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The “Handling” of power in the physician-patient encounter: perceptions from experienced physicians Nimmon, Laura; Stenfors-Hayes, Terese Apr 18, 2016

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RESEARCH ARTICLE Open AccessThe “Handling” of power in the physician-patient encounter: perceptions fromexperienced physiciansLaura Nimmon1,2* and Terese Stenfors-Hayes3AbstractBackground: Modern healthcare is burgeoning with patient centered rhetoric where physicians “share power”equally in their interactions with patients. However, how physicians actually conceptualize and manage their powerwhen interacting with patients remains unexamined in the literature. This study explored how power is perceivedand exerted in the physician-patient encounter from the perspective of experienced physicians. It is necessary toexamine physicians’ awareness of power in the context of modern healthcare that espouses values of dialogic,egalitarian, patient centered care.Methods: Thirty physicians with a minimum five years’ experience practicing medicine in the disciplines of InternalMedicine, Surgery, Pediatrics, Psychiatry and Family Medicine were recruited. The authors analyzed semi-structuredinterview data using LeCompte and Schensul’s three stage process: Item analysis, Pattern analysis, and Structuralanalysis. Theoretical notions from Bourdieu’s social theory served as analytic tools for achieving an understanding ofphysicians’ perceptions of power in their interactions with patients.Results: The analysis of data highlighted a range of descriptions and interpretations of relational power. Physicians’responses fell under three broad categories: (1) Perceptions of holding and managing power, (2) Perceptions ofpower as waning, and (3) Perceptions of power as non-existent or irrelevant.Conclusions: Although the “sharing of power” is an overarching goal of modern patient-centered healthcare, thisstudy highlights how this concept does not fully capture the complex ways experienced physicians perceive, invoke,and redress power in the clinical encounter. Based on the insights, the authors suggest that physicians learn to enactethical patient-centered therapeutic communication through reflective, effective, and professional use of power inclinical encounters.Keywords: Physician-patient relationship, Patient-centred care, Qualitative researchBackgroundAlthough the role power plays in medical interactions isbecoming increasingly recognized as an important areaof inquiry, [1–12] research is still nascent in this area.When power is depicted in the physician-patient encoun-ter, it is rendered as something physicians own and yieldto their own advantage with little conscious awareness[13, 14]. To our knowledge, there is no qualitativeresearch that has explored with experienced physiciansthemselves how they both view power in the physician-patient encounter and the ways they are intentional withits use. Physicians’ qualitative descriptions of their aware-ness of power is important to capture in the context ofmodern healthcare eschewing a paternalistic approach tophysician-patient relationships, and espousing values ofdialogic, egalitarian, patient centered care [15]. Theseideals are pervasive, for example, in depictions of reflectivephysicians who “share power” through engaging in shareddecision making practices with patients [16–21]. With thecurrent emphasis in the healthcare literature on theequal sharing of power as an integral element of patient* Correspondence: laura.nimmon@ubc.ca1Centre for Health Education Scholarship, Vancouver, Canada2Department of Occupational Science and Occupational Therapy, 429 – 2194Health Sciences Mall, Faculty of Medicine, University of British Columbia,Vancouver, British Columbia V6T 1Z3, CanadaFull list of author information is available at the end of the article© 2016 Nimmon and Stenfors-Hayes. Open Access This article is distributed under the terms of the Creative CommonsAttribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a linkto the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedicationwaiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwisestated.Nimmon and Stenfors-Hayes BMC Medical Education  (2016) 16:114 DOI 10.1186/s12909-016-0634-0centered therapeutic communication, [17] we aimed toexplore how experienced physicians themselves per-ceive power and its distribution in the physician-patientencounter.Theoretical frameworkBourdieu’s social theoryUnder a broader paradigm of sociocultural theory, we drawon Bourdieu’s [22] work which emphasized that whateverpower language possesses is a power ascribed by the socialinstitution (e.g. social institution of medicine) with whichthe speaker is associated. We also apply Bourdieu’s the-oretical concept of “habitus” which is described as a setof learned “dispositions” and inclines individuals to actand react in certain ways. Through a myriad of pro-cesses, such as medical training and education, an indi-vidual