Hierarchies Within the Health-Care System

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Hierarchies Within the Health-Care System

To address the power relations between health-care providers and patients, many researchers argue that the existing hierarchies within the health-care system need to change [1-4]. The way health-care providers receive their training can shape their practice with regards to relations of power. Warshaw pointed out that many aspects of medical training are also abusive [5]. She described the demanding and debilitating schedules and peer isolation on clinical rotations, lack of validation during emotionally upsetting situations, harassment from attending physicians, and a failure to make more senior medical staff accountable for their behaviour towards medical students. She stated, "Recognizing the potentially abusive aspects of medical training and the importance of creating environments that do not permit such behavior is important not only in improving the health care response to domestic violence but also in creating a society that does not tolerate abuse" [5]. Campbell noted that "there is endemic paternalism in the medical system that tends to disempower women" [6]. The unequal distribution of power between different professions, most notably between doctors and nurses, is significant [4].
The health-care system itself is a gendered, racialised and classed hierarchy that in many ways mirrors society in general [7-10]. Jiwani wrote that "the western health care system is a system where the majority of doctors are male, and the majority of nurses are female - again gendered on power lines; where the people of colour tend to be found either in the rolls of the patients, or in the kitchens, laundries, and janitorial services of most hospitals" [4]. Commonalities between women in the health professions and abused women have been recognised. "The origin of the plight of abused women and the struggles of female health workers lie in the worldwide social and economic inequality of women," wrote Hoff "[and] the concomitant devaluation of women and their work keeps battered women with violent men, and women, especially poor women of colour, in inequitable service roles" [11]. In a study of a Toronto hospital, researchers found that racial minority nurses were severely underrepresented at the decision-making and supervisory levels [12]. Further, they were more frequently passed over for promotion, while white nurses were promoted at rates significantly higher despite sharing similar levels of qualification with black nurses.
Abuses stemming from these unequal relations of power within the health-care system are well documented in the literature. Studies report frequent abuse of nurses by physicians [13], and the sexual harassment of female physicians [9]. As well, health-care providers have been reported to be marginalised by their colleagues for addressing woman abuse [14]. Professions need to address the abuse of its own members and to recognise that, in the health-care system, there are both abusers and the abused [8]. Thus, unless the health-care system addresses oppression within its walls, it will be difficult for it to address issues of power and control in the larger society and their manifestations in the lives of female patients [4].
(adapted from: Dechief, L. (2003). Care, Control and Connection: Health-Care Experiences of Women in Abusive Relationships. Unpublished Masters thesis. University of British Columbia)


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