Following Orders: Obedience to Authority Figures in Medicine
When your doctor urges you to do something said to benefit your health, do you obey? If not, why not? This blog thread is about how my visitors feel about following orders from those who might be considered as "authority figures in medicine". What follows is a series of questions, a sort of a survey.
What do you consider as an order? "Stop your smoking?" "Loose weight" Do you look at a prescription written for you as an order?
If you tend to avoid following orders, is it because you disbelieve the benefit, it is impractical to carry out the order or you believe in personal decisional autonomy and you refuse to follow health orders by others, particularly those who appear as authority? Would you first want to know if those giving you the order would or have followed it themselves? How do you look at a doctor who is giving you not an order but giving you advice? Or how about a recommendation? Do you consider advice differently than an order? If so, what do you see as a difference between recommendation or advice and an order from a personal point of view? Should recommendation or advice be more acceptable to you than an order? Would you consider following such advice based on the professional responsibilities of the authority? For example, would you be more likely to follow advice from a nurse or a pharmacist than from your physician? Or how about from the next door neighbor? Would the neighbor's personal medical experience represent to you an "authority"?
Do you look upon certain members of the news media who speak about health issues as authority? Would you consider following their advice on their subject? How about pharmaceutical company advertisements? Do you consider the ads as representing the advice of a medical authority? When the ad says for a product "talk to your doctor", would you be willing to do that?
A lot of questions but without answers from my visitors there won't be much more to learn from this thread! So.. should I order your responses?? ..Maurice.
Graphic: My photograph of an exercise session, Santa Monica Beach, CA. Feb. 2013.
posted by Maurice Bernstein, M.D. @ 12:47:00 PM
22 comments
22 Comments:
Orders, authority figures, you're joking right? I don't perceive any physician as an authority figure and if they exhibit that attitude or demeanor, they won't be my physician for long. We don't check into the county jail when we see a physician either at their practice or in the hospital. They recommend a course of action and generally I comply. There have only been a couple of times I've disregarded a recommendation. One had to do with screening and another medication and I still have the same PCP. He recognizes the relationship as a team, which is what it is.
My apologies since I failed to sign my post as Ed.
Ed, authority is defined by Merriam-Webster in one way as applied to the current topic: "an individual cited or appealed to as an expert". This is the definition I am applying to the thread. Another definition which is not pertinent here refers to government as "persons in command" such as a governmental agency or corporation to administer a revenue producing public enterprise such as 'the transit authority'"
You wrote that you don't find the doctor as an "authority figure" and yet the patient comes to the doctor as the authority for medical knowledge and management of illness including having the authority to write prescriptions. Now you might say that the patient is the "authority" for the patient's own life experience and understanding of self..and I would agree but the creation of the doctor-patient interaction is started by the patient acknowledging that the doctor is the medical expert of that doctor-patient relationship and that accounts for the basis for the visit. The "authority" or medical knowledge of a doctor has, of course, nothing to do with a governmental authority such as the "jail".
With regard now to your experience, I presume, as you say, your doctor made "recommendations" and you disregarded them. So I assume these were not "you must" or "you cannot" commands but more "you should consider" or "I would recommend". Therefore you didn't feel "compelled" to follow what the doctor suggested and you didn't and stayed with your doctors. If the doctor gave you orders instead of recommendations then you would feel that a "team" relationship was dissolved and you would leave. Or would it be not so much the order itself but rather the authoritarian attitude and appearance that would discourage you from continuing the relationship? ..Maurice.
I consider a doctor an authority figure. I have disagreed with some recommendations due to past experience or as Ed noted, what I see as useless screenings used to either cover his own butt or get more money out of me. But doctors are the only authority figures I see in the medical world. I pay no attention to what nurses order or recommend because they are not professionals. They just think they are.
Wearing scrubs doesn't make a person a professional. As I see it they just get in the way. I try to be nice to them when they aren't overstepping their authority but I don't take them seriously and I don't have patience for them when they pretend to know more than they're trained to know. I also won't answer certain questions that are none of their business. Some things should be between only a patient and the professional.
