What+John+Stuart+Mill+has+to+teach+to+Dr+Cox+from+Scrubs

Name: Michele McEachern

Student Number: 08353646

Tutor: Colleen Niland

Artefact

media type="youtube" key="RK8dMRLVWvg" height="315" width="420"

Scrubs is a fictional comedy TV show made between 2001-2010, set in a public teaching hospital in the US. In the clip from youtube featured here, a senior medical doctor, Dr Cox, is seen talking to a patient who chooses to use the internet to find out about his health condition (Wikipedia 2011).

Issue

This wiki will examine crucial issues of power, trust and culture in the doctor-patient relationship and how this relationship is changing with internet technology. It will also explore the views of 19th century theorist, John Stuart Mill on power and autonomy and examine the application of these views to the doctor-patient relationship.

Literature Review

Bioethics literature is increasingly concerned with the need for greater patient autonomy in medical decision making (Ho 2008). Since World War II, the power that doctors hold over patients has expanded as medical technologies have expanded, but has also been increasingly questioned as populations have become more critical of institutional structures (Athanassoulis 2006). Veatch (2009) argues that in modern, diverse societies it has become impossible for doctors to know the value systems of their patients and therefore understand what will enhance their patient’s wellbeing.

Medical terminology has been examined as a reinforcement of the imbalance of power, doctors can understate or catastrophise a patient’s health condition in the language they use (Kokanovic & Manderson 2007) and terms such as “doctor’s orders” or “discharged from hospital” imply that the doctor has the right to tell the patient what to do (Veatch 2009).

Campo (2010) argues that debates about patient autonomy in health care often disregard the pervasive hegemony of the medical model. Campo argues that women have taken on a medical model regarding childbirth, seeing birth as a risky medical event and distrusting that they will be able to birth without medical intervention.

Some see a continued role for doctors to assume responsibility for medical decisions. Lo and Parham (2010) state that between 10-50% of patients want to defer some decisions about their medical care to their doctor, with men, people of low socio-economic status, elderly people and African-Americans, the most likely to defer decisions to their doctor. Lee and colleagues (2008) also argue that there are differences between Asian and Non-Asian conceptualisations of power sharing in the doctor-patient relationship. Pinninti (2010) argues that psychiatrists are required to independently evaluate the courses of treatment that they offer patients, but advocates using patient feedback in this process.

Documents allowing doctors to better understand patients wishes are perceived as underused, for example, living wills (Etheredge 2009) and birth plans (Campo 2010).

The doctor’s role to follow the patient wishes is challenged when patients request treatments that the doctor sees as unnecessary or potentially harmful. Some argue that patient autonomy is an overriding medical principle (Athanassoulis 2006). Others see non-wastage of medical resources to be a matter of medical professionalism (Dugdale //et al// 2008).

Analysis of the Hippocratic Oath does little to clarify the power imbalance of the doctor-patient relationship, some have argued that this oath is elitist (Veatch 2009; 12). Others have noted that some translations speak of the doctor’s role to “do no injustice” (Perez //et al// 2006).

Why do adults allow doctors to take control over decisions affecting their health?

