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Name: Brendan Schultz n8090831 Tutor: Katie Page

=‘At This Place Everyone Gets The Same Quality Of Healthcare'=

Australia is distinctly recognised throughout the world as a multicultural society that promotes, fosters and endorses the unity of various cultures under one amalgamated banner. The ramifications of sustaining such cultural diversity are having increasingly prominent effects on many aspects of daily life most notably the delivery of healthcare. Questions are being asked on the ability of primary and emergency service providers to be culturally ‘clued-in’ or aware of social and ethical obstacles that are attached to the convoluted topics of sex, pain and death. To attain an understanding of the actual legitimacy of such claims a detailed analysis of the doctor-patient relationship which forms the foundations or basis of healthcare must be conducted. Through the appraisal of relevant contemporary literature, the application of ethical, theoretical and philosophical analysis in conjunction to the examination of a socially constructed artefact the perceived issues surrounding the doctor-patient relationship and the subsequent administration of healthcare will be reviewed.

. **Cultural Artefact **

The doctor-patient relation is represented within contemporary society in a number of differing ways. An example of this relationship is illustrated within the socially constructed representation cartoon seen below (Russmo 2007). The author of this picture, known only by his pen name ‘russmo’, is an American born cartoonist who spent over a decade living and publishing work within Australia. This cartoon cleverly comments on the doctor-patient relationship through his depiction of the current delivery of healthcare.

**Public Health Ramifications Of A Lack Of Cultural Awareness **

Healthcare is perceived by many as a primitive human right that should be equally available to all those who require it regardless of their religious, economical or ethnical background or beliefs. Despite this common held ideology, disparities in the availability and effectiveness of healthcare among minority racial and ethical groups within Australia are becoming increasingly prevalent across the healthcare continuum (Betancourt, Green, Carrillo & Ananeh-Firempong 2003). These inequalities that marginalise various cultural or ethical groups render them more susceptible to developing disease or illness, which in turn effects all of the population who through taxation support and fund the public health system. In an attempt to counter this issue significant research has been conducted to attain what particular aspects of healthcare are contributing to this problem. Highlighted or ‘earmarked’ from this research has been the relationship which has been identified as most influential factor responsible for of this summating issue. Acknowledged concerns surrounding this relationship are the power or authority given to doctors and the lack of cultural competency or awareness many doctors exhibit; these issues subsequently have detrimental implications on the development of rapport, effective communication and the overall relationship that is formed.

**Literature Review ** The doctor-patient relationship is becoming an increasingly well documented focus of scholarly investigation with a number of studies and investigations being commissioned to attain further knowledge on this topic.

The doctor-patient relationship has unquestionably undergone significant transformation to become the working affiliation it now represents within contemporary society. This relationship was once characterized by a paternalistic model of delivery where a patient seeking medical assistance would compile with the decisions made by their doctor without hesitation, rendering the doctor absolute power or authority over the patient (Kaba & Sooriakumaran 2007). This is exemplified through a study conducted by Beckman & Frankel (1984) on the influences a health physicians behaviour has on the attainment of the patients compliments found that of the 74 consultations that were monitored in this study, only 17 cases (23%) of these cases did the patient complete their opening statement of concerns. In 51 (69%) of these consultations the physician interrupted the patients statement and directed questions to this particular concern. This study demonstrates the authority figure the doctor plays in the interaction between doctor and patient, with the doctor having complete control of proceedings.

There are a number of limitations from this study must notably its year of publication and the small sample size that was analyzed. These limitations were addressed in a comparative study by Marvel et al in 1999 which produced similar results. Of the 199 consultations included in this study, only in 74 (27%) cases did the patients complete their initial statement of concern. Gill (1998) in an observational study on the interactions that occur between a doctor and patient, it was found that when patients exhibited tentativeness or uncertainty about their concern or the symptoms they are experiencing, they also tentatively invite the doctors to give his assessment adopting his views on their health issue. This study again highlights the unquestionable authority or higher figure given to the doctor over the patient in this relationship.

