The exercise of power in clinical encounters Within modern societies, it is possible to discern the proliferation of power effects through “progressively finer

channels, gaining access to individuals themselves, to their bodies, their gestures and all their daily actions” (Foucault, 1980, p.151). The juxtaposition of health, wealth, appearance and well-being are nowhere more apparent than in the clinical encounter: “Overall,” according to Malterud (2001a, p.397) “[…] clinical practice is, at its worst, a private enterprise shut off from outside assessment, where pitfalls and fallacies are reproduced by dangerous and irrational subjectivism.”

In 1904, Sir William Osler advised doctors to listen to their patients as they were “telling you the diagnosis" (Osler, 1904, as cited in Appleby, 1996). However, in the exercise of power-as-authority in medical settings (Ainsworth-Vaughn, 1998), doctors do not routinely value patient perspectives. Doctors tend to control the consultation, interrupting patient narratives within 18 seconds of the patient beginning to speak (Beckman, Markakis, Suchman & Frankel, 1994; Groopman, 2007; Groopman, Miller & Fins, 2007; Schofield, 2005). Such interruptions resulted in less than a quarter of patients ever being able to complete their opening statement; doctors dealt with the first complaint rather than the presenting complaint and made unilateral closings.14 Consultations in which patients attempted to express their views have been associated

with considerable tension (Tuckett, 1985; 1985a). Practitioners may deliberately use technical language to limit patient questions (Lipton & Svarstad, 1974; Lyons & Chamberlain, 2006); when patients do not admit that they did not understand, then a virtual “communication conspiracy” is set in motion (Svarstad, 1974, as cited in Roter & Hall, 2006, p.128). This may be a face-saving manoeuvre when, for example, doctors express amusement at patients’ mistakes (Ainsworth-Vaughan).

Poor medical outcomes have been linked to cascades of problems resulting from constricted thinking (Groopman, 2007), or, a medical dictum that “the newest and most technological care" is the best care (Deyo & Patrick, 2005, p.16). The patient’s knowledge of their own body and disease processes are presumed by doctors to be limited (Tuckett, Boulton, Olson & Williams, 1985). Patient concerns may be disregarded and the possibilities of correcting errors in a doctor’s thinking or prescribing go unchecked even as they are developing (Groopman). In a reliance on evidence external to the interaction of the doctor and patient, a veritable “medicine by the numbers” (Schneider & Lane, 2005, p.xi), what is lost is the patient’s experience of his world and body. Formulaic diagnosis and intervention, that which Rosenfeld (2004, pp.153-155) has referred to variously as “dogma,” “religion” and “the codification of daily practice,” have distanced the patient (Leder, 1990) even as the partnership model15 is being promoted as the preferred relationship model for consultation.

Attempts are being made to include aspects of obesity as a brain disorder within the DSM V16 allowing obesity to be promoted as a disease based on an excessive drive for food. Any such inclusion raises the potential for an increase in discriminatory practices within consultations that already target the mental component of obesity to promote diet compliance and prevent relapse (Volkow & O’Brien, 2007). The over-reliance on pattern recognition or visual presentation to make diagnoses, snap judgments, and a failure to recognise alternative explanations, will likely be exacerbated with the ready availability of a new DSM categorisation. The opportunity for patients’ views to be

15_{I refer to a definition of partnership model as one that addresses the “incompleteness” of the} expert’s vantage point with knowledge being “an interweaving of multiple perspectives (with) different kinds of expertise” (Hatgis, Dillon & Bibace, 1999, p.22).

16_{The Diagnostic and Statistical Manual (DSM) (American Psychiatric Association, 1994) is a} handbook that categorizes or constructs mental disorders alongside the criteria for diagnosis. It is published by the American Psychiatric Association and includes reviews of the categories allowing new constructions in and others to be eliminated. Homosexuality was dropped from the seventh revision of the DSM-II, in 1974.

explored within a consultation will be further eroded by the potential to apply yet another diagnostic label.

Specialness in the relationship between doctors and patients may be seen as an ideological device rooted within medical paternalism (Bury, 2004). In such a relationship, “coercion and domination” (Morgan, 2003, p.168) take on the appearance of benevolence and choice (Wear & Aultman, 2007) by physicians who lay claim to “[…] certain kinds of legal and professional privileges – largely to autonomy over practice and dominance over other professions” (Bury, p.48). In his study of the medical profession, Brody (1992) discovered a myriad of allusions to the superiority of doctors’ professional power with little discussion of it. When power is placed at the heart of the moral discourse of medicine, it is possible to see how ethically responsible practice, in relation to informed consent, truth-telling, confidentiality and physicians’ virtues, are impacted by the way in which power/knowledge was invoked (Brody).

The Parsonian view of medical knowledge points to a knowledge and practice gap in which medical knowledge is earned, owned and may be passed on reluctantly. Patients have needed to rely on the physician to make best use of that information for them as individuals and have therefore tended to comply with instructions. When patients resist instructions or the condition does not respond to treatment, they may earn a malingerer’s status: “[…] no patient can truly want to get well if he or she does not cooperate with a doctor” (Roter & Hall, 2006, p.24). Patently, overweight physical appearance may signify a lack of compliance, an undersocialized (Granovetter, 1985) citizen whose appearance suggests a patient unlikely to comply in the future with medical instructions (Brownell & Puhl, 2003; Bruere & O’Connor, 1999; Eisenberg, 1979; Kristeller & Hoerr, 1997).

Good outcomes from medical consultation rest on the ability of a physician to critique medical research (Allen, 2004; Godlee, 2008). Physicians need to be committed to lifelong learning (Allen, 2004) and to be highly reflexive in relation to their practice (Malterud, 2001; Teunissen & Dornan, 2008). But “(e)ven at its scientific best, medicine is always a social act” (Elwyn & Gwyn, 1999, p.186). A holistic approach to medicine in the context of the patients’ beliefs, values and culture is required, while also “considering a range of therapies based on the evidence of their

much criticism (Freidson, 1975) and the role of the doctor is more complex than Parsons acknowledged. Still, when patients conform to Parsons’ ideal patient type, the patient who seeks professional advice, adheres to treatments, and (preferably) recovers, is evaluated positively (Millward & Kelly, 2005). Healthy patients are preferred (Stimson, 1975; Roter & Hall, 2006). Preferred patients are also those who consult a doctor only when they need to, do not take up the physician’s time, exhibit specific organic symptoms, are easy to diagnose, and require little in the way of ongoing management (Stimson).

3.6.2 Discrimination in the clinic. The term heartsink is regularly applied to