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Four divides of health care

In clinical practice, communication and trust between the registered massage therapist (RMT) and her patient is crucial to a healthy relationship and partnership resulting in positive health outcomes for the patient.

October 3, 2017  By Anne-Marie Côté

Trust between RMTs and their patients are crucial in establishing a healthy relationship resulting in positive health outcomes. In clinical practice

Miscommunication and distrust may lead the patients in feeling abandoned by their RMT, dismissed in their suffering, disbelieved when describing their symptoms, and/or objectified by impersonal care. On the other hand, the RMT may feel overwhelmed by the patient’s inflated expectations and demands that the care received will reverse years of unhealthy behavior, poor health choices or bad luck.

As RMTs, we may find ourselves in situations where we are unable to understand the true nature of our patients’ health concerns. At times, we are missing important information that would allow us to properly identify the problem and give us the data needed to create a valid treatment and home-care plan for the patient.

When a patient fails to progress, confusion and frustration may set in for both the patient and the practitioner, despite all due diligence, care and attention.

In her book, Narrative Medicine: Honoring the Stories of Illness, Dr. Rita Charon describes four different types of divide that contribute to the separation between RMT and patient, eroding the trusting bond needed for a successful health-promoting relationship.


These four divides are described as the relationship to mortality; the context of illness; the beliefs about causality; and the emotions of shame, blame and fear.

Each divide reflects a peculiar dimension of the difference between the sick and the well. These divides are capricious, unpredictable, sometimes reversible, but in the end, they are irrevocable.

It is important that RMTs see the chasms clearly if we want to bridge these divides and allow the patients to get healthier by feeling included among those who are well and those in charge of their care.

This article will focus on these divides and how they affect our clinical practice.

Relationship to mortality
The relationship to mortality refers to the difference between how a health-care practitioner may view and experience disease and death compared to the patient’s lived experience.

Although most RMTs have little contact with palliative care and the dying, we can extrapolate some of the concepts of this divide to our injured and ill patients.

The intensity of massage therapy schooling and training reduces other people’s sickness and injuries. RMTs are trained to look upon death, illness and injury as technical defeats, so deeply studied that the RMT is led to believe himself or herself immune to it all.

The patient’s past experience, on the other hand, will help dictate how they relate to death, illness and injury, “…it starts in infancy and so the experiences we had then are likely to orientate us in the patient role.” (Pilgrim, Tomasini and Vassilev 2011, 37)

Therefore, a patient might view death and illness as both unthinkable and inevitable, and sometimes as a personal enemy or a mere distant abstraction.

The RMT may look at illness or injury with the worry of having caused it, through error, passivity or negligence, while a patient may see it as something to be feared, defied or even desired (Stuart and Noyes, 1999).

Taking the time as RMTs to ask our patients to provide a frank appraisal of their own health, including their opinions and feelings about death, illness and injury, and their healing and re-injury chances, could be very beneficial to the relationship.

However, this demands that RMTs must be ready and able to face their own feelings about these same subjects. Keep in mind that death, illness and injury may separate our patients from those that are healthy, but they also unite us all as universal human experiences.

Context of illness
With context of illness we are faced with the difference between looking at the variables affecting illness narrowly – for example, only looking at what anatomical region is involved – or broadly, where we look at the full lives of our patients.

We can see here the appearance of the biopsychosocial framework of medicine, originally introduced by psychiatrist Dr. George Engel in 1977, where it is important to take into account not only the biological changes, but also the familial, community and societal context of the ill patient. Dr. Elliot Mishler, a psychiatrist, also describes this framework as the battle between the world of medicine and the life world, where the health-care practitioner is placing the symptoms on the forefront and in order of chronological appearances, to make biological sense, while patients describe them in the unfolding order of their life, to make personal sense.

It becomes important for RMTs to connect all the factors involved in order to find what permits illness or injury to exist, alter the patient’s behaviour in the face of the illness or injury, and influence the effectiveness of the RMT treatment. RMTs need continual thought and research as to what constitutes health and what signifies an effective response to a lack of it.