acquires a set of “dispositions” that becomesecond nature and embodied. These dispositions generatepractices, perceptions, behaviour, and attitudes which re-flect the social conditions (e.g. medical training) withinwhich they were acquired.Bourdieu’s concept of doxa further elaborates his no-tion of habitus. Doxa is a conceptual tool that can beused to make sense of how physicians subconsciouslyaccept and internalize attitudes, knowledge, beliefs andvalues of the institutional and organizational culture ofmedicine without knowing they are doing so [23]. Ac-cording to Bourdieu, doxa is transmitted through thebody, language and dispositions towards things that arebelow a level consciousness [23]. This subconscious in-ternalization of physicians’ position of power is evident,for example, in empirical research where physicians havedescribed themselves as at the top of the healthcare hier-archy; as the “leaders” and “decision makers” who have“training”, “knowledge” and “skills” that are more valu-able than that of other health professionals [11].According to Bourdieu [22] when individuals interactthey do so in specific social context: “the field”, which inturn shapes their practices, perceptions and attitudes.There are various levels of social fields in medicine; suchas macro level field of medicine or healthcare, the me-dian level field of the hospital, and the micro level fieldof patient-doctor interactions [24]. Habitus can thuschange over time in relation to exposure to specific so-cial fields, and is not static or permanent. Social fieldsare sites where positions of power are determined by thedistribution of different kinds of capital, which can in-clude, for example, “cultural capital” (e.g. medical know-ledge & skills) or “symbolic capital” (e.g. accumulatedprofessional prestige or honour). This “symbolic power”can be understood as an everyday form of power (ratherthan the power of physical force) and is deployed in so-cial context. A social field is thus a site of negotiation inwhich individuals seek to maintain or alter the distribu-tion of different forms of capital.The nature of power“Power” as used in this study is defined as a relationalco-constructed process and represents a potential toexert influence [25]. Power is present in all interpersonalrelationships; there is thus no interaction in whichpower is not relevant in healthcare. Power is neitherpositive nor negative, but “comes into being” when it isput into action through “strategies” [26]. These strategiesare observable in that they are expressed through lan-guage; language is tied to structures of power such asthe social institution of medicine [22]. Physicians canexert power by drawing on the legitimized institutionallanguage of medicine they are affiliated with by virtue oftheir qualifications and training [22].A challenge facing physicians is that at a micro level ofinteraction, the very nature of their relationship with pa-tients is asymmetrical. This unequal relationship is aproduct of physicians possessing legitimized, referent,and expert power [22, 27] and patients being reliant onphysicians to provide the care and services they need [28].Although a caring, respectful, and empowering communi-cative physician-patient context is proven to improve pa-tient outcomes, [29, 30] there are real barriers in regardsto the enactment of this kind of care because of the inher-ent power imbalance in the physician-patient dyad charac-terized by physicians’ possession of expert knowledge.The nature of language and meaning“Language” used in this study is a meaning making sys-tem that is always co-constructed and shaped by differ-ent gradients of power [31]. The power of language andwords is tied to the legitimacy of the words and of thelegitimacy of the person who utters them, a belief whichwords themselves cannot produce but is determined inrelationship [32]. With this perspective, we can observehow the language strategies physicians use when inter-acting with patients is a reflection of their habitus - pro-duced in part from exposure to the field of medicine, afield imbued with symbolic power.MethodsResearch designThis current research was part of a larger study that ex-plored how physicians conceptualise their teaching andconsultation practices and their thoughts about theirprofessional development in these roles. For this currentstudy we wanted to understand how physicians perceivepower relations in the physician-patient encounter. Toachieve this, 30 physicians were interviewed and thetranscribed data analysed using an inductive thematicapproach further described below.Nimmon and Stenfors-Hayes BMC Medical Education  (2016) 16:114 Page 2 of 9This study was conducted within four Royal Collegespecialties at the University of British Columbia, Canada:Internal Medicine, Surgery, Pediatrics, Psychiatry as wellas Family Medicine. These five disciplines were selectedas they represent the top five choices of Canadian MedicalGraduates and top five available residencies in the