Power

“As the doctor, you were the one with all the power.”

As I’ve spoken and written about the abuse and violence that I experienced at the hands of a serial predator who was also my patient, several people have made some version of the above comment. Some brought up the subject of power in a curious way, wondering how a presumably powerful physician could end up being abused by a patient. Others have been accusatory, blaming, and disbelieving that it could even happen.

The accusations and blame are painful to me, but I’m glad that people are thinking about power dynamics in the context of abuse. Power is central to abuse, violence, and control, and I saw this play out in the lives of many of my patients who themselves were abused. Power was also the foundation of what happened to me, but it isn’t simple and it’s impossible to do the subject justice in a brief Tweet or quote. So instead, I’ve decided to write about my thoughts on the complexities of power as it intersects in medicine and abuse in this post.

Of course, the traditional view is that doctors are always powerful compared to their patients. The stereotypical picture of the privileged, patriarchal doctor holding power over his weak, vulnerable (often female) patient has deep roots in Western medicine. It is certainly true that many doctors have wielded this power to the harm of their patients. Paternalism and this power imbalance was, for many generations, taught as the foundation of the doctor-patient relationship, both within professional training and by the public (Dr. knows best!).

In recent decades, however, a number of shifts both within medicine and outside of it have changed that stereotypical picture. Medicine has gone from being an all-male occupation to a profession that now graduates more women physicians than men. New physicians are trained in patient-centred care and shared decision making. In medical schools and residency programs, the mantra is that we are supposed to facilitate the empowerment of patients. I should know, as I participated in delivering these programs and in the development of residency evaluation at the local and national levels.

At the same time, the public has become much more willing to pull doctors off their pedestals and have assumed more control over their own health. Much of this is good, I think. However, it is also true that these days physicians are openly criticized on internet rating sites, maligned in the media, confronted by angry patients and their families, and sued — not always fairly.

That’s not to say that doctors no longer hold any power. Physicians are trained to diagnose and treat illnesses, reduce pain, and enact interventions that improve and extend lives. Most people can’t get medical testing, prescription medication, or surgery without going through a physician. Doctors hold the power to grant or deny these things. This has not changed from our patriarchal days.

Physicians also have the privilege of being with patients in their darkest hours, when they are vulnerable for very different reasons. I know well what it is like to be a hurting, vulnerable patient. I’ve seen a physician twice a week for the past three years to recover from the trauma of my experiences and, in that time, I’ve been very vulnerable. It’s often felt like I’m tearing myself open as I’ve shared my experiences of rape and violence, my overwhelming shame and despair, and my thoughts of ending my life. I’ve repeatedly made myself very vulnerable in front of my psychiatrist and that vulnerability has enabled him to help me through some incredibly difficult times.

Still, it’s not true that patients, including me, are powerless in their interactions with physicians. To take an all-too-common example, consider the fact that countless prescriptions for antibiotics have been written at the request of patients when the prescribing physicians have known very well that those antibiotics should not be prescribed because the illnesses were almost certainly viral. Similarly, millions of dollars have been spent on imaging and lab tests that physicians knew would be fruitless and of no medical benefit. Why do patients get prescriptions and MRI appointments that physicians know they shouldn’t offer? Because, like it or not and for all sorts of reasons, patients have power.

This shouldn’t be surprising for one very simple fact: both physicians and patients are human. There are power dynamics in every human relationship, including those between a physician and a patient, that aren’t simply determined by a look-up chart of social hierarchy. Power dynamics are influenced by a multitude of factors including age, gender, ethnicity, religion, money, physical strength, life experiences, and all sorts of specific details pertaining to the particular circumstances at the time.

No doctor holds absolute power by virtue of their profession or medical degree. If a physician is alone in an office with a patient who pulls out a weapon, as happened in the recent violent death of a doctor in western Canada, his professional title does not mean that he holds the power. The abuse or death of a physician at the hands of a patient doesn’t fit that old stereotypical picture, but does starkly illustrate the reality that power is about much more than simply one person’s title.

As a woman physician who wholeheartedly embraced patient-centred care, shared decision-making, and the collaborative inclusivity that I was trained to provide, I can honestly say that there wasn’t a single day of my career that I felt powerful. I am sure that some of my patients felt otherwise, but I sincerely say that my role was to listen, empathize, serve, and empower people to make choices that would improve their health.

There were many times that, as a gentle, petite, youthful woman, I felt considerably less powerful than the patient I found myself alone with. This was especially true when that patient was angry, demanding, or confrontational, or when he was a large intimidating man, had a history of violence, or was threatening to sue or complain about me if I didn’t do what he wanted. In my dealings with different individual patients, multiple factors contributed to the power that each one of them held.

Yet, even under circumstances when I felt scared or threatened, I trusted (perhaps naively, in retrospect) that each patient in my office was ultimately there because they needed my help in some way. This is what we teach — that patients are hurting, ill, or in need, and that it is our job to work through difficult situations in order to be helpful. It never occurred to me that a patient would come to my office with the goal of abusing and harming me; until one man did.

The man who lured, raped, and extorted me did the same thing in my office that he does to women in malls, restaurants, bars, apartment buildings, and on the streets. He identifies vulnerabilities and manipulates women into situations where he can isolate, assault, and control them. He manoeuvres himself into a position of power and then uses that power to terrorize his victims. He’s very good at it, as too many women have discovered — too late.

In a previous post I wrote about some of the ways that this man claimed power over me while we sat in my own office. That power manifested itself in many ways, including the fact that I did something that crossed a line that I did not want to cross, one that so many other physicians have crossed as well: I prescribed him a medication when I knew that he didn’t have the condition that it was intended to treat. Benzodiazepines are typically used to treat anxiety. They calm, relax, and sometimes disinhibit people in a way that is similar to alcohol. Despite this, it has become relatively easy to obtain a prescription for them, but my policy was to prescribe benzodiazepines only very seldomly because of their potential to be addictive and abused. Yet when this man repeatedly pressured me for that medication, I eventually caved and gave him what he wanted.

Why did I write that prescription? Was it because he was older, larger, and stronger than me? Because I had seen him get angry with others and I was afraid that he would turn that anger on me? Because I knew about his extensive criminal record and history of assault? Because we were alone in a small office? Because I wanted him to stop pressuring me? Because I wanted to please him? It was for all those reasons and more. Multiple factors contributed to his power in the room, regardless of the fact that I was the one with an MD. It was just the start of what was to come.

Little did I know that, in the not-too-distant future, those pills I prescribed would be one of the many tools that he would use as he coerced, controlled, and raped me. I am sickened every time I recall the moment that he held those very pills out to me, pressuring me to take them myself, before he abused me for the first time in a motel room. My power to write the prescription meant that my name was on that pill bottle, but that meant nothing when he used those pills against me as a weapon.

From my experience of being a physician, a patient, and a human being, I can say with certainty that many factors contribute to both vulnerability and power, including the vulnerabilities and power of both physicians and patients. Interestingly, medicine’s most powerful doctors are the ones that most ardently continue to perpetuate the patriarchal myth that doctors are always in power. Perhaps this myth serves them well, and they want to keep it.

It’s easy to use simple concepts to identify power and abuse but, in reality, those simple concepts fail far too often. To ignore the fact that every human relationship has power dynamics that are complex and multi-dimensional is at best naïve, and at worst dangerous, because it can actually enable and facilitate abuse. That’s exactly the kind of cover and support that abusers need in order to escape accountability and hold on to power.