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25(4)319-329,1995
PETER SALMON
CARL R. MAY
ABSTRACT
Objective: Extensive empirical data and theory describe the inequality of
power in relations between doctors and their patients. However, the focus has
been on the ways in which doctors control the doctor-patient relationship.
This has meant that the extent to which patients influence the consultation,
and the ways in which they do this, have been neglected. Methods: In this
article, we use a single case to identify and illustrate distinct ways in which
patients exert power to determine the outcome of consultations. Conclusion:
This analysis leads to a more powerful explanation than is presently available
to understand the somatization of psychological needs. According to this, the
patient organizes strategies, which include the presentation of emotional and
social distress, around a biomedical model. Because of their prior decisions as
to their role, doctors permit themselves to be trapped in this model.
(/nt’/.J. Psychiatry in Medicine 25:319-329,1995)
319
(9 1995, Baywood Publishing Co.,Inc.
doi: 10.2190/JUNY-QCER-GWLF-H60R
http://baywood.com
320 / SALMONANDMAY
imbalance has been attributed to the power with which the scientific authority of
medicine can overwhelm patients’ own models of their bodily disorders [4].
In addition to broad issues of power relations between doctors and patients,
research has closely examined the ways in which doctors control the consultation
and mold patients’ behaviors [5, 61. There is detailed evidence of the ways in
which general practitioners [7] and hospital doctors [2] structure the consultation
so as to preserve their authority at the expense of the patient’s ability to influence
its course. These tactics include closed interviewing techniques, restricting infor-
mation, use of medical jargon, focusing attention on somatic rather than emotional
concerns, and responses that reflect, not just patients’ medical need, but social
dimensions of age, sex, social class, or ethnic origin [8,9].
patient’s influence had taken and because its detection was simplified by the
absence of significant objective pathological signs. A further simplification is that,
as a patient within the UK National Health Service, neither her nor her doctors’
decisions could be influenced by fee-for-service. The case therefore represents the
use of purposeful extreme-case sampling to develop and illustrate a theory of
general relevance [30, 311. The case study is based on two sets of data. First, the
patient was interviewed for fifty to sixty minutes on each of two occasions by one
of the authors (PS). Second, the patient’s medical records were read in detail by
both authors and used to chart her recent career of medical and surgical inter-
vention. The letters included in these records contained further evidence of the
way in which she presented to doctors.
THE CASE
History
Mrs. CS (age 47) was referred by her general practitioner in December 1992 to
a surgeon. She complained of a pain in her right breast dating from surgical
reduction by a different consultant early in 1992. Mrs. CS requested mastectomy
as the solution, although the firm opinion of the examining consultant was that
surgery was not indicated by objective signs.
By way of background, CS had been without any significant recorded medical
history, apart from a cholecystectomy, before her husband left her in 1983. He had
left her and their eight children for a much younger woman, to whom CS had
previously introduced him. Two years later her husband, now spumed by his new
partner, began pressing his wife to accept him back. She refused, still feeling bitter
and angry toward him. In 1984, CS presented with abdominal pain which led to an
appendectomy and then with menorrhagia, for which she underwent hysterec-
tomy. A few years later she developed backache which she attributed to the weight
of her breasts. Approximately 1 kg of histologically normal tissue was removed
surgically from each in March 1992. She was discharged from follow-up in March
but returned in April complaining of pain in her right breast. Fat necrosis was
discovered, containing a little fluid that was drained before she was once again
discharged in May. The pain returned and, in June, another referral requested
“urgent” treatment. The pain resolved for a while after an exploratory operation in
August (which again confirmed fat necrosis). Meanwhile she had been referred
to a plastic surgeon because she sought surgical removal of abdominal fat. He
examined her in August and declined to offer what he considered to be cosmetic
treatment. In December her GP referred her to a different surgeon for treatment of
her breast pain. He examined her in December, noting that she appeared depressed
and that surgery was not indicated. Unproductive referrals to a pain clinic and a
clinical psychologist followed, where she insisted on the need for mastectomy and
was unwilling to contemplate other treatment. In December 1993 the surgeon
322 I SALMONANDMAY
neurological models, pain and fatigue are widely accepted as requiring medical
explanation and treatment. By this analysis, the power that symptoms give
patients such as CS is entirely contingent on the doctor’s choice of a model in
which pain alone, if sufficiently intense, justifies somatic treatment. It is possible
to use a different, broader model which encompasses evidence that the experience
and report of physical symptoms reflect psychological and social processes
[25, 26, 28, 34, 351 and its adoption by CS’s doctors would have allowed them
greater freedom to choose an effective non-organic response which did not deny
her experience of pain.