GR
Dr Bernstein, thanks for the clarification. Based upon the definition you describe, I agree a physician can be described as an "authority" figure. Since you didn't clarify "orders" I'll presume either an examination, prescription, or procedure presented as a recommendation; is that correct? "Authority" and "orders" are synonymous with my experience in the military; hope you understand.
We're talking generalities here; so much depends upon the context. To my recollection, I've never had a physician say "you must" or "you cannot." Additionally, I've never felt compelled (either by words or demeanor) to follow what the physician ordered/recommended. There are few issues in medicine where the choice is simply right or wrong. In the two cases cited, that was especially true and I reached my decision after discussing the pros/cons with my physician.
A physician's orders presented without discussion of risk/benefit or alternatives in a commanding or "authoritarian" manner, we're done!
By the way, I wholeheartedly agree more with GR comments about doctors being the only "authority" figures in medicine.
Ed
Thanks to Ed and GR for beginning the discussion on this topic. But I want to carry the discussion one step further.
Compliance. Don't you think that physicians give orders to their patient, rather than advice or recommendations or even "suggestions" because the physician finds that the patient's health and safety is at risk without giving that order? And if the patient doesn't comply with the order, isn't that a disturbing observation to the physician and isn't it reasonable for the physician to wonder about or even consider it a criteria regarding the patient's interest in their health and safety? On the other hand, you might expect non-compliance would raise the possibility in the physician's mind that some other personal financial or personal factors might be responsible. But do you really think that doctors actually consider that non-compliance to an order represents a rejection based on the patient's anger toward the physician authoritarian attitude in presenting the order to the patient? I would say, with confidence, even confidence from personal experience, that doctors would not consider that as a possibility for non-compliance by their patient. How else can the doctor make the point to a patient regarding the professional decision of the importance to the patient's health and safety by simply giving "a suggestion", "advice" or "recommendation", as the communication is usually understood by using any of these 3 terms?
Orders coming to the patient from the patient's physician should be considered as a very high form of authority based on the physician's professional knowledge and skills,the authority being the very reason the patient selected and went to the physician for help.
How is that for the defense of "authority", "orders" and "expectation of compliance"? Any response? ..Maurice.
Doctors and even nurses are authority figures to patients. Just like teachers and trainee teachers are to pupils or parent and child(The power exchange is different). It is the fact there is a responsibility placed on those that have been given the power in that particular relationship at that time. A doctor and patient are not considered equal in status in there meeting.
Example 1. The more suggestive and helpful, and able to explain the reasons for such recommendations, is showing there authority in a passive way. Similar to a teacher and pupil relationship when the teacher is explaining something new.
Example 2. Demanding something to be done without explaining why it should be done is more military style. Usually these "professionals" don't like being asked questions.
I my opinion, many people would be more likely to follow doctors recommendations if it was given with an explanation as to why that was recommended. Does the doctor follow there own advice? Credibility on looking healthy and actually actively involved in sport or exercise of some sort as a GP is very important when prescribing remedies to improve a patients health.
With Example 1, patients will feel more empowered due to having more relevant information. If they believe the doctor is credible, the more likely they will treat the information they have gotten as credible.
MM
MM,in fact the doctor is the patient's teacher. A doctor's order without educating the patient about the reasons for the order is indefensible. It is also the duty of the physician to be assured that the patient understands the order and it's rationale. The patient should be given the opportunity by the doctor to demonstrate understanding of the order or any needed clarification. Time must be allotted for this communication.
But an order is an order and not a suggestion,advice or recommendation. That is so because the doctor should be satisfied with the clinical significance and/or urgency and that no lesser way of expressing direction is appropriate for the current situation.
So what might be examples of orders that a physician would give the patient? "You have moderately severe emphysema with current shortness of breath symptoms. My order is that you must stop smoking as of today if the course of the illness is to be reversed and your breathing improves." Not very haughty, is it? Could this be put to the patient as a suggestion or advice such as "Maybe you ought to consider the possibility of stopping smoking for improving your breathing"? Maybe so..but doesn't that show professional ambivalence regarding the importance of the communication?
Of course, orders given to the patient by the physician should never be presented with the order alone and without support. Support is critical for most any order to be carried out. In the above example order, the doctor must follow it with "I know smoking is a habit and hard to break but I will try to help you..."
