Paradox of Patient Empowerment and Care

By | March 16, 2017
I find myself looking at all my past experience, and making connections between what I know as an educator, and PhD student, to what I have experienced as a patient with critical/chronic illness. Leading off from Autumm Caines’ post about Virtually Connecting focus groups, I want to chat a little more about the paradox of patient empowerment and care. I watched the first focus group and attended the second and third. It was during the third focus group that I was challenged on using a famous Audre Lorde quote “you cannot dismantle the master’s house with the master’s tools” – that challenge led to an ah-ha moment for me – the paradox of patient empowerment and care. When we talk about the need to empower patients, we talk about patients taking an active role in their healthcare. This is a challenge the often very paternalistic healthcare system – where we as patients are suppose to do what we are told. The language often used is that of “compliance”. It goes further to sometimes even blame the patient. We hear things like “the patient failed to respond to this medication”, rather than “the medication failed the patient”. Language matters. In one breath, I see patient empowerment as giving patients a larger voice in the healthcare system. I talk about medicine being practiced with patients rather than on patients. On a side note, I wonder how much of this is an American view point – where here you often (if you live in a populated area and have the privilege of good health insurance) get to choose who provides your healthcare? This is the land of second and sometimes even third opinions – but it is also the land of shopping for healthcare providers that align with your needs/personality, etc. The choice of provider affects the culture. I do think the empowerment situation is somewhat different in a socialized system, where you don’t have the choices in who you see (at least not to the same extent). In Canada, the gatekeeper is your family medicine physician (primary care physician or PCP). When you need a specialist, you go through your PCP. In the US, at least from my experience, your insurance company plays a much larger role of gatekeeper. Your insurance company determines if your PCP needs to make a referral or if you can self-refer. Your insurance company (and bank account) determine which providers are in-network – and which ones you can afford to see. In many cases, self-referral is what happens. When I was diagnosed with cancer, once I had a confirmed pathology, I could self-refer to any surgeon or oncologist. I didn’t need my PCP to make the referral. Where do I see the paradox? I see it in the need for the healthcare system to provide care. When you are in the middle of a health crisis, you need to know that the healthcare system is going to care for you. You need the maternalistic sense that someone(s) has your best interests in mind, and that they will ensure you are cared for. When you are in crisis, you don’t need, nor do you really want empowerment. You need care. Going back to the Audre Lorde quote “you cannot dismantle the master’s house with the master’s tools”, the patient empowerment movement isn’t so much about dismantling the tools completely, although it is about dismantling some of the paternalistic tendencies in the system. There are times when we need the use of the master’s tools. We need the expertise of our physicians and other allied health professionals. We rely on them for care. But when we are not in crisis, we also need to know that our voices are heard. In online teaching, we talk about the transition of teacher from “sage on the stage” to “guide on the side”. In many ways, this is the transition that empowered patients are looking for in healthcare. They want their physicians to be guides rather than sages. The expertise is desired, but also the recognition that patients carry prior knowledge and expertise. I like to use the phrase “I am an expert in my body”. My medical oncologist is an expert in breast cancer and the pharmaceutical treatments for it, but he is not an expert in my body. I am the one that is living in it. Do you see a paradox between patient empowerment and care? How is patient empowerment different in socialized medicine settings? 

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