Understanding the Power Hierarchy in Patient-Provider Relationships

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.