Doctors write orders to the nursing staff in the hospital charr and they write prescriptions to the pharmacists and so it is only natural and part of the doctor's professional responsibility to give orders to patients.
Now, whether the patient follows the order, is compliant or not..well..that is the question that I have posed for this thread. ..Maurice.
Doctor Bernstein,
I understand your question, but the fact remains that the doctor does not have the authority or legal standing to "order" a patient to do anything.
From a legal standpoint, the physician is nothing more or less than a paid professional consultant. As such, what they provide to the patient are, in fact, professional medical services, opinions and recommendations, regardless of what you may want to call them.
As Ed stated, an "order" implies some legal authority on the part of entity giving the order, such as a military officer, with specified legal consequences for non-compliance. Physicians, with some extremely limited exceptions empowered by enacted statute, do not generally have this type of authority, and thus can not "order" the patient to do anything.
Hexanchus, again meaning of a word is determined by it's definition. In the case of "order" as used in this discussion, I am using the dictionary definition as a "command usually by someone in authority." It is a command and is usually not open to modification or rejection as one would expect with suggestion, advice or recommendations. An "order" does not necessarily require any legal authority. In the case of a medical order, it is based on the professional authority of the physician or other professional.
So the topic of this blog thread is to find out how my visitors consider orders given by their physicians and whether they are obeyed. If they are not obeyed, why not?
I have previously noted that if the physician fails to explain the order to the patient then one might not expect the patient to follow an ambiguously presented or understood order. But is that the main reason doctor's orders may not be followed by patients?
Is there consensus that doctors should never give orders to patients under any circumstances? If so, why?
Shouldn't patients entering and accepting a relationship with a doctor also accept that orders may be given to them with the orders being based on the culmination of the skills that they expect of a doctor who is attending to the patient's illness and overall health? Sure, there will be mostly advice, suggestions or recommendations but there also may come orders.
I ask my visitors: when you give orders (and I mean not "suggestions") to others at your work or at home, what do you expect as a response? And why? ..Maurice.
Dr. Bernstein,
It goes back to the two definitions of "authority" that you previously referenced.
In the first instance ("an individual cited or appealed to as an expert"), which I agree applies to the physician with respect to their relationship with a patient, their standing is as an expert to provide medical advice or recommendations based upon their knowledge. Their advice or recommendations do not carry any legal authority - they can't "order" the patient to do anything.
The ability to "order" someone to do something falls under the 2nd definition, which can be summarized as "the power or right to give orders, make decisions, and enforce obedience". For example, this could apply to either public officials (police, judges, etc.) as empowered by law, or those in supervisory positions within public or private organizations with respect to their subordinates in carrying out their duties.
A physician could also fall into the 2nd definition, but only with respect to employees of their practice or their subordinates within the structure of a medical facility they work for. It never applies to patients in this context.
This dichotomy is not uncommon. In my profession as an engineer, my relationship with my clients falls under the first category of providing expert analysis and recommendations based on my expert knowledge and experience, while in my relationship with my employees I have the "authority" to direct, or if you prefer "order" how they are to carry out the tasks relative to their job responsibilities.
What I expect from a physician that I have consulted is both analysis and recommendations, with supporting information on how and why they got there, so I have all the information I need for me to decide what I will do. A physician presumptuous enough to "order" me to do something, I would likely (and in fact have) dismiss on the spot.
The physician can consider it an order if he/she likes, but I consider it only a recommendation. The physician is (hopefully) knowledgeable, but they don't have the authority to order me to do anything. I also very much dislike the term compliance - it implies a subordinate relationship to me. My relationship with a physician is that I pay them for a service - using their knowledge to make a recommendation.
I find a physician at times a necessary 'consultant' - especially as I can't prescribe my own medications, even if I knew what I needed. But I view whatever they say as their professional recommendation. I don't feel remotely obligated to 'comply' - I still entirely have free will.
I might not go along with it because either 1) I think the doctor is wrong - it has happened 2) the side effects or difficulty of the treatment outweigh the benefits for me 3) maybe I couldn't afford a medication.
That said, if I had a doctor whose advice I frequently wouldn't follow, and whose ideas I generally questioned, I'd try to find a physician that I respected more.