CaRMSmatch [33]. In addition these five disciplines represent dis-ciplines with a mix of both outpatient and inpatient care.While Family Medicine is not a Royal College Specialty, itrepresents a significant number of providers and traineesand it is conceived using a similar framework as the RoyalCollege of Physicians and Surgeons of Canada [34]. Wereceived ethical approval from the University of BritishColumbia’s Behavioural Research Ethics Board to conductthe study.Population, sample and data collectionWe used purposeful sampling to capture a wide range ofphysicians to ensure we could fully understand the topicunder study. The co-investigators on the larger studyrepresented one of the five disciplines, and thus identi-fied colleagues that fit the study’s inclusion criteria ofhaving at least five years of experience in teaching pa-tients and trainees. An email introductory letter that de-scribed the larger study was sent to all colleaguesidentified by the study’s co-investigators. Approximately4 (70 %) out of 6 (100 %) of those physicians initiallycontacted in each discipline were interested in partici-pating, and were subsequently sent a consent form priorto the interview taking place. To recruit the additionaltwo participants we used a snowball sampling techniquewhich involved asking those interviewed if they couldprovide names and email addresses of colleagues who fitour recruitment criteria. We then contacted the newrecruits by sending an introductory email describingthe study. The interviews were held either in person atthe participant’s office (n = 12, 40 %) or on the phone(n = 18, 60 %) and were approximately 1 to 1.5 h in dur-ation. The majority of interviews were conducted bythe first author (LN) and the remaining by a researchassistant, all interviews were recorded and transcribed.After the first six interviews were transcribed, the re-search team (LN & T S-H) met and reviewed the tran-scripts to fine tune the interview protocol.Data analysisIn this exploratory analysis we wanted to focus on physi-cians’ conceptions of the phenomena of power in thephysician-patient encounter, and thus this present ana-lysis drew on a subset of data from the larger study: Weexplicitly asked two open-ended interview questionswithin the larger study: “Do you find that there arepower relations in your interactions with patients?” And“How do you deal with these power relations if youexperience that they are there?”. and in this current ana-lysis, we focused on responses to these two interviewquestions. Follow up questions and probing techniqueswere also used to stimulate more information, such as“can you tell me more about that?” or “right, I see”. How-ever, we also coded all content within the full transcriptsand analyzed any data found that highlighted physicians’perceptions of power dynamics as they unfold with pa-tients in the clinical context.Analysis of data began by multiple readings of the ver-batim transcripts. We then used LeCompte and Schensul’s[35] approach to analyzing qualitative data that involves asystematic process that takes place in three stages: (1)Item analysis, (2) Pattern analysis, and (3) Structural ana-lysis. We used each of LeCompte and Schensul’s threetiered inductive strategy as this analytic approach involvescompiling items together at the specific level and thencreating more abstract statements about patterns of re-lationships in the data to generate overall insights intothe topic of interest [35]. Theoretical visibility was alsopresent throughout all stages of analysis to enhance re-search rigour [36].(I) First, we coded the transcripts for key phrases ortracts of text related to “physician-patient power dy-namics”. We used ATLAS.ti qualitative coding softwareto visually display items in the margins of the programrendering visible the relationship to each other acrossdata sets.(II) We then engaged in pattern analysis, which in-volved a process of comparison, contrast, and integra-tion and where items are organized, associated withother items, and linked together into higher order pat-terns. Examples of themes that were generated in thisstage were: “awareness of power”; “the contextual natureof power”; and “the strategic handling of power”. Thesepatterns emerged from drawing on prior research studies,the study’s theoretical framework, and our research pur-pose. For example, in operationalizing the item “awarenessof power,” we drew on Bourdieu’s [22] notion that peopleoften experience power differently depending on the differ-ent social circumstances or fields they find themselves in.