The limitations of a negotiation model for perimenopausal women

Abstract

The clinical negotiation model proposed by Katon and Kleinman (1981) puts culture at the very heart of the patientdoctor relationship. As opposed to the asymmetric model that stresses an unequal power relationship between a dominant physician and a powerless patient, this transactional model suggests that we view the clinical encounter as the locus of a negotiation that takes place between two kinds of knowledge (lay and professional), and between two agendas: the doctor's and the patient's. According to such a model, the doctor is taught to listen to the patient's own explanatory model of disease.Using an in-depth analysis of clinical encounters between perimenopausal women and female physicians, and of separate interviews with individual doctors and patients concerning their respective explanatory models, this pilot study puts emphasis on both the limitations of a transactional model and on the strategies deployed by doctors for enhancing the credibility of hormonal replacement therapy.Keywords: menopause, clinical encounter, negotiation model, transactional model, practice patterns IntroductionThe difficulties in the doctor-patient relationship in Western medicine have been treated as emblematic of its profit-oriented, dehumanising system of health care and as mirroring, in the local setting of the clinical encounter, asymmetric power structures in the wider society. Through a rich diversity of hermeneutic, constructivist, case-study or discourse-analysis methodologies, social scientists have tried to identify the factors that make these doctor-patient relationships problematic (Roter et al. 1988, Cosnier et al. 1993, Roter and Frankel 1992. As an alternative to functionalist and critical asymmetric models of the doctor-patient relationship which emphasise the cultural dimensions of the medical encounter, some medical anthropologists and sociologists have suggested focusing on more symmetric`negotiation' models. As early as the 1950s, as illustrated by Tuckett (1978), and drawing on the literature on negotiated order in the realm of health care (Strauss 1979), a number of medical sociology studies suggest that beyond the activity-passivity and guidance co-operation models of a doctor-patient interaction there has emerged a mutual participation model that stresses the active role of the patient and a mutual negotiation process. While recognising that`the basic consideration in situations of bargaining and negotiation is where the power lies' (Tuckett 1978: 206), research now focuses on the conditions (local, interactionist or structural) that influence this negotiation. One interesting variant of this negotiation model, developed from a cultural-interpretativist approach, is the cognitive-interpretative`transactional model' developed by Katon and Kleinman (1981). This model stresses the negotiation process between two divergent explanatory models of illness: the medical-clinical model and the patient-popular model. Tensions and ineffectiveness in clinical encounters are thus explained by communication...

Internet : un facteur de transformation de la relation médecin-patient ?

“…La maladie chronique s'installant dans la durée incite en efet le patient à s'informer et peut favoriser un transfert de connaissances et de compétences entre médecins et malades. On s'intéresse ainsi à la participation du patient et au processus de négociation mutuelle qui s'engage entre les protagonistes de la relation de soins (Massé et al, 2001). De nouveaux modèles émergent, ils reposent sur plusieurs prémisses : 1) la possibilité pour chacune des parties de présenter sa vision de la maladie lors de la consultation, 2) l'engagement dans une véritable négociation concernant le diagnostic et le traitement, et 3) l'atteinte d'un consensus mutuel (Gafni, Charles, Whelan, 1998).…”

“…De nouveaux modèles émergent, ils reposent sur plusieurs prémisses : 1) la possibilité pour chacune des parties de présenter sa vision de la maladie lors de la consultation, 2) l'engagement dans une véritable négociation concernant le diagnostic et le traitement, et 3) l'atteinte d'un consensus mutuel (Gafni, Charles, Whelan, 1998). Ces étapes ne sont pas toujours présentes dans la rencontre médecin-patient, comme l'ont montré Massé et al (2001) dans leur étude de consultations entourant la ménopause. En efet, les patients ne disposent pas nécessairement de l'espace pour présenter leur vision de la maladie, ni de l'expertise pour le faire.…”

Hormone therapy prescription among physicians in France and Quebec

“…23 In Quebec, women physicians seem to be involved more often in the care of the menopausal women. 24 Indeed, women physicians have among the highest rates of HT use in the world. 25,26 Physicians from Quebec were more likely than French physicians to be high-frequency prescribers.…”

Intercultural Health Care as Reflective Negotiated Practice

“…I acknowledge the presumption that health workers will want to engage with clients from other cultures but may not do so when their anxiety of difference (or the fear of making a cultural mistake) leads to a "freezing" or a "do nothing" response such as withdrawal (Gerrish et al, 1996). I also acknowledge that the rhetoric of negotiation may not always match practice when a health worker believes that their authority is exercised in the best interests of the client (Gerrish, 2000;Masse, Legare, Cote, & Dodin, 2001). Rather than reject the concept of negotiation, these failures in its operationalization may indicate why health care services remain unresponsive to the needs of immigrant minorities and what failures need to be addressed.…”