Re. the stopping smoking example - I wouldn't want to hear "I order you to stop smoking" - that's ridiculous, to another adult. To say "I recommend as strongly as I possibly can that you stop smoking. If you don't, I really believe that ....... will happen" is giving an adult the basic respect that they deserve.
As far as other professionals - I consider nurses, pharmacists, etc. professionals - within their scope of practice. I don't appreciate when nurses, or especially medical assistants (who I don't consider professionals) go beyond their scope.
Ads on TV - I might research a medication myself, and if interested, ask the physician I suppose. I do believe that I am competant to research it.
TAM
OK, here is a current example of what we are discussing here:
Former White House physician Connie Mariano, M.D. stated recently on CNN regarding New Jersey Governor Chris Christie: "I'm a Republican. I like Chris Christie. I want him to run. I just want him to lose weight," Mariano said. "I'm a physician more than I'm a Democrat or Republican. And I'm worried about this man dying in office."
"He could actually save lives out there if he turned around and did something with his weight and became healthy"
"I'm dead serious," she said.
More from CNN:
During the 1990's, Mariano helped then-President Bill Clinton in his own struggles with losing weight. She recalled how Saturday Night Live once lampooned Mr. Clinton as an insatiable junk food addict, pounding Big Macs from McDonalds.
After Clinton stumbled on some steps and tore a quadriceps tendon, Mariano said she worked with the White House chef and a personal trainer to help the president lose nearly 30 pounds.
All of that explains why Mariano winced when she saw Christie munch on a donut while waiting for Letterman to ask a question to the delight of a studio audience Monday night.
These remarks by the doctor as they were quoted are not simply suggestions..they are frank orders with a prognostic lethal threat if the orders are not followed.
Those who have already written here and my new visitors, how do you evaluate this example in terms already expressed on this thread? ..Maurice.
I would also add that Dr. Mariano delivering that order could also be considered an "authority" in view her former White House medical experience with the former President. ..Maurice.
I don't view any of that as orders, but rather voicing strong opinions, and warnings about what is likely to happen. Which is fine.
Truly Maurice, and I mean this in a nice way - it seems that you may have a quite different view of the physician/patient relationship than many of us do. To me it appears that you seem to view it as a very special relationship with extra authority and privilege, and somewhat paternalistic. I think some of us view it just as another professional that we consult for advice in one area of our lives. Nothing more, nothing less. And we would quite resent if the physician attempts to make it more.
TAM
TAM
TAM and my other visitors: Don't take what I write to my blog, in every thread, my own personal view. Why? Because I am the Moderator of this blog. My duties beyond screening for "spam" (which by the way is a very common attempt at posting), keeping the conversation pertinent to the thread and screening for ad hominem discourse, is to stimulate discussion on, if possible, all sides of a thread issue. That means I have to present questions to my visitors on all sides of the issue. I rarely insert my own personal view, though I do disclose as facts my own personal and professional experiences. This blog should be one of discussion of all sides of an issue and not a tool for me to advocate or propagandize one view.
So, don't take what I write on all the threads of my blog as personal opinions but look at them simply as an attempt of a Moderator to develop and keep a conversation of ethical issues going and productive of the views of my visitors. ..Maurice.
"Don't you think that physicians give orders to their patient, rather than advice or recommendations or even "suggestions" because the physician finds that the patient's health and safety is at risk without giving that order?"
No. While the physician may feel that way, the patient makes the decision to either accept or reject the "order".
"And if the patient doesn't comply with the order, isn't that a disturbing observation to the physician and isn't it reasonable for the physician to wonder about or even consider it a criteria regarding the patient's interest in their health and safety?"
The physician is free to interpret the patient's decision in whatever manner they choose.
"On the other hand, you might expect non-compliance would raise the possibility in the physician's mind that some other personal financial or personal factors might be responsible."
While this may be true, your point is?
"But do you really think that doctors actually consider that non-compliance to an order represents a rejection based on the patient's anger toward the physician authoritarian attitude in presenting the order to the patient?"
Absolutely!
"I would say, with confidence, even confidence from personal experience, that doctors would not consider that as a possibility for non-compliance by their patient."