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Fredriksen and colleagues (2010) describe the doctor-patient relationship as an attachment relationship, a term generally used to describe the infant-carer relationship. It is argued an adults need to find powerful and familiar caregivers is activated when we are ill, distressed or threatened. This motivates adults to seek a consistent doctor-patient relationship (Fredriksen //et al// 2010).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Others indicate a patient’s trust in their doctor that allows the power dynamic to develop (Campo 2010; Skirbekk //et al// 2011). In Ancient Greece, Plato wrote about the importance of building a doctor-patient relationship based on trust (Dugdale //et al// 2008). Patients have more trust in their doctor if the doctor is sensitive, understanding, professionally attired, allows time, builds alliances with the patient and shows a sense of humour (Skirbekk //et al// 2011; Pettit 2008; Kokanovic & Manderson 2007; Rehman //et al// 2005). Patients with complex or ongoing illnesses place more trust in their doctors than other patients (Skirbekk //et al// 2011).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Doctors recognise that time spent listening to patients improves patient outcomes (Mendoza //et al// 2011; Levinson & Pizzo 2011). However, Rhoades and colleagues (2001) found that when hospital residents speak to a patient for the first time, they will interrupt the patient one-quarter of the time.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">There are a number of explanations for why doctor-patient communication is difficult. Funding systems often provide financial incentive to see more patients (Levinson & Pizzo 2011; Mendoza //et al// 2011). Doctors often adopt a task-oriented approach to deal with complex medical issues with limited resources, or when patient symptoms seem inexplicable (Lee //et al// 2008; Skirbekk //et al// 2011). Medical schools tend not to focus on teaching doctor-patient communication (Levinson & Pizzo 2011; Lee //et al// 2008). As doctors become increasingly concerned with litigation, ordering medical tests can take precedence over listening to patients (Levinson & Pizzo 2011). Doctors may subconsciously distance themselves from patients who are dying to minimise their own grief (Berry 2007). Patients may fear reproach by doctors and not disclose vital health information (Kokanovic & Manderson 2007).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Culture is a crucial influence on the doctor-patient relationship and how patients perceive their illnesses (Kokanovic & Manderson 2007). Patients reported more trust in their doctor and a stronger intention to follow their doctors recommendations when they believed that they and their doctor had similar values, beliefs and communication styles (Gupta 2008). A doctor’s inability to communicate in the patient’s own language can be a barrier to patient access, undermines trust in the doctor, decreases the doctors perceived satisfaction with their treatment of the patient and decreases patient compliance with treatment (Babitsch //et al// 2008). Socio-economic status may also influence whether a patient follows treatment recommendations (Mendoza //et al// 2011).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Patients from minority cultures may also use medical services differently, such as using a hospital emergency department as an entry point for accessing health services, affecting doctors perception of these patients’ medical needs (Babitsch //et al// 2008).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Recent studies examining whether the internet has changed the nature of the doctor-patient relationship have found that 75-84% of internet users have searched for health information online (Lo & Parham 2010; Kim & Kim 2009). The internet also allows for other initiatives, such as online patient-controlled health records, potentially giving patients greater responsibility in health management (Lo & Parham 2010).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">A study of Korean doctors (Kim & Kim 2009) found that 20% believed their authority was being challenged if a patient presented internet health information. A multinational study found that 3.8 % of pregnant women who had presented internet health information to medical professionals had been advised not to use the internet for health information (Lagan //et al// 2010). Yet Lo and Parham (2010) found that 71% of patients who presented internet information to their doctor did this to get their doctors valued opinion. Studies have shown that 49 - 83% of people using internet health information indicated online research gave them more confidence to speak to a health professional (Lagan //et al// 2010; Lo & Parham 2010).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Kim and Kim (2009) found Korean doctors were sceptical of internet health information as 64% disagree that internet health information is accurate and 85% believe that most patients could not assess the relevance of internet health information. The majority of doctors surveyed also perceived internet health information as increasing inappropriate service utilisation (56%), making patients overly concerned for their health (74%), reducing time efficiency (60%) and discouraging patients from following doctors advice (54%). In contrast, a survey of women using online health information indicates that patients take a discriminating approach to information found online, whilst 68% of respondents had found information they thought was wrong or misleading, 83% believed that online health information was useful (Lagan //et al// 2010).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Online social networking creates other potential issues for the doctor-patient relationship. A study of French doctors (Moubarak //et al// 2010) found that 73% of respondents use Facebook, but only 61% of users had changed the Facebook default privacy settings, highlighting the possibility for patients to find information on Facebook that was not intended for them to read. Lo & Parham (2010) also highlight that sites such as Facebook may host health support groups, yet the use of targeted advertising by Facebook may increase people’s exposure to misleading health advertising, increasing uptake of unproven treatments.

<span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; font-size: 20px;">Critical analysis