(III) Following pattern analysis, we developed broaderthemes that involved blending many of the initial codesinto finer tuned themes that captured similar conceptualdimensions across the data. These broader themes, forexample, were named: “perceptions of holding and man-aging power”; “perceptions of being disempowered”; and“perceptions of power as non-existent”. These broaderthemes were then pulled together into a meaningfulwhole – the interpretation.We began the interpretation by returning to the ori-ginal research purpose and reviewing the theoreticaland research literature that contextualized the study.This process helped us focus the interpretation on whatNimmon and Stenfors-Hayes BMC Medical Education  (2016) 16:114 Page 3 of 9others can learn from the study and how this is sup-ported by concrete, specific examples.Trustworthiness and rigourWe employed strategies of credibility to establish qualita-tive criteria for trustworthiness and rigour in the research.To ensure credibility in an attempt to compensate forsingle-researcher bias, LN and T S-H engaged in re-searcher triangulation by both being involved in theanalysis of data [37]. To further enhance credibility andbecause all steps in qualitative analysis involve acts of in-terpretation, we also engaged in peer-examination [38]that involved discussing the research process and findingswith impartial colleagues. We engaged in an ongoingdialogue with Dr. Glenn Regehr (a well-respectedscholar in the field of medical education) and WendyHartford (a research assistant who read all of the interviewtranscripts), comparing insights about our emergingthemes and confirming the reliability of our analysis ofdata. Finally, credibility was ensured by engaging in a thickdescription of the research process so the reader would beable to follow the research process, such as rational forthe study, data collection, and analytic process. These de-tailed descriptions allow others to be able to determine ifthe insights can be transferred to their local context andsetting [39].ResultsIn the presentation of results, we have selected directquotes from participants to illustrate the major themeswith exactness and precision. To maintain participantconfidentiality the quotes are only identified by partici-pants’ discipline (Internal Medicine = IM; Surgery = SUR;Pediatrics = PED; Psychiatry = PSY; Family Medicine =FM. For example, a quote from a family physician wouldbe identified as [FM].The average length of time physicians had been prac-ticing was 16 years, with the minimum length of timepracticing being 6 years and the maximum length oftime practicing being 41 years. We found no evidence ofphysicians’ responses differing by gender or discipline.An even larger data sample using a different researchdesign may have been able to make some supportedclaims in regards to whether the responses vary by gen-der, years in practice, and discipline, and if there is atrend in terms of responses predominantly found in onecategory.Physicians in this study appeared to be surprised bythe interview questions that inquired into their percep-tions of power relations in the context of teaching theirpatients. Many physicians asking us to restate the questionor repeating back to us the word power for clarification:“what…sorry…power?” [FM]. Once they had a moment toreflect on the questions, physicians in this analysispresented a range of descriptions and interpretations ofpower relations in the physician-patient encounter. Over-all, there were three broad categories of similar responsesthat highlighted how experienced physicians perceive thenature of power, and the meaning they attribute to powerin their role as a healthcare provider to patients. We didnot find any evidence of physicians’ responses overlap-ping into the three different categories. For example, nophysicians who were acutely aware of their power (firstcategory) did not in the same interview articulate thatpower is balanced and dissolved in their equal relation-ship with patients (third category).Category 1: Physicians’ perceptions of holding andmanaging powerA first category of responses highlighted how physiciansperceive themselves to hold power in the context ofphysician-patient interactions. These physicians reflectedon the presence of power extensively, describing howthe power dynamic between a physician and patient isexplicit and unambiguous: “Sure, yeah, I think that theredefinitely are [power imbalances] and anyone who saysthere isn’t would be lying. So certainly, I mean, ultimatelywith a patient, like the surgeon has the power to make thedecision about the treatment and patients come to youand they entrust you with their lives. So– and it’s amazingto me every day when people will trust their surgeonswith– but really that’s the way society views these things.Where some people would spend much more time andefforts investigating where to get their car fixed than them-selves” [SUR]; “There is a definite power imbalance whichneeds to be addressed and modified as much as possible”[PSY]; “Even though we don’t think of ourselves as beingpaternalistic and we’ve stepped away from this modelthere is always a power relationship, in any relation-ship…acknowledging it and recognizing it is important”[IM]; “There is always a power relationship…Patientsthey have to put their trust in you because you’re talkingabout and doing things that really they don’t understandor don’t have a background in. So