Physician Authority Research Articles

High-Stakes Treatment Negotiations Gone Awry: The Importance of Interactions for Understanding Treatment Advocacy and Patient Resistance.

Doctors (and sociologists) have a long history of struggling to understand why patients seek medical help yet resist treatment recommendations. Explanations for resistance have pointed to macrostructural changes, such as the rise of the engaged patient or decline of physician authority. Rather than assuming that concepts such as resistance, authority, or engagement are exogenous phenomena transmitted via conversational conduits, we examine how they are dynamically co-constituted interactionally. Using conversation analysis to analyze a videotaped interaction of an oncology patient resisting the treatment recommendation even though she might die without treatment, we show how sustained resistance manifests in and through her doctor's actions. This paradox, in which the doctor can both recommend life-prolonging care and condition resistance to it, has broad relevance beyond cancer treatment; it also can help us to understand other doctor-patient decisional conflicts, for instance, medication nonadherence, delaying emergent care, and vaccine refusal.

Zasługi Karola Linneusza dla postępu nauk farmaceutycznych w XVIII w.

The importance of Linnaeus’ taxonomy for the progress of pharmaceutical science in the 18th century Fundamentals of Linnaean taxonomy were established from the late 1730s and had a gradual ordering impact on all plant knowledge of the time. Pharmaceutical botany was enlivened by the following assertions, ideas or publications issued by Linnaeus: 1) the sexual system as a tool for practical identifi cation of genera; 2) the genera were newly defi ned or corrected to build a clear system; 3) botanists were encouraged to construct and study a natural system of genera which was expected to reveal similarities in pharmacological actions (as analogous to morphological similarities of allied species); 4) a critical and minimalist review of medicinal species and their therapeutical uses was published; 5) the synonymy of species was rectifi ed by selecting only good and suffi ciently descriptive polynomials; and fi nally 6) it became the new scientifi c standard to typify the name and description of a species on a proof sample, the role of which began to be played by a herbarium specimen of a plant, called a type. The practice of assigning binominal names to known or newly described species enabled botanists to place them immediately in the sexual system (by assigning a generic name, the genus was ranked in terms of fl ower structure). The increase in the number of medicinal plant species at the end of the 18th century was the result of a desire to make the knowledge complete and modern, and to add new facts about related species in a wellorganized form. Canons for the experimental and clinical study of effects of known and new medicinal plants on healthy and sick patients were being developed. The introduction of many new species into practical therapy took pharmacy by surprise, as the pharmacist had to learn to recognise medicinal plants previously unknown to pharmacy, which was not without its mistakes. Misrecognised plants that became drug ingredients could exert unintended effects in therapy, undermining the authority of physicians, hindering the evaluation of drugs and threatening to fl ood scientifi c pharmacy with a stream of erroneous knowledge. Continued practical self-education of pharmacists in the fi eld of plant taxonomy was therefore claimed.

Advance Care Planning in the Philippines: A continuing narrative of advocacy

This article discusses the current state of Advance Care Planning (ACP) in the Philippines, where the health system operates within a fragmented environment, with mixed private and public provisions. Despite some attempts to introduce legislation to foster ACP implementation, patient autonomy remains subordinate to family values and physician authority within the Southeast Asian culture. The article also highlights how the COVID-19 pandemic has challenged the norms of the global healthcare force and pushed Palliative Medicine specialists to take on stronger roles in the battle lines against health-related suffering. The Palliative Care Consultants, advocates along with Philippine Society of Hospice and Palliative Medicine (PSHPM) and Hospice Philippines Inc. have been playing a significant role in promoting and supporting ACP through education and training, advocacy, research and development, networking and collaboration.

How Does the Design of Consultation Pages Affect Patients' Perception of Physician Authority and Willingness to Seek Offline Treatment: A Randomized Controlled Trial.

This study aimed to assess the impact of the color and font size of a dialogue box on an online physician-patient interaction page on patients' perceptions of the physician's authority and their willingness to schedule an offline appointment. A 2 × 2 between-group experiment was conducted to compare the effects of two dialogue box colors (gold vs. grey) and two font sizes (large vs. regular) on patients' perceptions. The results showed that a larger font size had a significant positive impact on patients' perceptions of the physician's authority, and the use of a gold-colored dialogue box also had a significant positive effect. A significant interaction was found between the dialogue box color and font size and patients' perceptions of the physician's authority. In addition, it was found that positive perceptions of the physician's authority significantly affected patients' willingness to schedule offline appointments and played a fully mediating role in the path of page design affecting offline appointment intentions. This study provides evidence that the design elements of a dialogue box-particularly, its color and font size-can influence patients' perceptions of a physician's authority and their willingness to schedule an offline appointment. These findings suggest that modifying the page design could improve the effectiveness of physician-patient communication.