Medicine tends to narrow its attention, eliminating the extra elements around the biological phenomena of illness or injury. Therefore, it is crucial to be aware of our own impulse to reduce as it is in direct contrast to the patient’s own impulse to multiply.

Beliefs about disease causality
Beliefs about disease causality is rooted deep in culture, religion, family and education of both patients and RMTs, making discrepancies of beliefs of disease causality, at times, very difficult to mediate. Gaps between what the practitioner believes is causing the disease or injury and the patient’s beliefs can lead to ineffectual treatments, as the patient may refuse self-care advice.

RMTs typically review etiologies and treatment plans every time new knowledge and data is acquired. For us, science is both a rigid and revisable process allowing for the incorporation of new information as it becomes available. Whereas for patients, beliefs are rarely based on up-to-the-minute information, more often rooted in past knowledge and experiences.

Health-care practitioners look for etiologies that apply to more than one patient, to generalize the symptomology to find theories and treatments that can be clinically applied to all.  Patients tend to look for what is unique to them, in hopes that caregivers can see the importance of their situation. In an effort to know and control the disease or injury, the health-care practitioner will assign causality to a series of symptoms. Patients only want to get better and be assured they will be treated as the unique person they feel they are, therefore looking for their individuality within this “symptomatology bunching” we have created.

Patients have more of a qualitative approach to their health, narrative in nature, and focused on how their condition is singular and therefore needing unique attention.

“Our clashes, in the end, over the causes of disease signify the desperate need for answers, for knowing, for certainty about why disease comes and how to remedy it.” (Charon, 2006, 30)

Emotions of shame, blame, fear
Feelings of shame, blame, and fear among patients are very common and difficult for practitioners to address. Most of what goes on inside the body is, to some, shameful and therefore not to be discussed.

Patients often do not feel comfortable talking to their RMTs about their sexual practices, bowel habits, substance abuse, or emotional problems. Most RMTs are also somewhat uncomfortable hearing about those same subjects, therefore leaving these questions unasked for fear of seeming unprofessional or being branded a voyeur.

Patients can also refuse to share information for fear of being blamed and judged for their illness or injury. The smoker with lung issues might be fearful of being mistreated.

In an effort to make their condition easier to accept than just random unfairness, patients may also irrationally look for their part of the blame for their condition – food they eat or not eat, exercise they do or don’t do – resulting in a grave sacrifice of self-esteem.

Fearful of being blamed for the patient’s condition, health-care practitioners can practice defensively and with suspicion toward their patients. Malpractice and unprofessional conduct complaints and litigation are common, although Levinson et al found patients sue their health-care practitioners when they feel they have not been listened to.

Blaming the patient for causing their own disease or injury or by branding them as non-compliant when they do not follow self-care advice, gives the health practitioner an excuse for failing to cure the disease or injury. On the other hand, to avoid being branded as noncompliant, patients may lie or avoid revealing certain facts of their condition or behaviour.

RMTs also need to keep in mind that patients might be fearful of the diagnosis, afraid that we might recommend rest, or worse, cessation from their favourite activity.

Communicating through patient’s fears may allow for a shared experience of suffering, which in turn lessens said suffering.

Knowledge and understanding that different notions of mortality, context of illness, causality and emotions exist between health-care practitioners and their patients may allow for a trusting and healing clinical relationship.

Patient-centered care is health care without the presence of the divides, it may be viewed as a partnership that equalizes the ground between the sick and the healthy, helping to see our bodies and lives in time, in relation and in meaning.

RMTs can use charting time to reflect on the patient’s stories and fears, their outlook on life, and relationships with their families and their community. We also need to reflect on our own understanding and beleifs about these divides and how they affect our professional judgement, treatment planning and homecare for our patients.

Anne-Marie Côté has been a RMT in Vancouver since 1997. She teaches for Langara College and is presently working on her master’s degree at SFU in health education and active living.

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