Navigating Power Relations in Healthcare

This summer, I chose Adrienne Rich’s poem “Power” for one of our spring term’s final Narrative Medicine workshops attended by a group of interprofessional healthcare students. I chose the poem hoping it could help the students reflect on their complex relationships to power in their work as they approached summer break.  

In 2022, Americans are experiencing a great deal of anxiety about healthcare disparities, inflation, gun violence, restrictions on tribal sovereignty, and the stress of the historic reversal of laws limiting women’s access to healthcare. Considering this summer’s events, the need for contemplation of the role of power in medicine is increasingly vital. But it’s not simple. 

Rich’s poem is a meditation on Marie Curie’s relationship to the element radium. The speaker reflects on reading about Curie as a dying scientist and muses through poetry that: 

she must have known she suffered from radiation sickness
her body bombarded for years by the element
she had purified
It seems she denied to the end
the source of the cataracts on her eyes
the cracked and suppurating skin of her finger-ends
till she could no longer hold a test-tube or a pencil 

She died a famous woman denying
her wounds
denying
her wounds came from the same source as her power.   

Narrative medicine scholar Sayantani DasGupta wrote in “Narrative Humility” about the need for clinicians to listen with reverence and patience to a patient’s story—and in “Abolition Medicine” about the need to be cautious and intentional about the metaphors we use in and around healthcare settings. For example, the problem of choosing military metaphors to describe healthcare workers in the COVID pandemic. Along with Rich’s account of Curie, these analyses remind me of a critical idea put forth by cultural theorist Michel Foucault, who argued in the “History of Sexuality, Vol. 1” that “Power is everywhere” and “comes from everywhere.” 

This is to say that power is not an object so much as it is a relationship. Because power is relational, power hides—especially in our language choices. It hides in things right in front of our faces, like Curie’s radium as its effects emerged in her body: the cracked and suppurating skin of her finger-ends.  

Power, like radium, is neither inherently good nor bad. It can either kill or heal. And power’s capacity to hide isn’t just true of our words themselves but of all our modes of communication—the syntax of all the things we bring to the table when we connect with another person.  

Power is latent, potential energy carried in our very presence, whether or not we’re conscious of it. In this context, humility is a function of one’s awareness of how one relates to power and of the resultant capacity to negotiate power relations with discretion and care.  

Critically here, healthy uses of power—toward humility, toward care—are contingent on awareness of the statuses of power in a situation. And, inversely, as in Rich’s poem, power is made dangerous through denial of how it works or minimization of its presence or effects: till she could no longer hold a test-tube or a pencil.  

Minimization of power’s effects is harmful whether we are dealing with something that holds the place of radium in our personal lives or our communities, such as Jonathan M. Metzl discusses in “Dying of Whiteness.”

If power is everywhere, and if power hides, how do clinicians or patients negotiate helpful power relations in a clinical setting? How can a clinician’s relationship with the subtleties of power dynamics influence responses to their patients’ suffering and their need to feel understood or heard?  

If power is relational, these relations manifest in our healthcare stories, from clinical encounters to patient charts to research narratives. Narrative strategies can help us find the power dynamics that operate within ourselves, healthcare teams, and in broader healthcare cultures. The following strategies approach power systematically and will help you map power in healthcare settings: 

1. Power and the self:

Write reflectively about how you see power manifesting along your career path. Identify the resources that you bring to the table, that you share, or still need. For Curie, radium worked as a metaphor for a power relation in her life. What are the elements that represent power in your own life? Journal, write creatively, or otherwise document these metaphors and note how they shift for you over time. With this information in hand, look for ways to distribute your power mindfully in clinical settings, research, and in self-care. 

2. Power and the patient:

Use two key sites of interaction—clinical visits and patient charts—to use your power as a clinician to collaborate in shaping patient healthcare narratives with attention to equity. For clinical visits, engage in active listening and pay careful attention to how your presence—posture, language, status—might influence the patient’s comfort in sharing vulnerable information. Additionally, we’re now in the era of Open Notes; this mandate for transparency reflects a genre change from documentation historically meant for a healthcare audience to a hybrid audience now emphasizing the patient. With increased access to notes, clinical language will shape the patient’s view of self and of their healthcare experience.  

3. Power and the team:

Pursue narrative work with interprofessional healthcare teams and in interdisciplinary educational settings. Every interdisciplinary and professional category in a clinical setting will have unique approaches to how they engage with a patient’s data and thus healthcare story. The classic narrative medicine workshop is an ideal tool to bring diverse voices to the table and to learn how different team members interpret the same subject. Reading with and listening to those with different training and professional roles in a non-competitive and collegial environment helps teams understand and appreciate unique styles of learning, communicating, and observing that can translate to better collaboration in patient care. 

4. Power and the community:

Find ways to engage with Community Health Workers (CHWs) or other community-based organizations to better understand how diverse orientations to power impact health in your community. CHWs have their fingers on the pulse of community stories and strengths—as well as the needs communicated through these stories. Employ CHWs as mediators to show care for and interest in community-based wisdom and self-knowledge.