Disagree completely. This attitude is the fundamental problem with respect to patient autonomy, privacy, modesty, and dignity; that somehow patients are subservient to a physician.
"How else can the doctor make the point to a patient regarding the professional decision of the importance to the patient's health and safety by simply giving "a suggestion", "advice" or "recommendation", as the communication is usually understood by using any of these 3 terms?"
Through a rational discussion of risks, benefits, and alternatives and respecting the patient's decision.
"Orders coming to the patient from the patient's physician should be considered as a very high form of authority based on the physician's professional knowledge and skills, the authority being the very reason the patient selected and went to the physician for help."
From a subject matter expert perspective, I agree. However, a physician is in no position to compel or dictate our healthcare choices.
Ed
"Don't you think that physicians give orders to their patient, rather than advice or recommendations or even "suggestions" because the physician finds that the patient's health and safety is at risk without giving that order?"
I don't think that most doctors disrespect the autonomy of their patients and would find giving orders as the only way to communicate on all issues.
"And if the patient doesn't comply with the order, isn't that a disturbing observation to the physician and isn't it reasonable for the physician to wonder about or even consider it a criteria regarding the patient's interest in their health and safety?"
If it isn't patient interest, it still could be that the patient doesn't understand the basis for the order and needs to be further educated by the doctor as to the reason for the order.
Doctors have to be aware that their patients have issues beyond understanding and accepting an order such as accommodation, inter-personal or financial issues. By being aware of such possibilities, inquiry about them may lead the doctor to provide the patient ways to mitigate them.
"On the other hand, you might expect non-compliance would raise the possibility in the physician's mind that some other personal financial or personal factors might be responsible."
Not really since I think that most patients come to the doctor because they consider the doctor an authority figure with regard to diagnosing and treating illnesses and providing medical orders when needed would be a reasonable consequence of that skill.
Except in the operating room where the unconscious patient has no immediate control of the doctor's choices and directions, all doctors realize that the patient is not like a computer such as when pressing the "Shift key" what next comes out will always be an upper case character. Obviously, "orders" mean "orders" to the physician when given out of necessity but doctors know they might mean something else to the patient. The duty is to find out what. ..Maurice.
Those visiting this thread may be interested in a new thread which also deals with doctor-patient communication. It is about the questions related to "curbside consultations", informal consultations to educate a doctor on how to proceed in the care of a patient but without notifying the patient about the consultation. I thought you all might be interested to read and write there. ..Maurice.
I apologize if I upset you in any way, I really didn't mean any offense. It was just a tone that I felt from your writings. I did not mean that you were "bad" in any way - just that perhaps there was a basic difference in how the relationship was viewed, and thus, a different perception of issues at times.
TAM
Belinda on the Patient Modesty thread posted the URL to an article directed to physicians regarding how to improve patient compliance. I thought that that article would be appropriate for this thread. Read the article and then return and let me know what you think about it. ..Maurice.
I think that excellent article sums it up far better than I ever could:
"In this era of the empowered patient, it is time to think about compliance in a different way. Compliance implies an involuntary act of submission to authority, whereas adherence refers to a voluntary act of subscribing to a point of view. The difference is not just semantic; it goes right to the heart of our relationship with our patients. We need to influence our patients to become — or remain — adherents of good self-care. To do this, we need to establish three key conditions in our communication with patients: shared values, shared language, and mutual respect"
"The doctor remains a source of knowledge, but his or her role becomes more like that of a coach, teacher, or mentor. The patient visits the doctor to access technical resources, medical expertise, and psychosocial support, but maintains the responsibility for managing his or her illness. Compliance becomes less an issue of obedience and more an issue of setting and working toward realistic and relevant goals."
When I think about it, what other profession expects to issue orders to another adult? Your mechanic is an 'authority' on car repair, yet who would let them order you to have a particular repair? For higher education - even take your attorney. I've never heard of an attorney issuing orders. Strong recommendations and advice, yes. I believe that some physicians, as discussed in that article, still want to be the authority figure. But also as the article points out, that is more popular with older patients. Many in the current generation very much resent that attitude, and will not tolerate it.
TAM
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