Peter Elias: Empowerment and collaboration

Guest blogger Peter Elias, MD, a family physician, raises some interesting questions about the nature of patient empowerment and explores its implications regarding patient-physician collaboration. This piece originally appeared on the author’s blog, PeterEliasMD (personal observations and perspectives.

I was struck last week by a remark in a discussion of patient-centric care: “…patient empowerment is probably beyond the reach of individual doctors/nurses to easily provide…” Two questions come to mind: who “owns” the power, and what does it look like?

First, the speaker implies that power is something bestowed upon patients by clinicians. The reverse is true. I don’t empower patients to participate in my practice as much as they empower me to participate in their care. Once the patient and I start working together, the only question is how the power sharing works, and the only truly non-participatory patient is the one who doesn’t come.

Second, empowerment in any relationship is neither coherent nor easily definable. Much of the discussion of patient-centric care I see falls into this trap, addressing empowerment as a binary: patients are or aren’t empowered, implying that empowered and powerless patients can be defined and treated as distinct groups.

Even as simple a thing as a screwdriver comes in a staggering variety of shapes, tips (slot, phillips, cross, hexagonal, pozidrive, torx), sizes and uses. In any given setting, the wrong screwdriver can be as problematic as no screwdriver, and one can often get an excellent result with something less than the perfect screwdriver. Power in a relationship should also be seen as an infinitely variable phenomenon.

(Note: To the extent that power in healthcare is derived from knowledge or skill, it should be kept in mind that the clinician’s expertise is largely limited to one of the three components: biology. The other two, the patient’s psychology and context, come from the patient. I am indebted to my time in training with George Engel, responsible for the biopsychosocial model: more here and here and here.)

I don’t see power as something that clinicians can give to their patients, or empowerment as something that clinicians create. My vision is a world where clinicians are comfortable collaborating with their patients and erect no barriers to empowerment, and where patients are comfortable using their inherent power, allowing a wide variety of flexibly collaborative relationships.

  • I say this as a physician. I try to be open to relationships with my patients where power is shared. Part of this sharing is that I do not determine my patients’ roles. I cannot guarantee that my patients are aware of their power, let alone understand its value and limitations. I certainly cannot compel them to wield their power.
  • I say this as a family member of patients, some of whom have survived their medical challenges, and some not. Even among my relatively small sample, there has been a confusing and often upsetting variety of approaches to personal empowerment, from individual to individual, from illness to illness, from provider to provider, and even from Monday to Tuesday. Like the weather, the only constant is change.
  • I say this as a patient. I recognize that my need and ability to share power with my clinicians is inconsistent, varying quite widely with the problem, the provider, and my momentary mental state. To make things harder, my interest and my ability to share are not always aligned or rational (meaning cognitively driven) at any given time.

As a final note, I prefer to think in terms of collaboration rather than power or empowerment. For me, framing the discussion in terms of power/empowerment focuses on the relationship and predisposes to the error of a simple and too often inflexible model of empowered patients. Framing the discussion instead in terms of collaboration makes it easier to focus on the goals of care, rather than the relationship, allowing more easily for different relationships in different circumstances.

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