they have to have afaith that you’re doing what’s best for them, and so youhave to be cognizant of that to make sure that you neverever take advantage of that role” [FM]; “There is a powerimbalance.. I mean, you are empowered by the knowledgethat you have and the ability to treat patients. So thereis an inherent power imbalance…that power imbalanceis in knowledge” [SUR].This category of physicians believed that because oftheir medical training and credentials they were in positionof power in the physician-patient encounter. This positionof power was described as something which needs to beacknowledged and respected by physicians: “I’ve learnedvery early on that the relationship between a doctor and apatient is unequal. You are in a position of power as theNimmon and Stenfors-Hayes BMC Medical Education  (2016) 16:114 Page 4 of 9doctor. As much as you may try to minimize that, theactual reality is that they have you, in general of course,have you on a pedestal. You have to be respectful of thatdifferential nature of the relationship” [FM]. This group ofphysicians described how it was their ethical responsibilityto be cognizant of the effects of power in their relationshipwith patients, and to not take advantage of their positionof power.This category of physicians believed that because pa-tients trust their authority and knowledge, they have aninherent responsibility to act in the patient’s best interestby “managing” their position of power with integrity.They spoke at length about the deliberate strategies theyuse to “handle” power in order to engage in a profes-sional and ethical relationship with patients. We foundthat these strategies executed through language fell intofour different descriptions of power management: (1) theexertion of power (e.g. “pull the power card” [IM] byspeaking over interrupting family members or makingdecisive clinical decisions); (2) the sharing of power (e.g.engaging in collaborative shared decision making prac-tices and imparting medical knowledge); (3) the moder-ating of power (e.g. “humanizing” [PED] themselves byhaving the patient call them by first name and disclosinga similar personal experience); and (4) the relinquishingof power (e.g. accepting when the patient does not goahead with their treatment recommendation or acceptingwhen patients seek and use alternative therapies). For ex-ample, a family physician who believed that power was al-ways present in her interactions with patients, describedhow she shares power through imparting medical know-ledge and inviting shared decision making practices: “Oneof the benefits of being in family practice is that I thinkthey’ve got an ongoing relationship with you. And I thinkin the best scenario they know that you’re there for theirbenefit and their welfare. And so I would hope that, youknow, in situations where you’re imparting information fortheir good that you’re doing that with the best of inten-tions…I see information as power for them, really. If they’vegot information then they’re– they’ve got that ability tochange things up so I’m able to give them that informa-tion”. When and how experienced physicians in this studychose to strategically handle power was never stable oruniform, but was based on astute interpretations of situ-ational context.Category 2: Physicians’ perceptions of power as waningA second category of responses highlighted how physi-cians perceive that physician power is waning in thecontext of physician-patient interactions. Some of thephysicians in this group expressed a sense that theirpower is diminishing in the context of a changinghealthcare culture that encourages patient rights, patientsas consumers of healthcare, and informed patients. Onephysician captured this sentiment in the following quote:“It’s [power dynamics with patients are] rare, I think thingshave shifted. I think you’re seeing that patients probablythink they have more power. I think because there’s moreconsumerism within medicine people have a U.S.-style con-sumerist way/approach where ‘I have all the information,you should do this treatment because I think this is what Ineed’. I think that power differential [exists] versus I’vecome to you as an expert in this field…I’m not trying to beegotistical. This is what my opinion is. So, I’m seeing actu-ally that power differential…the trickier part is when thepatient is not agreeing with any care plan that I come upwith. So if it becomes a consistent pattern then I often atthat point will say, you know, we obviously have a dif-ference in philosophy in terms of how you wish to betreated. Perhaps it’s best that you see either anotherphysician” [IM].Overall this group appeared to conceptualize thephysician-patient encounter as site of struggle, often de-scribing how tensions emerge when patients make un-reasonable demands on the physician. For example,when asked about power dynamics with her patients, aphysician described how patients can be unreasonablydemanding, and sometimes bullies: “Yes, there are prob-lems with