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How the new subjective medicine is a paradigm shift

Schiffon
Schiffon
Jul 30, 2017 · 4 min read

To date, Mark Sullivan’s seminal “The New Subjective Medicine: Taking the Patient’s Point of View on Health Care and Health” has nearly 400 citations. Sullivan asserts, “The physicians’ job description will be changed to focus on patients’ lives rather than patients’ bodies. Definitive evaluations of medical effectiveness will occur within patients’ lives rather than within doctors’ hospitals” (Sullivan, 2003).

With the increasing realization that medical care is a negotiated process, patient-centered care has been identified as a care improvement target (Gillespie, 2001; The Institute of Medicine, 2013). This reorientation of health services has socio-cultural, economic, educational, institutional, conceptual, and empirical prerequisites. Patients, providers, and health care organizations are actively determining, holistically, and on a case-by-case basis, “What is the legitimate role of the patient and the role of the provider in the process of care?”

Unique boundary conditions influencing the patient-provider relationship

  • The authority and professional sovereignty conferred to physicians in the U.S. is uniquely dominant, relative to other professions (Starr, 2004).
  • In a typical clinical context, there is extreme information asymmetry — the patient may be presumed as naive relative to the clinician.
  • The patient may be vulnerable and/or dependent due to illness.
  • Patients report an expectation to “conform to socially sanctioned rules” and “[defer] to authority” within a clinical encounter (Frosch, May, Rendle, Tietbohl, & Elwyn, 2012). Patients also report a fear of being perceived as difficult by their clinicians.

Participatory medicine, setting new contexts

In contrast, traditional bioethics has an explicit patient autonomy imperative, demands patient empowerment, and establishes the supremacy of patients’ decisions about their care (Medical Professionalism, 2002). Millenson, a contemporary advocate of participatory medicine asserts, “The old culture will give way to a new, Information Age culture that will bolster the “moral and cognitive bases” of medical professionalism by anchoring them, finally in genuine power sharing and equal partnership” (Millenson, 2013). Clinicians may be sensitive to the loss of expertise based authority and the sharing of power. “Since autonomy is developed, exercised, and realized in a social context, it is important to create fair and supportive social contexts” for patients to participate in medicine (Ells, Hunt, & Chambers-Evans, 2011).

Patient-centered communication

Communication is a fundamental and complex influencer of the relationship between patient and provider, facilitates information exchange, and enables informed medical decision making (Ong, de Haes, Hoos, & Lammes, 1995). Patient-centered communication is a multidimensional construct that is influenced by patient, health systems, clinician, and relationship factors (Epstein et al., 2005).

Patient-centered communication involves:

  1. eliciting and understanding the patient’s perspective — concerns, ideas, expectations, needs, feelings and functioning;
  2. understanding the patient within his or her unique psychosocial context;
  3. reaching a shared understanding of the problem and its treatment with the patient that is concordant with the patient’s values; and
  4. helping patients to share power and responsibility by involving them in choices to the degree that they wish (Epstein et al., 2005).

Patient-centered communication is a contrast to dysfunctional communication styles that may be dehumanizing via their divestment from the individual illness experience (Barry, Stevenson, Britten, Barber, & Bradley, 2001). An unintended consequence of objective medicine is the hazard of disassociating disease from the context of the patient’s life and a non-patient-centered communication style.

This is the first in a series of posts where I will provide commentary on “how to” consult with patients, shared decision making, and how to assess the new subjective medicine.

This is my first publication on Medium. I want to connect with others who are passionate about this paradigm shift. If you enjoyed this post, please show your love - click the , share, and let me know! Join the conversation and share your insights.


Sullivan, M. (2003). The new subjective medicine: taking the patient’s point of view on health care and health. Soc Sci Med, 56(7), 1595–1604.

Gillespie, S. R. (2001). The Politics of Breathing: Asthmatic Medicaid Patients Under Managed Care. Journal of Applied Communication Research, 29(2), 97–116. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=ufh&AN=4563029&site=ehost-live&scope=site

The Institute of Medicine. (2013). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Retrieved from Washington, DC

Starr, P. (2004). Precis of Paul Starr’s The Social Transformation of American Medicine. 1982. J Health Polit Policy Law, 29(4–5), 575–620.

Frosch, D. L., May, S. G., Rendle, K. A., Tietbohl, C., & Elwyn, G. (2012). Authoritarian physicians and patients’ fear of being labeled ‘difficult’ among key obstacles to shared decision making. Health Aff (Millwood), 31(5), 1030–1038. doi:10.1377/hlthaff.2011.0576

Medical Professionalism, P. (2002). Medical professionalism in the new millennium: a physicians’ charter. The Lancet, 359(9305), 520–522. doi:http://dx.doi.org/10.1016/S0140-6736(02)07684-5

Millenson, M. (2013). Not In My Name: Real Patient-Centeredness Means Sharing Power. Retrieved from http://healthaffairs.org/blog/2013/02/26/not-in-my-name-real-patient-centeredness-means-sharing-power/?view=full

Ells, C., Hunt, M. R., & Chambers-Evans, J. (2011). Relational autonomy as an essential component of patient-centered care. International Journal of Feminist Approaches to Bioethics, 4(2), 79–101. doi:10.2979/intjfemappbio.4.2.79

Ong, L. M., de Haes, J. C., Hoos, A. M., & Lammes, F. B. (1995). Doctor-patient communication: a review of the literature. Soc Sci Med, 40(7), 903–918.

Epstein, R. M., Franks, P., Fiscella, K., Shields, C. G., Meldrum, S. C., Kravitz, R. L., & Duberstein, P. R. (2005). Measuring patient-centered communication in Patient–Physician consultations: Theoretical and practical issues. Social Science & Medicine, 61(7), 1516–1528. doi:http://dx.doi.org/10.1016/j.socscimed.2005.02.001

Barry, C. A., Stevenson, F. A., Britten, N., Barber, N., & Bradley, C. P. (2001). Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor– patient communication in general practice. Social Science & Medicine, 53(4), 487–505. doi:10.1016/S0277–9536(00)00351–8

Schiffon

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Schiffon

Growing in good things. #Progressive #Independent. #DemExit. Public Health, Social Justice, Youth. Wife, Mom, Christian. From NYC. I don't take bait. #StayWoke.

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