Rhetoric vs. Coercion   5 comments

In order for physicians or medical students to become more successful communicators with their patients and thus better doctors, I think the key is for physicians to recognize and understand the implications of their roles as rhetors capable of manifesting their authority over patients in a manner that might demean a patient’s social status, or even intelligence.  (Lay, page 27, regarding Paul Stair’s _The Social Transformation of American Medicine_)

Segal brings up an interesting observation that sometimes family members of patients (or even patients themselves) include biomedical terms within the dialogue of treatment options.  (Segal, 109)  This may be a way for the patient/family member to meet the physician half way in a language barrier that could so easily turn into a coercive situation otherwise. (Segal, 91)  Or this may be a way for a patient to exert a sense of personal power within a situation where they feel like they may be belittled or patronized as laymen unable to participate in making complicated medical decisions. (Segal, 109 & Lay, 30)

In my own personal endeavors (or mishaps) as a patient, on one hand I have experienced physicians who enjoy communication involving terminology that they commonly use within the medical field, and on the other hand I’ve also encountered physicians who try to return me to laymen-speak as though to exert control over a secret language within a club that I am not a part of nor should I try to be.  Some doctors feel like, “Oh thank God she gets what I’m talking about and I don’t need to water the information down.”  Whereas other doctors I sense an irritability that I’m trying to gain a balance within medical rhetoric in which I too can speak the secret language.  They would rather I stayed “in my place” so to speak, as uninformed patient.   

One thing that really struck me in our reading of _The Rhetoric of Midwifery_ by Mary Lay, is just how important simple reiteration of a concept, attitude, perception, or idea can eventually evolve into legitimacy, even within the medical community which society views as an arena that bases its actions on statistical data and thorough research.  “In contexts in which technology impacts health and safety, rhetorical scholars are just beginning to recognize how, as Beverly Sauer observes, ‘the conventions of public discourse sanction the exclusion of alternative voices and thus perpetuate [a] salient and silent power structure’ and how ‘the notion of expertise excludes women’s experiential knowledge.’”  (Lay, 29)  Physician accuracy, skill, and even legitimacy based on higher social status and prestige may eliminate the midwives as authoritative on anything.  The medical community exerts control in many areas within society beyond the scope of medicine, in turn society accepts that un-tested dominance as legitimacy, which in turn allows medicine to continue asserting its scope of authority and also intensify authority for which it exerts within the field of medicine.  And if there’s no one to contradict or question the method to the madness, then madness alone prevails?  And contradiction or questioning cannot arise unless there is a balance in communication; unless it is truly rhetoric and not “coercion.” (Lay, 91)  I believe this extends far beyond Segal’s chapter on Death and Dying, because this battle between rhetoric versus coercion can be found in any area of medicine.

For instance, as Lay points out, some women feel either alienated enough from the medical community or much more empowered by midwifery home delivery to proceed with breech births at home without a medical doctor present.  Within the parameters of the standard medical paradigm, “when faced with a persistent breech baby—one not turning head down in the womb—[a pregnant woman] might be urged to schedule a cesarean rather than being given information on how she or her caregiver might successfully turn the baby.” (Lay 23, 24)

In order for the midwives to “gain” authority within the community at large (whether society or in specifically medicine), they needed to bring about the recognition of a “knowledge system based on women’s experiential and embodied knowledge.” (Lay, 30)  In fact, one strategy of persuasion seemed to be the common goal of “protecting the public from harm.” (Lay, 34)

I wonder:  Can patient-doctor communication create a positive rhetoric if only the patient and the doctor first evaluate what is the desired goal at large or even specific outcome hoped for?  Can boundaries of medical “science” versus “embodied knowledge” be brought down by a common goal if that goal is definitively established from the get go?  And if patients in turn felt a stronger sense of personal power throughout the process of being a patient, would they be less likely to shy away from standard medicine altogether?

Yet, I have to also wonder how much fear of lawsuits will prevent good, balanced rhetoric to take place.  Aren’t hospitals more concerned with covering their own asses, so to speak, then of open discussion concerning all options?

—-Genevieve 

Lay, Mary M. The Rhetoric of Midwifery: Gender, Knowledge, and Power. New Brunswick: Rutgers UP, 2000. Print.

Segal, Judy Z.  Health and the Rhetoric of Medicine. Carbondale: Southern Illnois UP, 2008. Retrieved September 11, 2010, from netLibrary.