The Influence of Recommendation of Medical and Non-Medical Authorities on the Decision to Vaccinate against Influenza from a Social Vaccinology Perspective: Cross-Sectional, Representative Study of Polish Society.

Vaccination against seasonal flu is crucial to prevention of illness in modern societies. The level of influenza vaccination in Poland is low and, for many years, has hovered around a few percent of the general population. For this reason, it is crucial to understand the reasons for such a low level of vaccination and to assess the influence of medical and social authorities on the decision to vaccinate against influenza from the perspective of social vaccinology. For this purpose, a representative survey was conducted in 2022 among adult Poles (N = 805), orchestrated with the CAWI technique based on the author's questionnaire. The most significant authority in the context of influenza vaccination is held by physicians, especially among the oldest part of the population, over 65 years of age-in this group, 50.4% of respondents declare a very high level of respect for physicians on the issue of recommended influenza vaccination (p < 0.001), and the second-highest authority group for which seniors have respect in the aspect of influenza vaccination is pharmacists (p = 0.011). It was also shown that pharmacists have more authority on the issue of influenza vaccination than nurses, especially in the group that declared themselves opponents of vaccination (p < 0.001). The survey indicates the need to strengthen the authority of physicians and pharmacists regarding influenza vaccination, and, in the case of pharmacists, the need for changing the law to allow them to qualify for influenza vaccination.

The Nurse-Physician Relationship During the COVID-19 Pandemic in Shanghai, China: Cross-sectional Study.

The nurse-physician relationship is important for the stability of collaboration. The COVID-19 pandemic has put unprecedented pressure on the health care system and has placed greater demands on nurse-physician collaboration. Nurses and physicians often struggle to share mutual responsibility and communicate effectively. This study aimed to evaluate the relationship between nurses and physicians during the COVID-19 pandemic and construct a new model combining the attitude and behaviors of the 2 groups to assess various factors' impacts on job satisfaction and confrontational behavior. We conducted this quantitative cross-sectional study to assess the relationship between nurses and physicians based on the attitudes and behaviors toward nurse-physician collaboration. We first investigated the satisfaction of nurses and physicians with their relationship and how they thought the COVID-19 pandemic had affected that relationship. We used an adapted and modified Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration questionnaire that consisted of 17 items under 5 dimensions. Structural equation modeling was used to assess the relationships between domains. Ordinal logistic regression was used to evaluate the relationship between different domains of the questionnaire and the satisfaction of the current nurse-physician relationship. We included a total of 176 nurses and 124 physicians in this study. Compared to 7.2% (9/124) of physicians, 22.7% (40/176) of nurses were dissatisfied with the current nurse-physician relationship. Most physicians (101/124, 81.5%) and nurses (131/176, 74.5%) agreed that the nurse-physician relationship had become better because of the COVID-19 pandemic and that the public had greater respect for them. However, significantly fewer nurses (59/176, 33.5% vs 79/124, 63.7%; P<.001) thought that physicians and nurses were treated with the same respect. Nurses scored significantly higher scores in caring versus curing (mean 16.27, SD 2.88 vs mean 17.43, SD 2.50; P<.001) and physician's authority (mean 8.72, SD 3.21 vs mean 7.24, SD 3.32; P<.001) subscales compared with physicians. The shared education and collaboration subscale had a significantly positive relationship with the nurse's autonomy subscale (standardized coefficient=0.98; P<.001). Logistic regression showed that 4 subscales (shared education and collaboration: P<.001; caring versus curing: P<.001; nurse's autonomy: P<.001; and confrontation: P=.01) were significantly associated with the level of satisfaction of the current nurse-physician relationship. This study showed that nurses were more dissatisfied with the current nurse-physician relationship than physicians in Shanghai. Policy makers and managers in the medical and educational system should emphasize an interprofessional collaboration between nurses and physicians. Positive attitudes toward shared collaboration and responsibility may help to improve the relationship between the 2 parties.

Self-Sourced Medication Abortion, Physician Authority, and the Contradictions of Abortion Care.