The unopposed power doctors have received in the past can be attributed to some of the health inequalities still prevalent today within Australia, as doctors were placed in a position to treat patients at their own discretion which in some cases resulted in the abuse of this right. The much publicized ‘doctor death’ events that occurred in Queensland are a poignant example of a drastic misuse of power by a doctor that unfortunately resulted in the significant mortality and morbidity to the patients he treated. While this is an exceptional excessive instance of the exploitation of doctor power, the real ramifications of power issues are doctors ability to assume moral superiority promoting their own opinion on treatment and hence exerting undue influence, or offering ‘inferior care due to stereotyping’ (Parker 1997). This subsequently has resulted in discrimination, for example by race, gender or socioeconomic status reducing a patient’s access to service and lowering the quality of care that they will receive (Goodyear-Smith & Buetow 2001). In contemporary society there has been a identifiable shift in power in the doctor patient relationship with a more active, autonomous and patient-centred now prevalent which has endorsed a reduction in physician dominance and paved way more increased mutual participation (Kaba & Sooriakumaran 2007). Power issues are not the sole contributing factor that can be attributed to the inequalities prevalent throughout Australian society with communication being recognized as another central issue.

There is a well acknowledged relation between medical practitioners’ communication skills and their patients’ degree of satisfaction with the medical services the doctor provides. A study conducted by Tumble, O’Brien & Hartwig (2006), investigated the legitimacy of these claims within Australia. This study questioned the satisfaction levels of patients on their doctor following two consultations. Of these consultations one occurred before and after the doctor had participated in an educational workshop that highlighted the importance of effective communication. 75 obstetrician/gynaecologists and 99 general practitioners were utilized within this study, with each practitioner receiving a score out of 60 from their patients. The results of this study found that both general practitioners and obstetrician gynaecologists’ patients recording improved satisfaction with all measured aspects of their doctor’s communication skills following their doctor’s participation in the workshop. The biggest increase that was recorded within the study was the patients’ satisfaction with their doctor meeting their expectations, suggesting that the doctors had developed improved communicational skills thus becoming better attuned to the needs of their patients. These results mirror the findings of Beach, Catherine & Cooper (2008), who found an effective doctor-patient relationship, centres on the quality of a shared understanding on the nature of the patients’ problem in conjunction to the patient’s personal perception.

The importance of effective communication in healthcare has long been established and lies at the heart of healthcare delivery. Moreover, appropriate and sensitive language use is an integral part of this communication process and an essential consideration for embracing cultural diversity and fostering therapeutic relationships (Roberts et al. 2007). At the heart of the doctor-patient relationship is the consultation which is the cornerstone of their working relationship that allows for the development of rapport and mutual understanding between both parties (Booth, Robinson & Kohannejad 2004). This consultation has been the topic of a number of research studies throughout the world.

A study conducted in the Netherlands by Meeuwesen, Harmsen, Bernsen & Bruijnzeels (2006) investigated the relational aspects of medical communication patterns in intercultural consultations in general practitioners’ practices throughout the Netherlands. The results of this study were taken from 144 adult patients’ interviews and video observations of consultations between the patients and 31 Dutch general practitioners with the patient group consisting of 61 non-western immigrants and 83 Dutch participants. The findings of this study were quite surprising with the consultation duration of non-western immigrant patients well over 2 minutes shorter than the interactions with recorded with Dutch patients. The mean duration of all consultations were 8 minutes and 48 seconds respectively, with Dutch patients mean duration 9 minutes and 31 seconds compared to the immigrants’ 7 minutes and 21 seconds. Major differences were noted in the verbal interaction that was observed within the study with doctors investing more time attempting to understand immigrant patients, while showing more involvement and empathy when dealing with Dutch patients. These findings on the differing doctor interactions depending on the race of his patient are interesting when considering the findings of Hellin (2002) who found the importance of an intimate relationship between patient and physician can never be overstated as in most cases an accurate diagnosis, as well as an effective treatment, relies directly on the quality of this relationship.

The relevance of this study to the inequalities is somewhat limited due to the obvious differences in geography, culture and society evident between the Netherlands and Australia, but however some of the trends found may be mirrored within Australia. Unfortunately there are no contemporary studies that have been conducted within Australia to compare and contrast these findings against. The most applicable is a study conducted by Subotsky, Bewley & Crowe (2010) on the generalized duration of a patient consultation within Australia which found 10 minutes as the standard length of an appointment.