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">John Stuart Mill, a critical 19th Century theorist, believed the progress of human societies was inextricably linked to the capacity of individuals to make decisions to further their own best interests (Kors 2011). Mill saw the development and expression of diverse opinions as both an intellectual imperative, allowing genius to emerge in wider society (Athanassoulis 2006) and a moral imperative, protecting individuals from undue control by the state (Davies & Elwyn 2008).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Mill argued that the only grounds for public intervention in the lives of competent adults was to prevent the actions of one person from imposing on the interests of others (Taylor & Hawley 2006). Mill did not believe that preventing harm to an individual themselves was a reasonable imposition on the agency of a competent adult (Kors 2011). Mill saw human beings as inherently fallible, but argued that respect for human agency is morally justified, despite the possibility people may make decisions they would later regret (Athanassoulis 2006).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Mill was concerned about autonomy in a range of contexts, however his ideas have been used to describe and curtail the powers of doctors over patients (Kors 2011). The use of Mill’s work in this way highlights questions over the extent to which doctors are responsible for acting benevolently to protect the interests of patients, or allowing patients and their families to make their own decisions regarding care (Veatch 2009; Davies & Elwyn 2008).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Some question whether the idea of agency, as Mill saw it, can effectively be applied in health care contexts. Athanassoulis (2006) examines whether respect for agency extends from freeing people from constraints on doing what they choose, to a doctor actively assisting someone to do something that the doctor may not see as being in that person’s best interests. Athanassoulis concludes that to deny a request by a patient implies that the doctor has a monopoly on understanding what is healthy for that patient, which is usually not the case.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Other authors have critically examined the ideology of autonomy from a feminist perspective and argued that discussions of autonomy often falsely separate the individual making a decision from the social or institutional context in which a decision is made (Campo 2010; Ho 2008).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Ho (2008) examines whether the concept of agency is adequate to explain a pregnant woman’s choice to terminate a foetus believed to be at risk of being physically or intellectually impaired. Ho argues that there is a pervasive medical discourse that presents the birth of a child with impairment as a tragedy, and further argues parents are offered inadequate support to raise children with impairment. These factors constrain the pregnant woman’s choice to make a decision about continuing the pregnancy based on her own values, yet she is seen as an autonomous agent in making this decision.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Campo (2010) argues that in childbirth, women’s agency is limited by the choices and information that they are presented by their obstetricians. Campo found that women were reluctant to question the advice of obstetricians, even when their birth plans were disregarded. These women were also regarded as autonomous agents in the decisions that were reached.

<span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; font-size: 20px;">Reflection

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">The Scrubs clip demonstrates some key themes from the doctor-patient relationship that have been raised in this wiki, doctor’s power, the medical model’s pervasiveness and the doctor’s changing role in an online era.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">This leads to reflection on how health professionals respond when our clients present us with information found online. It seems inadequate to advise clients to be sceptical of the internet as a source of health information. It is more reasonable to examine the skills health professionals need to get scientifically informed health practice noticed in an era when advertising and misinformation is abundant.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">The Scrubs clip demonstrates a crucial aspect of the health professional role; just giving patients information is not enough, effective practitioners build trust and empathy with clients. In an online age, this will increasingly become what makes health professionals the most trusted sources of information from the many that clients can access.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Mill, in the 19th century, believed the free expression of diverse opinion would lead to the emergence of genius. Some would see the internet as our greatest ever tool for free expression. It is questionable though whether this has led to the emergence of genius, or allowed people to live healthier lives. Mill’s perspectives on agency do not suggest that a person needs to go to their doctor armed with printouts from having googled their health complaints, merely that it is up to the individual patient to decide whether to believe their doctor or a website. It is up to health professionals to know how to respond.

<span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; font-size: 20px;">References

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Athanassoulis N. 2006. Unusual requests and the doctor-patient relationship. //The Journal of Value Enquiry//. 40 (2). 259–278.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Babitsch B., Braun T., Borde T. & David M. 2008. Doctors perception of doctor-patient relationships in emergency departments: what roles do gender and ethnicity play. //BioMed Central Health Services Research//. 8 (1). 82-91.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Berry P.A. 2007. The absence of sadness: darker reflections on the doctor-patient relationship. //Journal of Medical Ethics//. 33 (5). 266-268.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Campo M. 2010. Trust, power and agency in child birth: women’s relationships with obstetricians. //Outskirts; Feminisms along the edge//. 22. http://www.chloe.uwa.edu.au/outskirts/archive/volume22/campo

