Acknowledging Patient Expertise and the Negotiation of Meanings in the Clinical Encounter

Abstract

Patient non-adherence is a common and important problem in clinical medicine. Some cases of patient non-adherence are cases in which the patient disagrees with the physician’s recommended treatment based on particular reasons. In this chapter, by drawing upon the science and technology studies literature, specifically the discussion by Collins and Evans and also Wynne of how best to understand scientific controversies, I relate their ideas to the analogous conflict that may occur within a clinical encounter. I draw upon their recognition of the importance of contributory expertise and interactional expertise in providing legitimate knowledge. I also draw upon Wynne’s idea of the ‘negotiation of meanings’ as an important element of the clinical interaction. To resolve potential conflicts between patient and physician before they develop into ‘non-adherence’, I propose the need for a new epistemological framework that recognizes legitimate knowledge offered by the patient as well as the physician. By situating this patient expertise framework within the paradigm of person-centred medicine, and by assuming the goal of medical treatment to be treatment of suffering, patient expertise becomes centralized as a means of determining the nature of patient suffering. Two aspects of the patient’s tacit knowledge - the body aspect and the meaning aspect - both of which are context-dependent and directly accessible only to the patient, are thus recognized as knowledge essential to the success of the interaction. The physician’s role becomes that of both medical expert and possessor of interactional expertise, by which the physician recognizes and includes patient expertise in the treatment decision. Finally, the patient expertise framework must also involve recognizing and incorporating the ‘negotiation of meanings’ into the development of a treatment plan. By acknowledging the importance of patient expertise and the negotiation of meanings, this patient expertise framework should dissolve the problem of patient non-adherence that derives from the patient disagreeing with the therapeutic plan.