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Posted September 14, 2010 by gentyrrell in Uncategorized

5 responses to “Rhetoric vs. Coercion

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  1. It is very interesting to contemplate the dynamics of power and control in the doctor-patient relationship. Your thoughtful discussion got me reflecting on my own experiences, not just with regard to doctors, but as it relates to interacting with anyone who might perceive themselves in a position of authority, power, strength, superiority or advantage. There is always a subtle battle going on when two people interact for dominance. We are always seeking to control the frame in the interaction, and generally, its seems the one with more guile (and dialectic ammunition) than innocence wins. The only reason I go to the doctor, knock on wood, is because I have serious allergy problems every year during allergy season. I’m there like clockwork getting a slew of various allergy medicines — I walk in, tell the doctor what’s wrong, tell the doctor what medicines I need, and walk out with the prescriptions. My sense of certainty and my goal (and if I stay any one place for any time, the paper trail of annual visits) make for a very smooth and efficient transaction. Wouldn’t it be funny if my self-diagnosis has been wrong all these years.

  2. Great post. Your question about how much fear of lawsuits affects rhetoric and patient/doctor relationships is especially pertinent in light of Lay’s discussion, since I liability is no doubt a factor with the prevalence of C-sections. It’s an easy approach to a myriad of potential problems. However, “potential” can be construed for convenience as well. A doctor likely prefers a half-hour surgery over a sixty hour labor. Liability creates a tension between patient and doctor that may negatively impact quality of care and, as you say, prevent “good, balanced rhetoric” from taking place.

    “I have to also wonder how much fear of lawsuits will prevent good, balanced rhetoric to take place. Aren’t hospitals more concerned with covering their own asses, so to speak, then of open discussion concerning all options?”

  3. What did you think of Segal’s discussion of the psychologist who saw family members’ and medical providers’ struggles with language as a positive sign of linguistic adjustment?

  4. Ah, that psychologist: Maurice Bloch. He supplied correctives to my thinking all along, had a kind of generosity; saw these conversations really as efforts of everyone to move toward common ground. If he were a rhetorician, he’d have been a Burkean.
    I’m interested in the idea of coercion. I do think it applies in so many cases of dr-patient interaction. But, of course, it is usually covered (eulogistically, as Burke would say) as cooperation. In my death chapter, I ask where the choices came from in the first place that patients and family members are asked to adjudicate on. That question kept coming up for me as I wrote the book, and it continues to arise, now that we tout “concordance” models of clinical decision-making. I still do wonder who knows what about what (are patients and doctors simply different sorts of experts?)–and who is really deciding on courses of action/treatment when doctors and patients decide together.

  5. Truthfully? I had a problem with the line, “Similarly, while I have noted what I take to be approval-seeking moves by family members, Bloch finds that clinical team members, no less than family members, seek approval of their attitudes and actions.” My only personal experience of this sort of seeking approval happened once: when I met my neuropsychiatrist ten years ago. This alone I found interesting because Block is a psychologist, leading me to wonder if in the psychology/ psychiatry world of medicine this is much more a substantial practice. I wonder if it’s the nature of psychology to seek approval to allow the doctor to treat the patient. It’s the only area of medicine in which a patient has to really personally relinquish control– the control over their thoughts and emotions which currently there aren’t really any standardized technological tests to quantify (like a blood test for manic depression or a brain scan to determine anxiety disorder for instance). Medical judgment is based on the relinquishing of truths to the doctor (by the patient and/or family member), in which case the doctor must gain approval if they are to succeed.

    But I cannot say I’ve ever had a cardiologist care about gaining my approval for anything. 😉 I honestly don’t think a lot of doctors look for approval from their patients because they rely so heavily on the approval of the medical diagnostic data, rather than the patient narrative. Why bother to break down language barriers with the patient if a blood test will simply tell them the patient has a good blood cell count, whether their liver enzymes are normal, whether an MRI proves they do or don’t have cancer? In fact, I’d say many doctors skip the patient communication part in the beginning, or somewhat disregard it anyway, because hell, they’ll get the answers they’re looking for in the lab work, right? (Of course for “zebras” this is terrible, because the usual lab work many times will come back “fine”. The key to diagnosis and proper treatment is patient narrative.)

    —Genevieve

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