Title: Assistant Professor of Health Policy
University: Ohio University
Email: skinnerd@ohio.edu
Twitter: danielrskinner
Description of Work:
The collaborative work we are undertaking broadly focuses on relationships between actors within health, including clinicians and patients, and hospitals and communities. We lean on rhetorical analysis as a tool for identifying problems – including power imbalances and conditions of domination – as well as offering solutions (for example, how hospitals might better interact and collaborate with communities). Rhetorical analysis, in our work, provides a means of understanding how epistemic power is bound to discursive practices. This research therefore finds important points of intersection not only in health services research, sociology and policy, but medical education.
Symposium Submission:
The Limits of Rhetoric in Patient Compliance: A Foucauldian Reading for the Era of Population Health
The language of patient ‘compliance’ has been called into question at least since the 1980s. Since then, alternative terms–especially ‘adherence’ and ‘concordance’–have been introduced in an effort to better reflect the move to patient-centeredness that most medical institutions champion. As the rhetoric scholar, Judy Z. Segal, notes in her influential book, Health and the Rhetoric of Medicine, attempts to “renovate” and rebrand compliance as concordance and adherence belie a deeper issue, namely that there is a lack of trust in medical relationships.
Building on the compliance/adherence/concordance scholarship, and using Segal’s argument as a springboard, this paper revisits the critique of compliance in light of the recent focus in American medicine on population health. While we acknowledge, following Segal, that a theory of rhetoric could play an important role in re-envisioning the problem of compliance, we also argue that the problem of compliance itself might also help us to come to terms with the limits of rhetoric’s ability to be the difference maker in addressing challenges in contemporary medicine.
Specifically, while rhetoric has much to offer the traditional doctor-patient relationship, and provides useful tools for improving and mending historical problems that undermine it, we also ask what role, if any, rhetoric might play in a quite different view of medicine, namely one focused on population-level health. For example, how could a theory of rhetoric offer a deeper critique of the individual nature of patient compliance–namely one that includes epidemiological and social determinants models of health? Any serviceable theory of rhetoric, especially one that aims to alter norms at work in the medical profession, needs to consider more fundamental considerations of power. Drawing on Michel Foucault’s understanding of power, in general, and his concept of power/knowledge, in particular, we argue that more than an assessment of rhetoric is required. Specifically, future efforts must target a health care system built around a fundamentally different series of power relations, and which includes a large cast of key actors, from patient navigators to biotechnology companies to insurance providers to public health departments and community health advocates. In support of a move from patient-centeredness to ‘population-centeredness,’ the language of compliance should be replaced with a richer collection of community-level investments in understanding and addressing the causes of illness and health disparities. Each of these new additions requires a fundamental rethinking of rhetorical relations and strategies. This focus on populations is aimed at developing an approach to health care that fully engages not only patients, but the collective experiences of communities and close attention to the communicative dimensions that accompany them in pursuit of health.
While the article we are prosing for this conference is self-contained, it also serves as the theoretical foundation for an interview-based project that we hope to undertake in 2018. This project will use interviews with physicians about their use (or non-use) of the rhetoric of compliance to better understand how post-compliance theoretical work has or has not become part of broader conversations in medical school, residency, and early post-residency years in practice.