**Social & Cultural Analysis ** <span style="font-family: 'Times New Roman','serif'; font-size: 110%;">As represented within the literature presented above, contemporary society has played a pivotal role in fashioning the doctor-patient relationship into its current form. Significant moves that have withdrawn power from doctors and rebalanced it to the patient are being increasing evident. Previously disadvantaged groups such as ethnical minorities or those of a lower socioeconomic standing that have been subjected to reduced accessibility and a lower standard of healthcare have subsequently had this disparity diminished. This reduction in inequality can be in a way attributed to the theories of Michael Balint, who can be considered a revolutionist in his approach to the then unexplored relationship between doctor and patient. Balint did not invent the doctor–patient relationship; however, he was the first to explore this in the context of general practice, in which that relationship remains central despite the huge social and political changes that have affected the delivery of health care in the half-century or so that have passed since his theory’s were first proposed. <span style="font-family: 'Times New Roman','serif'; font-size: 110%;">Balint in his theories formulated the idea that the doctor should be passive and listen to his patient; he should be patient and take his time to research and determine the proper diagnosis and treatment. The all-important role of the family doctor should be donned as opposed to ‘an army of specialists’ were one of his pivotal views that has been adopted contemporarily (Michelle 2002). In this work he introduced the ideas of the doctor as the important drug whose dosage and frequency needed determining, the importance of the initial presenting complaint of the patient, and the apostolic function of the doctor, meaning his attitudes and responses to the patient's complaints and his expectations of the patient. His basic premise was that any emotion felt by the doctor in his immediate relationship with the patient needed to be regarded as a symptom of the illness (Stewart 2002). The general practitioner, urged Balint, should become the doctor of the ‘whole person’ in strict contract to the hospital physician who worked merely within the specific entities of disease without reference to the subjective side of doctoring (Osborne 1993). Balint’s prevalence within modern society is unquestionable with groups that follow his theories known as ‘Balint groups’ becoming common place. Balint groups can be defined as a group where general practice cases are discussed in an ongoing group of peers with an emphasis on the psychological meaning found in doctor-patient communications (Lustig 2005). Over 50% of family medicine training programs within the United States, the majority or Europe and Australia, use Balint groups as part of their physician training programs (Klee 2010) <span style="font-family: 'Times New Roman','serif'; font-size: 110%;">It is these fundamental ideologies that have paved way for the highly effective doctor-patient relationship we experience when visiting our local practitioner.

**<span style="font-family: 'Times New Roman','serif'; font-size: 30px;">Analysis Of Cultural Artefact ** <span style="font-family: 'times new roman','serif'; font-size: 110%; text-align: justify;">A number of the issues that have been presented throughout this analysis are prevalent within the cultural artefact that is presented above. This cartoon cleverly depicts the commonly promoted assumption of the public that everyone regardless of race, religious background, gender or socioeconomic standing will receive the same quality of healthcare from their local health practitioner while demonstrating the repeated, mechanical and impersonal nature of healthcare that is actually delivered. The ‘conveyer belt’ system is illustrated represents the impersonal delivery of healthcare as it represents the patients as numbers or diseases rather than actual people. <span style="display: block; font-family: 'times new roman','serif'; font-size: 110%; text-align: center;">Speaking from the perspective of an individual who has not been subjected to any prejudice or ill-treatment due to belong to a differing race or social class i cannot speak first-hand of any experiences that may mirror what was been aforementioned within this analysis. Accordingly I found the extent and varying degrees in which health inequalities are found within Australia to be simply astounding. In such a modern age where cultural competency and acceptance are such prominent topics within the media and throughout society I did not believe such disparity could occur. This assignment has been extremely useful and I plan to take advantage of the knowledge of have gained during my career within the field of health.

**<span style="font-family: 'Times New Roman','serif'; font-size: 30px;">Learning Reflections **
 * Reflection 1:**
 * [|Face Of Evil]**

Prior to reading your wiki I was rather unaware of what proportion of the population are affected by mental illness, through your use of statistical evidence the magnitude this issue places on contemporary Australia society was clearly demonstrated. The moral and ethical questions you raise on the creation of the stigma associated with this topic were enthralling with your review into contemporary literature complimenting your analysis perfectly.

