What Happens after Diagnosis?: Patient and Physician Roles in Negotiating a Treatment Plan

Several interactional processes take place during a medical encounter. First, a patient discloses pertinent information, and the physician elicits further information to investigate the patient’s condition. Next, examination and testing are conducted. Then, a diagnosis is offered, which the patient may accept or reject. But what happens afterward? Classical models of physician-patient interaction assume that a physician gives the patient a course of treatment and that the patient does his/her best to carry out this course of treatment. But increasingly the diagnosis is of a chronic disease and the treatment plan is to modify one’s lifestyle. Lifestyle change is notoriously difficult and represents a departure from the treatment of infectious disease and acute conditions. Lifestyle change is often “low-tech” and relies on the patient to change his or her daily activities to prevent a health condition that may not even exist yet, such as being in a high-risk category for developing a chronic disease. This paper investigates how physicians are trained to broach issues of lifestyle change with their patients and contextualizes this interactional process in the broader changes in healthcare organization in the United States. Drawing on four years of ethnographic research at a U.S. medical school, I show how faculty physicians teach medical students about the nature of lifestyle change, the responsibility of the physician to help the patient achieve lifestyle change, and the way interactions about lifestyle change have shifted to accommodate changes in the nature of patienthood over the past 60 years. I find that medical training teaches medical students that physicians and patients take on distinct roles during these conversations; physicians bring knowledge, while patients merely bring their preferences. This throws other standards of care, such as patient-centeredness, into relief as medical students are taught to care for chronic disease patients.