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Davies M. & Elwyn G. 2008. Advocating mandatory patient autonomy in health care: adverse reactions and side effects. //Health Care Analysis//. 16 (4). 315–328.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Dugdale L.S., Siegler M. & Rubin D.T. 2008. Medical professionalism and the doctor patient relationship. //Perspectives in Biology and Medicine//. 51 (4). 547-53.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Etheredge H. R. 2009. Enhancing the doctor-patient relationship: living, dying and the use of the living will. //South African Journal of Bioethics and Law//. 2 (1). 28-31.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Frederiksen H.B., Kragstrup J. & Dehlholm-Lambertsen B. 2010. Attachment in the doctor-patient relationship in general practice: a qualitative study. //Scandanavian Journal of Primary Health Care//. 28 (3). 185–190.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Gupta R. 2008. The effect of race, culture and values on the physician-patient relationship. //Alternative Therapies in Women’s Health//. 10 (12). 94-95.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Ho A. 2008. The individualist model of autonomy and the challenge of disability. //Bioethical Inquiry//. 5 (2). 193-207.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Kim J. & Kim S. 2009. Physicians perceptions of the effects of internet health information on the doctor-patient relationship. //Informatics for health and social care//. 34 (3). 136–148.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Kokanovic R. & Manderson L. 2007. Exploring doctor-patient communication in immigrant Australians with type-2 diabetes: A qualitative study. //Journal of General Internal Medicine//. 22 (4). 459-463.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Kors A.C. 2011. The paradox of John Stuart Mill. //Social Philosophy//. 28 (2). 1-18.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Lagan B.M., Sinclair M. & Kernohan W.G. 2010. Internet use in pregnancy informs women’s decision making: a web-based survey. //Birth//. 37 (2). 106-115.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Lee K.H., Seow A., Luo N. & Koh D. 2008. Attitudes towards the doctor patient relationship: a prospective study in an Asian medical school. //Medical Education//. 42 (11). 1092 – 1099.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Lo B. & Parham L. 2010. The impact of web 2.0 on the doctor-patient relationship. //Journal of Law, Medicine and Ethics//. 38 (1). 17-26.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Mendoza M.D., Smith S.G., Eder M. & Hickner J. 2011. The seventh element of quality: the doctor-patient relationship. //Family Medicine//. 43 (2). 83-89.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Moubarak G., Guiot A., Benhamou Y., Benhamou A. & Hariri S. 2010. Facebook activity of residents and fellows and its impact on the doctor-patient relationship. //Journal of Medical Ethics//. 37 (2). 101-104.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Perez S.G., Gelpi R.J. & Ranchich A.M. 2006. Doctor-patient sexual relationships in medical oaths. //Journal of Medical Ethics//. 32 (12). 702-705.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Pettit M.L. 2008. An analysis of the doctor-patient relationship using Patch Adams. //Journal of School Health//. 78 (4). 234-238.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Pinninti N.R. 2010. Addressing the imbalance of power in a traditional doctor-patient relationship. //Psychiatric Rehabilitation Journal//. 33 (3). 177–179.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Rehman S.U., Nietert P.J., Cope D.W. & Kilpatrick A. O. 2005. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. //The American Journal of Medicine.// 118. 1279–1286.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Roades D.R., McFarland K.F., Finch W.H. & Johnson A.O. 2001. Speaking and interruptions during primary care office visits. //Family Medicine//. 33 (7). 528-532.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Skirbekk H., Middelthon A., Hjortdahl P. & Finset A. 2011. Mandates of trust in the doctor-patient relationship. //Qualitative Health Research//. 21 (9). 1182-1190.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Taylor G. & Hawley H. 2006. Health promotion and the freedom of the individual. //Health Care Analysis//. 14 (1). 15–24.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Veatch R.M. 2009. //Patient, heal thyself: how the new medicine puts the patient in charge//. New York. Oxford University Press.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Wikipedia - [|http://en.wikipedia.org/wiki/Scrubs_(TV_series)] – Accessed October 2011.

Comments on other wiki pages

To Lauren Hurst - Hi Lauren, I think you've done some very interesting work in linking women's participation in sport to improved self-esteem. I was interested particularly in your comments around what constrains young women's participation in sport, for example, you mentioned that one of the constraints was a lack of prioritising sport among parents, I wondered whether this might have been linked to longer working hours or increasing numbers of households where every parent works (both single parent and double parent households). I think you've also done very well to link the change in sports participation to the change from being intrinsically motivated to participate to being extrinsically motivated to impress others, great work.
 * ) Michele

To Samuel Kevin Bianchi - Hi Samuel, I thought you did really well in reflecting on the issue of condom use among adolescents and linking that definitions of sexual intercourse. After reading your wikipage, I'm interested in the topic of why adolescents protect themselves more often during vaginal intercourse than other sexual activities. Is it that health services and schools are predominantly teaching about protection during vaginal intercourse, or are the adolescents viewing pregnancy and not STI's as the greatest risk? This is really thought provoking work. :) Michele

To Challen Krichel - Hi Challen, I think it is bold of a male paramedic student to focus on the issue of a male health practitioner performing a pap smear exam as a topic. I think its important that we don't restrict the access of rural and remote women to pap smears by banning male doctors from performing this test. But I think your commitment to patient respect is really obvious in your work. :) Michele