patients. Mostly people with personality disor-ders, that may be unfair to say, but people who come inand feel that they know best, come in demanding whatthey want or…with very specific demands. And so therecan be a little bit of a power struggle there…very occa-sionally they can be a bit bulliesh” [FM]. For those expe-rienced physicians who perceived their power waning inthe context of the physician-patient encounter, there wasno elaboration on the mechanisms they employed to stra-tegically handle power when interacting with patients.Category 3: Physicians’ perceptions of power as non-existent or irrelevantA third category of responses highlighted how physiciansperceive that power dynamics are non-existent or irrele-vant in the context of physician-patient interactions. In-dividuals in this group perceived there to be an absenceof power: “Oh No, [there are no power dynamics] unlessthey [patients] have a major personality disorder, that’srare too, right” [PSY] or “I think patients have quite a bitof trust, you know, I don’t find [power dynamics] not apower struggle, no, not at all… I think my personality’sprobably easygoing. It’s hard to get into a power struggle”[PEDS]. While others in this group perceived power tobe dissolved through an equal and balanced power rela-tionship. These physicians describe how they are on alevel playing field with patients, which they emphasizehas the essence of a collegial and friendly relationship.One physician captured the notion that his interactionswith patients were situated in a flat hierarchical powerNimmon and Stenfors-Hayes BMC Medical Education  (2016) 16:114 Page 5 of 9structure in the following quotation: “A lot of patientsreally want to be an equal partner in the learning. Andsome of them are very intelligent and they will ask youdifficult questions. And that’s fine, I kind of like that”[IM] or “I think the power is more when it’s a doctor-medical trainee interaction…With the patients it’s a littlebit different. I hope there’s no power problem coming intomy interactions. I’m trying to enable them– in trying toempower them” [FM]. For physicians in this group, powerwas not a meaningful or important concept in the con-text of delivering healthcare to patients, either becausethey perceived that it does not exist OR because theyperceived that power dissolves through a balanced em-powering physician-patient power relationship. Thisgroup of experienced physicians, who perceived powerdynamics as non-existent or irrelevant in their interac-tions with patients, did not provide any further insightsinto power as it manifests in the physician-patientencounter.DiscussionPhysicians’ surprised reaction at our questions related topower dynamics in their encounters with patients sug-gests that power may not be a concept that physiciansroutinely reflect upon. Bourdieu’s theoretical concepts ofhabitus and doxa can be applied to make sense of thislack of reflection of physician power as part a processthat develops and (re)structures medical students’ habitusthrough contact with the broader institutional and organ-isational culture(s) of medicine [24], a socialization sub-conscious process that does not traditionally involvediscussions or considerations of one’s position of powerwithin the healthcare profession hierarchy. In particular,Bourdieu’s notion of doxa is a useful conceptual tool tomake sense of how medical education and training resultsin the construction of a medical habitus where there aremany taken for granted truths that are internalized sub-consciously [23]. However, as we engaged more with thedata and deepened our analysis, it became clear that thisone size fits all application of Bourdieu’s notion of habitusand doxa is incapable of explaining the variance in eachthree categories of responses in respect to experiencedphysicians perceptions of power in the physician-patientrelationship.Although trained within the same institutional andorganizational culture of medicine, physicians’ varyinginterpretations of power relations in this study suggestthat there is a crucial intersection of agency, context,time, training, and practice which are linked to percep-tions of social space and/or the social position an individ-ual possesses. Our findings thus reveal that physicianswho all acquire a medical habitus may in fact have aflexible generative [40, 41] medical habitus that adapts tochanging circumstances through varying exposure todifferent social fields within medical training and practice,and further shaped by individual factors, such as values,tastes, beliefs and preferences. These individual values,tastes, beliefs and preferences are socially determined andshaped by experiences as they navigate different socialfields within medicine (e.g. the formal curriculum and thehidden curriculum), [42] and the different social fieldsthey are exposed to outside of medicine over time.With this insight, we further triangulated into the ana-lysis Bourdieu’s theoretical concepts of structure andagency to make sense