Patient engagement and the epistemics of medical authority: Diagnosis resistance in US primary care

When patients visit their primary care physician with some new health concern, they bring along their own ideas or worries about what might be wrong and expectations for how the visit might go. Patients are more engaged in their healthcare than ever before, and patient-centered care advocates have long emphasized the importance of pursuing and addressing the patient perspective. Yet in clinical encounters, both patients and physicians maintain an orientation to the physician’s medical authority and the primacy of the biomedical perspective. Patients often feel unheard, and their concerns remain unmet. This may at least partially be due to the interactional structure of primary care encounters, which is shaped by a legacy of medical paternalism. When patients have lingering concerns after a physician has assessed their condition, they have limited interactional opportunities for raising those concerns. In this dissertation, I use conversation analysis and recordings of primary care visits to examine diagnosis resistance, one resource patients use to raise concerns about the fit between a physician’s assessment of their condition and their own experience or expectations. I find that patients resist more often than previously thought, especially when the physician’s assessment of their problem diverges from their own. But patients resist carefully, relying primarily on actions that present the least overt threat to the physician’s medical authority. In turn, physicians tend to respond in ways that prioritize their own agenda over attending to or pursuing patient concerns. This is made easier by the fact that patients resist in the least overt ways to begin with. These findings suggest a tension between patient engagement and a legacy of medical paternalism. Patients are working to get their concerns addressed, but are undermining their own efforts by strongly deferring to the physician’s authority to assess their problem in the first place. In order for healthcare to more adequately attend to, respect, and treat as central the patient’s perspective, more work is needed to find ways for practices like pursuing and attending to the patient’s perspective to become a clinical reality, rather than the aspiration they currently are