Power

Although doctors tend to think of their relationships with patients in terms of care, almost everyone who has looked at these from the outside has seen them in terms of power. Many have drawn on the work of Michel Foucault, the French historian and philosopher. Foucault argued that power suffuses all human encounters, especially those involving professions and institutions.1 You only have to cast a critical eye on any interaction in the medical clinic to understand his basic premise. Consider, for example, the way that case notes are piled up tantalisingly on the reception desk for the doctors to come and fetch. It would be perfectly possible to give them to the patients themselves as they arrive, so they could spend time reading them and even (heaven forbid) write in them to correct errors or add personal details if they wish. In spite of this, most doctors find such an idea hard even to consider, because it challenges our innate assumptions about power relations in medical practice.

In fact, almost everything we do in the clinic sends clear signals to patients that we are the people who make and apply the rules, and they are the ones who are obliged to comply. We don't just express power in the way we behave towards patients. According to Foucault, it arises from the fundamental way that doctors see patients as bodies—what he termed ‘the medical gaze’. Seen from his perspective, the way we organise our appointment systems is entirely consistent with everything else we do as doctors. It is one of a myriad of ways that we scrutinise and regulate people in order to take control of them. For much of the time, this may be partly concealed, but in waiting rooms it is there for everyone to see.

Ceremonies

Even if we are able to regard the doctor–patient relationship in terms of power, it may still seem strange to think of our work in terms of ceremonies. Yet there are social scientists who commonly use this word to describe what goes on in medicine. They use it in a special sense, following the leading sociologist of institutions, Erving Goffman. When Goffman talked about ceremonies, he was referring to the way that institutions and their members implicitly impose a set of rules to instruct people how to behave.

One outstanding piece of medical research that applied this approach was Philip Strong's study of paediatric clinics entitled ‘The Ceremonial Order of the Clinic’.2 Strong examined consultations with parents and asked questions, including: ‘Who has the right to criticise what is happening, what type of criticism is allowed, who has rights to the overall control of the interaction, and how far are topics and speaking rights pre-allocated?’ Not surprisingly, his research showed that the doctors gave strong indications to parents about what it was legitimate to express in consultations about their children. The doctors were also the arbiters of what parents were allowed to consider as appropriate conduct in relation to their children, irrespective of whether this fell within the realm of medical expertise or not.

Although Strong didn't draw an explicit analogy with the priesthood or with formal religious ceremonies, it isn't hard to see from his description how many of the traditional activities of the clergy have actually been re-assigned to doctors. If this seems improbable, you only have to think of the way that patients are lined up in many waiting rooms like a congregation at prayer, even facing the reception desk as if it was an altar. And when doctors emerge every few minutes from consulting rooms to retrieve a set of notes and then vanish again, it has a close resemblance to a Greek orthodox priest disappearing behind the icon screen, or the high priest of the Israelites entering the Tabernacle. Modern doctors, it seems, have done more than take on the moral function of priests. In the waiting room, they enact priestly forms of ritual as well.

The unconscious at work

While sociologists have looked at medical institutions using concepts such as power and ceremonies, organisational psychologists have brought rather different frameworks. Many who work in this field apply ideas taken from studying individuals, including an emphasis on the unconscious mind. One of the commonest principles they use for understanding clinical activity is that much behaviour that appears designed to meet the needs of patients may covertly be serving darker purposes. This can include protecting clinicians from unmanageable anxiety, or enacting a concealed wish to punish others. It is relatively easy to notice this in the way that some people behave at work: you have only to think of your most controlling or bossy colleagues in order to perceive. What is harder for many people is to accept that such psychological mechanisms are present in all of us, indeed universal in the caring professions, and may even guide how whole institutions function. Yet some psychologists argue this is indeed the case.

In a classic collection of essays about how the unconscious mind affects the workplace, Anton Obholzer and Vega Zagier Roberts look at both troubled organisations and healthy ones.3 They demonstrate that places such as waiting rooms are inevitably ones where we have licence to treat patients badly, and to make up credible excuses for doing so. Unlike most sociologists, however, they also offer remedies for this. They show how clinical teams can learn to acknowledge their own destructive tendencies and bring these under conscious control. They give examples of how professionals who can do this behave more compassionately towards patients, and indeed towards each other. Teams then feel free to start changing dysfunctional systems that seemed unchallengeable, or just part of the natural order of things. If Obholzer and Roberts are right—and I believe they are—each of us can take responsibility for changing some of the things that patients most dislike, or find inexcusable in doctors. An improvement in waiting times would be a good place to start.