of how the social institution ofmedicine constrains and enables dispositions, actionand perceptions, while accounting for the importantinterplay of individual action and agency [43]. The co-alescing of the many factors that shape physicians med-ical habitus explains the production of their varyingperceptions of power relations in the micro level fieldof physician-patient interactions, illuminates “the worldnot as imposing itself immediately and uniformly on allsocial agents, but as realized through complex pro-cesses involving the expectations and hopes of agentsthemselves…([40](pp.71)).Following this in depth integration Bourdieu’s socialtheory to understand the nature of each three categoriesof responses, we present the implications and/or insightsthat can be drawn from each group.For the group of physicians who perceived their powerto be waning in their interactions with patients, we be-lieve future research could explore physicians’ languagestrategies and interpersonal complexities that may arisefrom physicians’ perceptions that their medical authorityis declining in a cultural climate of patient autonomyand empowerment. Furthermore, for the group of physi-cians who perceived that power dynamics are non-existent or irrelevant when interacting with patients, wequestion what the implications are for communicativeapproaches and the patient experience when physiciansdo not perceive power dynamics to hold any significancein the clinical encounter. We believe these foci, andother related foci, deserve exploration and reflection andare to be important areas of future investigation.For the group of physicians who were reflective abouthow they held and managed power, they demonstratedan astute awareness of their power, which suggests atype of reflexive awareness of their internalization of thesocial and cultural structure of medicine and the way itinteracts with the field through practice. This group ofphysicians appeared to be aware of the legitimized insti-tutional medical power [22] available to them, yet theydescribe how they do not necessarily “share” this powerin any given situation. Physicians in this group ultimatelydraw our attention to a “handling” of power that is not al-ways as straightforward as “sharing” per se, but is in factcontext-specific. Rather than being “shared” uniformly,Nimmon and Stenfors-Hayes BMC Medical Education  (2016) 16:114 Page 6 of 9power appears to be moderated by a range of strategies(exerting, sharing, moderating, relinquishing) executedthrough language to meet physicians’ purposes of culti-vating an ethical therapeutic relationship with patients.In other words, such physicians who are aware thatthey always hold power by virtue of their cultural andsymbolic capital [22] are deliberate in how they ethic-ally handle power through language strategies to servethe patient’s best interest. The way this group of physi-cians use language strategies to handle their power, alignswith Bourdieu’s notion that language is not simply ameans of communication but a medium of power [22].Although this later group illuminates some of the waysexperienced physicians are aware of the power availableto them, we recognize that power is inherently relationaland cannot be “owned” by physicians. As language andmeaning are co-constructed and always contextualizedby gradients of interpersonal and institutional power,[31] patients play a significant role in the way powerplays out in the medical encounter as they must (1)recognize the hierarchal position and legitimate authorityof physicians who wield power and (2) be complicit inphysicians’ strategies for handling power [22]. In otherwords patients must internalize and believe in the rules ofthe game within this particular field (i.e. illusio), [44] andbe complicit in the rules of the game.LimitationsThe purpose of our study was to gain insights into thedifferent ways experienced physicians perceive power(e.g. how they invoke power and for what purposes) inthe clinical encounter. This study that used 30 qualita-tive data sources was appropriate for developing mean-ingful themes that resulted in rich insights into the topicof interest. This study needs to be understood as an indepth exploration of physicians’ perceptions of power re-lations in their interactions with patients in one smallsample of participants documented in a particular spaceand point in time. The thick description and rich in-sights generated from this particular context offers astarting point for others to extend insights into the waysphysicians perceive power in their interactions with pa-tients in a variety of cultural contexts.Implications for trainingBourdieu has been charged with being too deterministicin his theoretical approach, [45] yet he does invite possi-bilities for reflexivity which he describes as “the systematicexploration of the un-thought categories of thought thatdelimit the thinkable and predetermine the thought”,([44](pp.40)). Our data suggests it is possible for physi-cians to be astutely