The growing acknowledgment of the phenomenon of individuals terminating their pregnancies by obtaining the medications necessary for an abortion-which this article refers to as "self-sourced medication abortion" (SSMA)-has shed light on the current contradictions in the world of abortion provision. This article offers a brief historical overview of the relationship between abortion provision and mainstream medicine, pointing to the factors that have led to the marginalization of abortion care. It then discusses interviews with 40 physicians who provide abortions about their perspectives on SSMA, and it explores how this group responds to the contradictions presented by SSMA. In doing so, it interrogates the changing meaning of "physician authority" among this subset of physicians. The authors suggest that these interviewees represent an emergent sensibility among this generation of abortion physicians, a sensibility strongly tied to a commitment to social justice.

The Role of Health Care Communication in Treatment Outcomes.

The physician-patient relationship has evolved significantly in the past century. Physician authority has been reduced while patients have been empowered. This review focuses on face-to-face clinical care and argues that current physician-patient relations range from partnerships between social actors who each play critical roles in negotiating care to a more adversarial duel in which both participants advocate for goals that are not necessarily shared. While the former is the hope of increased patient involvement, the latter is increasingly common. Through our discussion of existing studies, we document that while high levels of patient participation are beneficial to treatment outcomes, this engagement also has a dark side that threatens treatment outcomes. We discuss some communication resources patients use that affect treatment outcomes, exemplify how patient engagement affects physician communication, and discuss some strategies that current research finds effective for communicating about treatment with today's engaged patients.

Restoring Physician Authority in an Era of Hospital Dominance

Restoring Physician Authority in an Era of Hospital Dominance

Engendering connection: The embodied emotional labor of U.S. cosmetic surgeons

Emotional labor has typically been analyzed as a gendered phenomenon in managed workers like nurses. Broadening this frame, this study analyzes how a different strata of workers perform emotional labor: surgeons. Drawing on 42 in-depth interviews with U.S. cosmetic surgeons and a content analysis of online reviews by patients, we argue that cosmetic surgeons perform both intimate and professionalized strategies of emotional labor to build long-term relationships with patients. We highlight how some surgeons strategically use their gender and bodies to forge emotional connections with patients, combining physician authority and their own embodied experiences. We identify two intimate, embodied strategies of emotional labor used by cosmetic surgeons (Paternalistic and Empathic) which are highly gendered and two additional strategies that more closely resemble professional norms (Egalitarian and Technical). Cosmetic surgeons can and do switch between strategies, subject to the constraints of gender norms and expectations; embodied strategies have different payoffs for men and women. Women surgeons, in particular, may sometimes adopt professionalized strategies of emotional labor to assert their physician authority and status and resist expectations of feminized emotional labor. In commercialized medicine, emotional labor enables elite healthcare providers to negotiate power dynamics with dependent patients. In addition to making patients feel better, embodied labor can confer meaning on surgeons’ work.

The Deception of Certainty: how Non-Interpretable Machine Learning Outcomes Challenge the Epistemic Authority of Physicians. A deliberative-relational Approach

Developments in Machine Learning (ML) have attracted attention in a wide range of healthcare fields to improve medical practice and the benefit of patients. Particularly, this should be achieved by providing more or less automated decision recommendations to the treating physician. However, some hopes placed in ML for healthcare seem to be disappointed, at least in part, by a lack of transparency or traceability. Skepticism exists primarily in the fact that the physician, as the person responsible for diagnosis, therapy, and care, has no or insufficient insight into how such recommendations are reached. The following paper aims to make understandable the specificity of the deliberative model of a physician-patient relationship that has been achieved over decades. By outlining the (social-)epistemic and inherently normative relationship between physicians and patients, I want to show how this relationship might be altered by non-traceable ML recommendations. With respect to some healthcare decisions, such changes in deliberative practice may create normatively far-reaching challenges. Therefore, in the future, a differentiation of decision-making situations in healthcare with respect to the necessary depth of insight into the process of outcome generation seems essential.

“The kind of doctor who doesn't believe doctor knows best”: Doctors for Choice and the medical voice in Irish abortion politics, 2002–2018

This article examines how the physician advocacy organization Doctors for Choice articulated a collective pro-choice “medical voice” over the course of sixteen years. This voice was central to the successful 2018 campaign to repeal Ireland's Eighth Amendment, which had imposed a virtual ban on abortion in the Republic of Ireland since 1983. I examine how DfC set itself in opposition to the powerful cadre of anti-abortion Catholic physicians who had dominated Irish public discourse on abortion for decades. DfC not only had to provide a strong alternative argument, but also had to distance itself from a legacy of physicians as gatekeepers to abortion. Based on oral histories and documentary sources, I argue that DfC developed a collective pro-choice “medical voice” and a politics of physician advocacy by leveraging the cultural authority of physicians and using discourses of medical expertise and patient autonomy. Doctors have been called upon to use their social position to fight health-related social inequality. By providing a detailed case study based on individual experiences of and perspectives on physician advocacy, this article examines the framework of “physician advocacy” in practice. It identifies affective and structural barriers to physician engagement in abortion politics across medical specialties. Finally, it considers how, in the face of these barriers, a small group of physicians helped to set the terms of a movement for accessible and equitable abortion care in Ireland.

