Blog | Tuesday, May 8, 2012

QD: News Every Day--Authoritarian doctors and the fear of being labeled 'difficult'

Surely, it's not the first time the television comedy "Seinfeld" was cited in the scientific literature, was it? A study in Health Affairs interviewed patients on why they don't challenge their doctors more often on shared medical decisions, and the answer was clear. They don't want to be labeled as "difficult" for fear of reprisal.

Study participants were recruited from three primary care practices in Palo Alto, California, an affluent suburb in the San Francisco Bay Area. Data collection took place between October and December 2009. The patients trended to be older than 50, affluent and well-educated.

Forty-eight patients first watched a video that depicted equal and reasonable alternative to treat coronary artery disease and then broke out into focus groups. Four themes emerged.

Patients feel compelled to conform. Patients want collaborate with their physicians in making clinical decisions, but they also noted that their ability to do so depended on the physician. They described a sense of needing to adopt the role of a "good" patient and awareness that questioning a doctor raised the impression of challenging their expertise and raising the risk of reprisals.

Physicians can be authoritarian. "Although participants recognized the expertise of physicians, they also felt that the authoritarian stereotype was often perpetuated by physicians themselves," the authors wrote.

Patients work to fill information gaps. Patients reported seeking online information, either to not "rock the boat" with the doctor or because the allotted visit time left them with no other option.

Patients feel the need to bring social support to the consultation. participants talked about bringing family members or friends into clinical encounters, to help take notes, assimilate details and ask questions.

"Knowing they may need to return at some later time, participants felt they were vulnerable and dependent on the good will of their physicians. Thus, deference to authority instead of genuine partnership appeared to be the participants’ mode of working," the authors wrote. "These findings are striking, given that participants were mostly wealthy, highly educated people from an affluent suburb in California, generally thought to be in a position of considerable social privilege and therefore more likely than others to be able to assert themselves in a medical consultation."

The authors suggested a few steps to alleviate the problem: adequate reimbursement, decision support tools, increasing efficiency and directly addressing the difference in perspectives with physicians. They didn't provide an entry in the study references for the Seinfeld episode, but the clip about the character of Elaine being labeled difficult is here.