aware of their power and able to han-dle their power deliberately in reaction to context, whichwas so vividly described in the first category of responses.We believe that medical education and training and on-going professional development can play a key a role inraising physicians’ awareness of their position of powerand introducing strategies that will enable them to man-age and handle their power when practicing medicine. Wesuggest that early-career and ongoing professional de-velopment training should include opportunities to cul-tivate: (a) an awareness and the capacity to be reflexiveof physician power and how it plays out in various in-teractions and (b) communication strategies for physi-cians to “handle” power with insightful deliberation in arange of clinical encounters. Further, we suggest thatthe depiction of communication in international spe-cialist physician competency frameworks (e.g. Canada’sCanMEDS; the USA’s ACGME; the UK’s GMC), [46–49]that are used for accreditation, evaluation and examin-ation purposes and have such far reaching implications formedical training and practice, broaden to include the con-textual and power laden nature of communication andmeaning.Recommendations for future researchTo understand richly the nature of power in thephysician-patient encounter, future research could con-sider both physicians’ and patients’ perceptions of powerrelations in the clinical encounter. To deepen even fur-ther this exploration we might be better positioned toexamine how power flows through all interpersonal in-teractions (i.e. family members, partners, friends, otherhealthcare providers, and so forth) that contextualize thephysician-patient encounter - given that the physician-patient micro level “field” is comprised of a myriad ofcomplex interpersonal relations of power that unfold inclinical and community settings.ConclusionsOne of the central values underpinning patient-centeredcare is the equal sharing of power that can be enactedthrough communication practices like shared decisionmaking [15–19]. However, power cannot really be “owned”by physicians, but rather is activated through a relationaldance in the therapeutic encounter with patients. Althoughthe “sharing of power” is an overarching goal that we ap-propriately seek to achieve in modern patient-centeredhealthcare, our analysis highlights how this concept doesnot fully capture the complex ways experienced physiciansperceive, invoke, and redress power when interacting withpatients in the clinical encounter. Physicians’ always havepower available to them through their cultural and sym-bolic capital legitimized by the institution of medicine, andevidently those who are aware of this power strategicallyshare, exert, moderate and relinquish power in response tosituational context to best meet the needs of patients. Webelieve that medical education training that integrates theNimmon and Stenfors-Hayes BMC Medical Education  (2016) 16:114 Page 7 of 9insights from the group of physicians who were aware oftheir power and use it strategically can better preparenovice and practicing physicians to enact patient-centeredtherapeutic communication. We suggest that medicaleducational initiatives socialize and habituate physiciansto be reflective, analytical, and creative, in their “hand-ling” of power in a way that is attune to context in clin-ical encounters.Ethics approval and consent to participateThis study received approval from the University of BritishColumbia’s Behavioural Research Ethics Board on May29th, 2012. Reference number: H12-00022. All participantsconsented to participating in this study.Consent for publicationNot applicable.Availability of data and materialsDue to the sensitive nature of the raw data on which theconclusions of the manuscript rely, it is not publicly avail-able. Please contact the authors for further information.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsLN, PhD collected the data, integrated theory into the study, analyzed andinterpreted the data, and drafted all components of the manuscript. T S-HPhD conceived of and designed the larger study and contributed to analysisand interpretation of data for the current study. T S-H also was involved inediting the manuscript and revising it critically for intellectual content. Bothauthors read and approved the final manuscript.AcknowledgementsThe authors wish to extend their sincere appreciation to Dr. Glenn Regehrand Ms. Wendy Hartford for their insightful feedback on the analysis of data.The authors would like to thank the co-investigators on the larger study thisdata derived from for supporting this research endeavour: Drs. Joanna Bates,Ian Scott, Ravi Sidhu, Paris Ingledew, Summer Telio and Mattias Berg.FundingThis research was funded by a 2013 Royal College CanMEDS Research andDevelopment Grant. This grant program is supported by the Royal Collegeof Physicians and Surgeons of Canada and the Associated Medical Services,Inc. 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