The utilization of such a prominent figure in Martin Bryant gave reading your wiki and real sense of direction and offered a well-known exemplar of the horrific ramifications this stigma can have on an individual.

Thank you for a captivating read.

Reflection 2:

[|Hit The Nail On The Head]

I agree with all the issue you raise throughout your wiki and feel until as a society we can break free from the <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">patriarchal attitudes of the masculinity roles assigned to males and females significant changes will not be seen

I’m not sure if you may have come across this in your research but the Sepp Blatter the current president of FIFA made a pretty controversial comment on female soccer players saying they should wear tighter shorts to increase popularity which coincides and demonstrates the continuing struggle woman are facing for equality. here a link to it if your interested []

A really well written analysis of the issues females are facing on and off the sporting field.

Thanks **<span style="font-family: 'Times New Roman','serif'; font-size: 30px;">References ** <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Beach, S.S., Catherine, M., & Cooper, L., (2008). Patient centeredness, cultural competence and healthcare quality. //Journal of the National Medical Association, 100//(11), 1275-85 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Beckman, H.B., & Frankel, R.M., (1984). The effect of doctor behaviour on the collection of data. //Annals of Internal Medicine,// //101//(4) 692–696 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Betancourt, J.R., Green, A.R., Carillo, E.J., & Ananeh-Firempong, O. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and healthcare. //Public Health Reports, 118//(1), 293-302 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Booth, N., Robinson, P., & Kohannejad, J., (2004). Identification of high-quality consultation practice in primary care: the effects of computer use on doctor-patient rapport. //Informatics in Primary Care, 12//(1), 75-83 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Gill, V. T., (1998). Doing attributions in medical interaction: Patients' explanations for illness **and** doctors' responses//.// //Social Psychology Quarterly,// //61//(2), 342–360. <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Goodyear-Smith, F., & Buetow, S., (2001). Power issues in the doctor-patient relationship. //Health Care Analysis, 9//(4), 449-462 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Hellin, T., (2002). The physician-patient relationship: recent developments and changes. //Hemophilia, 8//(3), 450-454 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Kaba, R., & Sooriakumaran, P., (2007). The evolution of the doctor-patient relationship. //International Journal of Surgery, 5//(1), 57-65 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Klee, T., (2010). ‘//Michael Balint//’ [|http://drklee.com/balint.htm accessed 2nd November 2011] <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Lustig, M., (2005). Balint groups. //Australian Family Physician, 34//(9), 712 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Marvel, M.K., Epstein, R.M., Flowers, K., & Beckman, H.B., (1999). Soliciting the patient's agenda: Have we improved? //Journal of the American Medical Association//, //281//(8) 283–287 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Meeuwesen, L., Harmsen, J., Bernsen, R., Bruijnzeels, M.A., (2006). Do Dutch doctors communicate differently with immigrant patients than with Dutch patients? //Social Science & Medicine, 63//(9), 2407-2417 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Michelle, M. R. (2002). Michael Balint: An introduction. //American Journal of Psychoanalysis, 62//(1), 17-24. <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Osborne, T., (1993). Mobilizing Psychoanalysis: Michael Balint and the General Practitioners, //Social Studies of Science//, //23//(1), 175-200 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Parker, H., (1997). Beyond ethnic categories: Why racism should be a variable in health services research. //Journal of Health Services & Research Policy,// //2//(4), 256–258. <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Roberts, G., Irvine, F., Jones, P., Spencer, L., Baker, C., & Williams, C., (2007). Language awareness in the bilingual healthcare setting: A national survey. //International Journal of Nursing Studies, 44//(7), 1177-1186 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Stewart, H. (2002). Michael Balint: An overview. //American Journal of Psychoanalysis, 62//(1), 37-52. <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Subotsky, F., Bewley, S., Crowe, M., (2010). Abuse of the doctor-patient relationship. //RCPsych Publicatoins 6//(1), 55-60 <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">Tumble, S.C., O’Brien, M.L, O’Brien, M, Hartwig, B., (2006). Communication skills training for doctor’s increases patient satisfaction. //Clinical Governance: An International Journal, 11//(4), 299-307