Doctor, your boss is in the exam room

A new study shows us ways in which power dynamics in the exam room can influence the care patients receive

Most of the time when we’re talking with and examining patients, our attention is directed toward figuring out what’s going on with them and what we might be able to do to help them. It’s pretty easy to forget what an incredibly humbling experience it is to be a patient; we usually get that reminder when we become patients ourselves.

The second a doctor walks in the door, they hold power over their patients. To seek medical care is to give a stranger access to everything about you; meanwhile, you may not know much more about them than their name. The doctor has years of training and access to resources, giving them the knowledge and ability to help patients solve problems that they cannot solve alone. As patients, we place a lot of trust in physicians to use their power in our best interests.

Suffice it to say, a power imbalance tilted toward the doctor is inherent to the vast majority of doctor-patient interactions. But there are some situations where the power dynamic is different—perhaps less tilted toward the doctor—when the patient holds some sort of elevated status. When a celebrity, billionaire, CEO of the hospital, or even a physician colleague walks into the exam room, the power dynamic shifts in ways that could impact their care.

While it’s a reasonable assumption that power dynamics can impact patient care somehow, it’s a difficult question to study. But some researchers found a way.

At ease, doctor!

In a new working paper, US Army/UT San Antonio economist Stephen Schwab and UMass economist Manasvini Singh found a way to study doctor-patient power dynamics by turning to a population where status and power are quite clear: the U.S. military. While military physicians tend to be relatively high ranked officers who will outrank many of their patients, they also care for plenty of patients who outrank them.

While the doctor always has more control over valued resources in the medical context, such as access to information, clinical services, decision-making rights, and medical authority, higher-ranking patients will have greater control over resources outside the medical context, such as status, networks, and military authority.

They looked at patients in the emergency department in U.S. based military hospitals. As in other EDs, patients tend to be assigned to the next available doctor in a queue—meaning even if a highly-ranked officer somehow used their influence to move up in the queue, which doctor they saw was as good as random. This also meant that the rank of the doctor they saw was as-good-as-random, and by extension, so was the difference in rank between doctor and patient.

They looked at two scenarios for doctor-patient interactions: ones with “high power patients” who outranked the physicians who happened to be caring for them, and ones with “low power patients” for whom the physician happened to outrank them. But because doctors’ ranks can vary, patients of the same rank may be a “high power” or a “low power” patient depending on which doctor they happen to be assigned to.

Here’s some of what they found, based on military medical records where they can identify ranks of patients and their doctors:

• For patients at a given rank, when they happened to outrank their doctor and were “high power,” their doctors put in 2.6% more effort (as measured by RVUs, a measure of the amount of work a doctor puts into patient care) and used more resources compared to when patients were outranked by their doctor and were “low power.”

• This pattern persisted when they examined practice patterns of physicians whose power changed with respect to patients of a given rank shortly after a doctor was promoted to a higher rank (where additional experience wouldn’t explain changes in their practice)

• When patients at a given rank were “high power,” the greater care they received in the ED led to a 14% reduction in the likelihood of later being admitted to the hospital (within 30 days) compared to when they were “low power” and outranked by their doctor.

• As a result of the finding above, the authors estimate that if “low power” patients were treated the same way as “high power” patients—with more effort and resources at the outset—it would actually save money, since it is more expensive to care for the consequences of lower effort and less resource use

They went on to do some additional analyses to dive deeper into how the power dynamics might influence care:

On days the physician attends to a high-power patient, they decrease effort for their concurrently seen lower-ranked patients (whose health outcomes suffer in turn), suggesting suboptimal effort re-allocations by the physician from their relatively less powerful to more powerful patients.

Second, we present “power heterogeneities” in which we show that power stemming from military rank interacts with doctor-patient race and gender concordance in interesting and predictable ways, suggesting that power dynamics are indeed an amalgam of several factors even beyond military rank. For example, being high-power allows Black patients to overcome the lower effort they normally receive from higher-ranking White physicians.

What does this tell us about care in the civilian world?

The military health care system is obviously much different than the civilian one, and the dynamics of rank and power are unique to the military. So while we must be careful not to overgeneralize findings from the military to the civilian world, we should also remember that there is something universal about doctor-patient interactions that transcends the setting, the language, the culture, and even the century in which that interaction takes place.

We probably won’t have the chance to study doctor-patient power dynamics in the civilian population on the scale and level of robustness as Schwab and Singh’s military study, so if we think there is some aspect to this study that applies to the civilian world, we should try to learn from it.

It’s reasonable to think that the equivalent of “high power” patients in the civilian world also enjoy additional effort and resource use from physicians. The challenge is in identifying who, exactly, these patients might be outside of obvious cases like celebrities, which emergency departments are often forced to treat differently to maintain their privacy. (One idea that comes to mind would be to study patient outcomes and care re-allocation in a given hospital or ED during periods when celebrities are cared for, an event that is sometimes captured by media).

Many hospitals around the country have units where patients can pay for additional comforts while, theoretically, receiving the same care as they would on regular units. Might they be “high power” patients? What about patients who pay a concierge fee to their primary care doctor? Or patients who pay thousands of dollars for an “executive physical”? We think it’s reasonable to assume patients like these, among others, likely bring out differences in practice similar to higher ranking military officers.

But if we are also to assume that, as in the study, treating “low power” patients the same as “high power” patients would lead to better outcomes and cost savings, it seems like an answer is pretty clear: doctors treating everyone as well as they would treat their boss might be good for everyone. The evidence here supports what medical ethics has told us all along: there’s no such thing as a VIP patient.