Understanding the Power Hierarchy in Patient-Provider Relationships

July 23, 2018 - The ideal patient-provider relationship will always include a mutual respect between both parties that then leads to a healthcare partnership. A true patient-provider partnership can lead to better care outcomes and deliver on value-based care priorities. But as power hierarchies pervade the healthcare industry, those true partnerships remain out of reach.

Power hierarchies are tiered levels of power within interpersonal relationships. In healthcare, those hierarchies can present themselves in many different areas. Medical professionals see hierarchy between different types of clinicians such as doctors, nurses, or other clinical workers.

Power hierarchies can also present themselves between clinicians and their patients and family caregivers. The traditional relationship between patient and provider has been viewed as paternalistic, with the provider directing the patient on a treatment path that should mitigate a health concern.

In those relationships, the patient took a subordinate role. After all, the provider was the medical expert with years of clinical training that could inform those treatment decisions.

But healthcare professionals are now calling these power hierarchies into question, saying that they do not align with patient-centered and value-based healthcare models. With healthcare priorities trending toward overall patient wellness, medical experts have asserted that a more balanced partnership between patients and providers to be key.

READ MORE: Enhancing Patient Engagement through Shared Decision-Making

A balanced patient-provider relationship should lead to more shared decision-making, or the practice of making treatment decisions based upon clinician expertise and patient lifestyle needs, values, and preferences.

Wisdom goes that patients should see better outcomes and higher treatment adherence if they play an active role in determining their own healthcare journey.

But research published in the BMJ Quality & Safety indicates that these power imbalances aren’t going away. A 2018 survey of over 1,000 current or past intensive care unit patients showed that very few patients or family members are voicing their concerns during care encounters.

Between 50 and 70 percent of respondents reported hesitation when voicing concerns about possible mistakes, mismatched care goals, confusing or conflicting information, or inadequate clinician hand hygiene.

About half of respondents said they did not want to be perceived as a “troublemaker,” or that the team appeared too busy to hear a concern. Patients also said they did not know how to report a healthcare concern in this setting.

As value-based care models continue to take hold across the country, it will be important that providers transition to a more patient-centric approach to care. This will include integrating the patient and family caregivers as members of the care team.

Failure to do so could result in limited treatment or medication adherence, as well as patient safety issues.

Patient partnerships in shared decision-making

Shared decision-making has become a critical aspect of patient-centered care goals. Central to shared decision-making is the ability for the patient to participate during care encounters.

This will require providers to create a space in which patients feel comfortable contributing their opinions, values, and care goals.

Clinicians who deliver thorough patient education and elicit patient viewpoints will be successful in this area. When the provider both gives patients the information necessary for forming an opinion and invites the patient to give the opinion, it is more likely that the patient will actually participate, according to Press Ganey partner consultant Gary Yates.

“One of the best ways to manage the authority gradient and minimize power distance is when the party that's perceived as being in the higher power position invites others to participate and welcomes questions,” Yates explained in an interview with PatientEngagementHIT.com. “It helps to set the tone and helps to create an environment where individuals are more likely to contribute.”

Providers should use certain patient-provider communication skills, such as open body language and active listening, to display to the patient that this is a partnership. Providers should turn away from the computer, allow patients to finish their statements, and give physical affirmations such as nodding and eye contact to show patients that they are listening.

Providers who do not work to create a better power balance run the risk of harming shared decision-making. Patients who do not feel invited to the decision-making process or feel inferior to the provider are less likely to participate in treatment decisions than patients who feel welcome.

Providers should remember that they bring the medical expertise to the table during shared decision-making; it is only the patient or family caregiver who can share information about quality of life preferences and overall care goals. This should reinforce the notion of equal partnership, rather than a hierarchical system between patient and provider.

The danger to patient safety

Patient reluctance to speak up during care encounters also carries with it dangers to patient safety. Patients serve as another check on the patient safety process.

Patients can notify providers when they are given the wrong dosage or a prescription to a wrong medication. Patient engagement in the safety process can even be as simple as asking a provider if they have washed their hands before an exam.

The BMJ Quality & Safety study reinforced this notion, suggesting that power hierarchies in healthcare can lead to limited patient safety. This can be especially dangerous in the ICU, the research authors pointed out.

“Given the high risks of errors, the exquisite preference sensitivity and the fraught dynamics of the ICU, we estimate that the ICU is one of the most important settings for optimising speaking up opportunities for patients and families,” they wrote.

The issue of power hierarchies is not solely applicable to patient-provider relationships. Imbalances of power can also affect different clinicians, much to the detriment of patient safety initiatives.

According to a 2006 paper on the subject, power hierarchies in healthcare are a “Berlin Wall to patient safety.” Hierarchies between younger physicians and older leadership, or physicians and nurses, can lead to misreports of patient safety events.

“Maintaining a good relationship with those higher up the ladder understandably becomes a prime focus, often at the expense of other priorities such as reporting on errors or on poor patient care,” the report authors wrote. “Calling attention to a supervisor's mistakes or potential mistakes may have repercussions for the junior.”

Just as many patients feel uncomfortable calling out their physician’s potential mistakes, as do younger, junior physicians or nurses, both of whom are perceived as lower on the hospital totem pole.

Healthcare organizations must foster an environment in which all clinicians can put the patient first and address a clinical mistake, regardless of who made the mistake.

As the healthcare industry continues to embrace the idea of patient-centered and value-based care, clinicians will likely integrate patients as a part of the care team. Ideally, this will work to close power hierarchies between patients and providers, as well as among different providers.

However, completely addressing power imbalances will also require a concerted effort on the part of patients and providers. Using key patient-provider communication strategies to create a welcoming environment will help patients feel more comfortable becoming a part of that care team.