of the that both sides of the relationship need each other and despite causes of the situation in which therapeutic relationships in differences in the attitude to the illness they cooperate because Polish medicine seem to be fixed on a paternalistic formula, they are inspired by the same aim i.e. seeking to recover from is justified. While undertaking the analysis with such profile, illness. Parsons stressed that the status of participants in the some starting observations should be made. The author a- therapeutic relationship in medicine is not equal: the doctor dvances the thesis that the paternalistic formula of the doctor- has an advantage of power and “technical” competence be- patient relationship should be treated as a customary, reac- cause s/he has exclusive rights regarding treatment [10] and tive formula of treatment, dependent on the social, clinical, possesses the prerogative of legitimizing the social role of and individual specificity of a concrete therapeutic situation the patient. According to Talcott Parsons, the doctor-patient [cf. 7] rather than as a basic, starting pattern or a model of relationship is of paternalistic character [10] and is character- the therapeutic relationship from which one lean more towards ized by distinct asymmetry: the doctor has power, authority a strongly marked partnership. A partnership model is the ba- and a dominant position, s/he is an expert-professional and sic model of the therapeutic relationship because it constitutes the position of the patient is characterized by dependence and an expression of indispensable autonomy and the right to self- subordination [11]. The model of the therapeutic relationship determination of an adult patient. As Jan Hartman, on the ba- described by Parsons, which is an element of the sociologi- sis of bioethics, writes, “autonomy is not something that the cal description of American society of the 1940s and 1950s, doctor gives the patient […] autonomy is something that the became a starting point for chronologically subsequent so- patient possesses independently from the doctor’s views on the ciological analyses in which attention was focused on the issue of paternalism” [7]. In turn, in the sociology of medicine, process of changes in doctor-patient relationships consisting A Ostrowska stresses that in the realities of medical practice in shifting towards partnership in the therapeutic relationship both models of the therapeutic relationship (i.e. the paternalis- in medicine. It was stressed that this was a consequence of the tic model and partnership model) rarely occur in a pure form declining social status of medicine and of the growing agency and doctors face the situations which can be located at va- of laypeople in the processes of healthcare.
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