Physician Authority, Family Choice, and the Best Interest of the Child.

Two of the most poignant decisions in pediatrics concern disagreements between physicians and families over imperiled newborns. When can the family demand more life-sustaining treatment (LST) than physicians want to provide? When can it properly ask for less? The author looks at these questions from the point of view of decision theory, and first argues that insofar as the family acts in the child's best interest, its choices cannot be constrained, and that the maximax and minimax strategies are equally in the child's best interest. He then proposes a guideline according to which the family can demand LST if it is physiologically possible to preserve a life the child can be expected to welcome, and refuse such treatment if it causes suffering that is "more than can be borne" even if an uncompromised life is expected to emerge.

From Medicine to Health: The Proliferation and Diversification of Cultural Authority.

In his account of the medical profession's ascent, Paul Starr drew a distinction between the social authority of physicians and the cultural authority of medicine-between doctors' capacity to direct others' behavior and the ability of medical institutions and discourses to shape meanings of illness, health, wellness, and treatment. Subsequently, scholars have reflected on the social-structural transformations challenging physicians' social authority but neglected shifts in cultural authority. Focusing on the United States, we find a proliferation and diversification of cultural authority, reflecting a partial movement from the domain of medicine into new terrains of health. This shift is apparent in the resurgence of alternative healing, the advent of new forms of self-care and self-monitoring, the rise of health social movements, and the spread of health information online. We advance a research agenda to understand how the mechanisms and dynamics of cultural authority shape contests to speak in the name of health.

Unpacking gatekeeping in medical institutions: A case study of access to end-of-life patients

We use end-of-life decision making as a case for examining processes of gatekeeping in medical settings. End-of-life is an exemplar in a broader context of research in professionalized and institutionalized medical settings. Influences of biomedicalization, increases in consumer (patient) options, decreases in physician authority, and a proliferation of treatment options all contribute to a context in which ethnographic study of medical settings is more complex, more urgently needed, and potentially more difficult at the same time. Building on existing literature, we suggest that gaining access to a research site is less a matter of entrée through a gate and more a long-term navigation of a dynamic social web of actors, relationships, and organizations. Further, we borrow from Nader’s (1974) concept of ‘studying up’ to examine how elite power processes may be reflected in gatekeeping. Our discussion of lessons learned considers methodological and conceptual implications with broad relevance for qualitative researchers.

Countervailing powers in the labor room: The doula–doctor relationship in the United States

How do health professionals with fundamentally different philosophies toward health, and different status levels, manage power in their work relationships? This paper argues that taking a negotiated order interactionist approach, which contends that the social order shapes behavior but is continuously negotiated through social interactions, and synthesizing it with a countervailing powers perspective can yield insight into the power dynamics between health professionals. It focuses on the birth field, with attention to the relationship between two very different types of birth professionals: obstetricians and doulas. Unlike doctors, who maintain a dominant place in health care and subscribe to a biomedical perspective of birth, doulas hold a low-status position and take a holistic approach toward birth, which may cause conflict in the labor room. In-depth interviews with 43 birth doulas based in the US (May–July 2018) found that the doula–doctor relationship is a complex story of power, deference, and countervailing responses. Doulas reported that doctors are more receptive to them now than in the past but that this is an outcome of creative countervailing responses involving deferential maneuvers and direct challenges to physician authority. Doulas’ strategic management of their relationships with health professionals has allowed them entry to the hospital, permitting them to represent a holistic voice in the labor room. A minority of doulas have begun to develop relationships with doctors that constitute a collaborative approach toward birth care, indicating that changes in standard care are possible. By revealing how a subordinate actor can challenge physicians and effect change in care, this study contributes to scholarship seeking to understand the nature of unequal relationships between health professionals in a context of biomedical dominance.

