Not Your Father’s Doctor-Patient Relationship – A Positively Revolutionary Approach

In pediatrics, research has shown that not all parenting styles produce equal outcomes. Researchers often categorize parenting styles into four groups according to parents’ level of expectations for their children and their level of empathy, their responsiveness to their children’s cues.

What would high expectations look like? Parents of first graders, for example, might expect their children to not interrupt while adults are talking, to cooperate smoothly with unexpected changes in plans, and so on. I’ve paid most attention to these parenting styles and their effect on teaching children to enjoy eating healthy foods.

Those who have high expectations and demands but who are not very sensitive, warm, or responsive to their children are called authoritarian. They tend to be critical. They focus more on shortfalls than on successes. When it comes to feeding, they tend to be strict. They pressure their children to eat certain foods, while placing other foods off limits—at least until the veggies are eaten. This approach is dramatically ineffective at achieving desired goals. In spite of such well-meaning efforts, the children of authoritarian parents tend to eat fewer fruits and vegetables and, when studied, have the highest odds of being overweight by first grade of any of the four parenting styles.

Parents who are very sensitive and responsive, but who don’t maintain high expectations, may be too permissive or indulgent. Their children may be a bit better off nutritionally than the children of authoritarian parents, but they may still be likely to emerge overweight and with an unhealthy diet. Even though these parents clearly care, the outcomes are no better than for children of neglectful parents — parents with low expectations and low responsiveness

Children of both permissive and neglectful parents are about twice as likely to end up obese as the kids of parents who display both high expectations for their children’s best behavior and high empathy to their wants and needs.

Authoritative parents are warm, sensitive, and emotionally responsive, while maintaining high expectations for their children and setting firm boundaries. These parents are tuned in to their children’s unique needs and temperaments. They are supportive of their children’s successes, no matter how small. They understand and acknowledge their child’s perspective. They respect their children. They interact warmly and avoid language that seems like a put down.. They don’t get irritated easily.

A Modest Proposal

I propose that the authoritative style may be the ideal approach for patient’s to take when trying to help their doctors grow into the participatory practice of medicine. Of course patients don’t have responsibility for their doctors, and may not have the luxury or desire to improve the system. But if they do, the authoritative style might be most successful at achieving their goals.

Some patients behave in authoritarian style towards their doctors. They have appropriate, high expectations for the way their doctors should behave, but little empathy for their doctors. They tend to be critical and to focus more on shortfalls than on successes. While these patients’ goals may be admirable, and complaints may be reasonable, they may have less success with getting behavior change in their doctors than they wish.

Far more patients are permissive toward their doctors. They are warm, have low expectations for participatory care, and have a tendency to give in to what their doctor wants or demands. This may not be any more successful than neglectful patients: those for whom doctors are no more than interchangeable parts that they use as needed and discard freely. Recent times have been marked mostly by permissive or neglectful patients.

I’d love to see a generation of firm, confidant, and authoritative patients — those who have appropriate high expectations for their doctors’ behavior. At the very least, they expect their doctors not to interrupt them every 18 seconds, to give them unfettered access to their health data, and to inform them about the benefits and risks of various treatment options available. These patients are clear about their expectations, but they are supportive of their doctor’s steps in the right direction, and focus more on their successes than their shortfalls. They understand and acknowledge their doctor’s perspective. They interact warmly, and don’t put their doctor down. They don’t get irritated easily. Firm patience and goodwill may achieve change faster than does frustration.

Oh – and authoritative doctors may be a good idea, too. Far too often we doctors act in one of the other three styles. But mutual respect, mutual appropriate high expectations, and mutual empathy lead to true participatory medicine. Let’s create 21^st century healthcare together.

Alan Greene, MD

Patrick. H., Nicklas, T. A., Hughes, S. O., and Morales, M. “The Benefi ts of Authoritative Feeding Style: Caregiver Feeding Styles and Children’s Food Consumption Patterns.” Appetite, 2005, 44: 243–249.

Rhee, K. E., Lumeng, J. C., Appugliese, D. P., Kaciroti, N., and Bradley, R. H. “Parenting Styles and Overweight Status in First Grade,” Pediatrics, 2006, 117(6): 2047–2054.

Greene, A. Feeding Baby Green. John Wiley and Sons, 2009.