Suffering
A second element in CS’s account was the distress and psychosocial disruption
caused by her symptoms: that is, her suffering. She richly described the distress
caused by the pain: how “it’s unbearable” and how “it makes me feel like
screaming” or how she would “lie awake all night” with an ice-pack to her breast.
She described being tearful and having been forced to withdraw from life apart
from looking after her daughters: “all day I’ve got nothing to do”; “I need
something in life.” Although she did not report problems in dressing or moving
about the house, she explained that she could no longer knit (previously her main
pastime) because of the pain she would feel should a knitting needle touch her
breast through her clothes, that she could no longer swim because of the pressure
of the swimming costume on her breast and that she could no longer work as
a waitress because of the danger of someone brushing past her. Her account
extended to describe the suffering of the three of her daughters who still lived with
her: “I don’t have to say the pain’s bad; they can tell just by looking.”
This aspect of her presentation strengthens her influence over the doctor in two
ways. First, she strengthens her expert position by increasing the amount of
subjective or nonverifiable information about the intensity of her symptoms.
Additionally, by telling the doctor about her suffering, CS is giving him the
responsibility for managing it: he has now to be concerned, not only with her
symptoms, but with the poor quality of her life. The surgeon’s decision to operate
might be attributed to lack of time or resources to respond more effectively to the
patient’s distress [36]. However, his behavior also reflects agreement to take
responsibility for his patient’s distress. That is, the power that the patient acquires
by reporting suffering is contingent, not only on organizational constraints on the
doctor’s behavior, but also on decisions made by the doctor.
Coercion
Threat is implicit in many of CS’s statements of suffering: “sometimes I want to
pull the ceiling on top of me.” Here it was metaphorical, but often it was explicit:
“I’ve wanted to top myself twice, but I phoned the doctor [her general prac-
titioner] and she’s come and spoken to me.” Her discharge from the pain clinic
back to the surgeon was accompanied by a warning that “she feels like doing
324 I SALMONANDMAY
something to herself.” More dramatically, she threatened that “I’ll take a knife to
myself [to cut her breast]; then the doctors will have to do something about it.”
CS’s threats were restricted to herself. Other patients have described threats to
their spouses. “I don’t think he’ll cope much longer” or children “They’re living
half a life while I’m like this”; “I’m frightened what I’ll do to them.” These
statements are coercive: they transparently exert strong pressure for intervention.
Once again, however, the power that they give the patient is contingent on the way
that the doctor views a failure to respond to them. In particular, because of the
adoption of a model that assumes that physical symptoms are, in principle, always
explicable or remediable by physical medicine, their persistence would be per-
ceived as professional failure. The doctor has taken on the responsibility for his
patient’s suffering that the patient has given him. The corollary is the respon-
sibility that he would have for her suicide or self-harm, or even for further
deterioration in her quality of life.
scale [41]. CS has clearly perplexed her doctors: their own explanatory models
cannot explain her presentation. The solution to the problem is to acquiesce to her
model. Here, the patient has pressed a narrow medical model of her problems
upon the doctors. This direction of transmission is. of course, opposite to the
conventional view that doctors press a medical model of illness onto patients.
ACKNOWLEDGMENTS
W e are grateful to Dr. Keith Sharp and Dr. Michael Gopfert for comments on a
draft of this article, and to two anonymous reviewers for their helpful comments
on the version submitted to the journal.
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Peter Salmon
Department of Clinical Psychology
University of Liverpool, Whelan Building
P.O.Box 147
Liverpool L69 3BX, United Kingdom