Physician Use of Stigmatizing Language in Patient Medical Records

Negative attitudes toward patients can adversely impact health care quality and contribute to health disparities. Stigmatizing language written in a patient's medical record can perpetuate negative attitudes and influence decision-making of clinicians subsequently caring for that patient. To identify and describe physician language in patient health records that may reflect, or engender in others, negative and positive attitudes toward the patient. This qualitative study analyzed randomly selected encounter notes from electronic medical records in the ambulatory internal medicine setting at an urban academic medical center. The 600 encounter notes were written by 138 physicians in 2017. Data were analyzed in 2019. Common linguistic characteristics reflecting an overall positive or negative attitude toward the patient. A total of 138 clinicians wrote encounter notes about 507 patients. Of these patients, 350 (69%) were identified as female, 406 (80%) were identified as Black/African American, and 76 (15%) were identified as White. Of 600 encounter notes included in this study, there were 5 major themes representing negative language and 6 themes representing positive language. The majority of negative language was not explicit and generally fell into one or more of the following categories: (1) questioning patient credibility, (2) expressing disapproval of patient reasoning or self-care, (3) stereotyping by race or social class, (4) portraying the patient as difficult, and (5) emphasizing physician authority over the patient. Positive language was more often more explicit and included (1) direct compliments, (2) expressions of approval, (3) self-disclosure of the physician's own positive feelings toward the patient, (4) minimization of blame, (5) personalization, and (6) highlighting patient authority for their own decisions. This qualitative study found that physicians express negative and positive attitudes toward patients when documenting in the medical record. Although often not explicit, this language could potentially transmit bias and affect the quality of care that patients subsequently receive. These findings suggest that increased physician awareness when writing and reading medical records is needed to prevent the perpetuation of negative bias in medical care.

Self-Reported Social Media Use among Ophthalmology Residents

Abstract Objective To assess ophthalmology trainees' self-reported use of and attitudes toward social media. Methods An online survey was distributed by email to ophthalmology residency applicants of the Bascom Palmer Eye Institute between September 2016 and January 2020. Results Of the 1,688 email recipients, the survey was filled by 208 ophthalmology trainees (12.3%). Nearly all trainees reported using social media for personal purposes (92.3%), while less than half used social media for professional purposes (43.4%). There were mixed sentiments regarding the impact of social media on the patient–physician relationship, with the majority feeling that it challenges a physician's authority (55.2%) but also empowers the patient (57.5%) and encourages shared care (92.8%). Twenty-five percent of trainees had reviewed professional social media guidelines, and most rated the quality of medical information on social media as “poor” (60.9%). There were low rates of trainees looking up patients (13.8%), providing their account information to patients (1.5%), responding to patients' messages (2.6%), following patients' accounts (2.6%), and being followed by patients (2.6%). Conclusion The majority of ophthalmology trainees are active on social media. As these trainees enter practice, ophthalmology will likely see a rise in social media use. Training programs should consider a formal social media policy that is shared with all trainees as part of their education.

THE HISTORY OF SYPHILIS IN THE XVI CENTURY AND THE PIVOTAL ROLE OF LUIGI LUIGINI IN THE RENAISSANCE

Syphilis is the prime example of a "new disease" which triggered a transnational (European) discussion among physicians. It appeared between the end of the Middle Ages and the beginning of the Modern Times (at the beginning of the sixteenth century), a time in which medicine was changing from a dogmatic to an experimental discipline. The main changes were in the field of anatomy: in 1543, the same year of the astronomy-disrupting work by Nicolas Copernicus, the new less dogmatic and more empirical approach to anatomy by Andreas Vesalius was published. Nevertheless, in the Renaissance, medicine remains a tradition-bound discipline, proud of its millennial history and its superiority over the empirical, non-academic healers. When syphilis appeared in Europe, several explanations were elaborated. In the mid-16th century, an Italian doctor Luigi Luigini (born in 1526) published in Venice a collection of all the works on syphilis that appeared until 1566. He wanted to entrust to colleagues, contemporary and future, a compendium of all that was known about the "new" disease (the Latin term Novus means both "new" and "strange"). According to the most authors of the collection, the disease is in fact "new" and "strange". Some authors of the collection find it impossible that authorities like Hippocrates and Galen overlooked it. Luigini's work shows the authors' effort to absorb syphilis in the corpus of academic medicine and affirm the authority of academic physicians against the empirical healers.

An implementation history of primary health care transformation: Alberta\u2019s primary care networks and the people, time and culture of change

BackgroundPrimary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province’s healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment.MethodsOur implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders’ perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses.ResultsOver time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another’s cultures to achieve the transformation towards PHC has been central to the PCNs’ survival and success.ConclusionsGeneralizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another’s cultures; and how best to support the transformation of a system while delivering care locally.