INT’L. J. PSYCHIATRY IN MEDICINE, Vol.

25(4)319-329,1995

PATIENTS’ INFLUENCE ON DOCTORS’ BEHAVIOR:

A CASE STUDY OF PATIENT STRATEGIES
IN SOMATIZATION

PETER SALMON
CARL R. MAY

University of Liverpool, United Kingdom

ABSTRACT
Objective: Extensive empirical data and theory describe the inequality of
power in relations between doctors and their patients. However, the focus has
been on the ways in which doctors control the doctor-patient relationship.
This has meant that the extent to which patients influence the consultation,
and the ways in which they do this, have been neglected. Methods: In this
article, we use a single case to identify and illustrate distinct ways in which
patients exert power to determine the outcome of consultations. Conclusion:
This analysis leads to a more powerful explanation than is presently available
to understand the somatization of psychological needs. According to this, the
patient organizes strategies, which include the presentation of emotional and
social distress, around a biomedical model. Because of their prior decisions as
to their role, doctors permit themselves to be trapped in this model.
(/nt’/.J. Psychiatry in Medicine 25:319-329,1995)

Key Words: doctor-patient relationship, biopsychosocial model of health, communication

skills, professional power, somatization

THE DOCTOR’S POWER

It has become a commonplace observation that power is distributed unevenly in
the doctor-patient relationship, and that this imbalance is in the doctor’s favor so
that patients find it difficult to influence decisions made about them [l-31. The

319
(9 1995, Baywood Publishing Co.,Inc.

doi: 10.2190/JUNY-QCER-GWLF-H60R
http://baywood.com
320 / SALMONANDMAY

imbalance has been attributed to the power with which the scientific authority of
medicine can overwhelm patients’ own models of their bodily disorders [4].
In addition to broad issues of power relations between doctors and patients,
research has closely examined the ways in which doctors control the consultation
and mold patients’ behaviors [5, 61. There is detailed evidence of the ways in
which general practitioners [7] and hospital doctors [2] structure the consultation
so as to preserve their authority at the expense of the patient’s ability to influence
its course. These tactics include closed interviewing techniques, restricting infor-
mation, use of medical jargon, focusing attention on somatic rather than emotional
concerns, and responses that reflect, not just patients’ medical need, but social
dimensions of age, sex, social class, or ethnic origin [8,9].

THE PATIENT’S POWER

The way in which patients’ influence has been conceptualized has contributed
to this view of doctor-patient interaction as one in which patients have little
power. Conventionally, their power has been conceptualized in terms of com-
pliance or non-compliance with doctors’ instructions [ 10, 111. Despite the
consumer-orientation of health care in the United States and other countries, and
an increasing consumer-orientation in health care policy in the United Kingdom
[12], there have been few attempts to extend our understanding of the way in
which patients, as consumers, influence their doctors. One approach has been to
study the intentions that patients have upon visiting their doctor [ 13-15]. Never-
theless, work in this area continues to neglect the ways in which patients pursue
their intentions. Concern with the ways in which doctors influence patients should
be matched by an equally systematic approach to the ways that patients influence
doctors.
The absence of such an account at present restricts our ability to explain a
pressing problem of Western medicine: the high level of invasive investigation
and treatment, including surgery, that is carried out in the absence of objective
pathological signs [ 16-191. It has been suggested that patients who consult with
functional disorders, and who receive medical and surgical attention for them,
may be emotionally disturbed [20-241. However, emotional disturbance is not
always present and, whether or not it is, many such patients do not mention it but
confine their complaints to physical symptoms [25-291. Therefore, to attribute
their subsequent somatic diagnoses, investigation, and treatment to misdiagnosis
by the doctor of an emotional disorder [26] is insufficient. A full explanation
should consider the way in which the patient influences the course of events. It is
surprising that the ways in which such patients can exert this influence have not
formally been described.
This article begins this analysis by delineating strategies by which a patient
who presented unexplained somatic symptoms influenced her doctors. The case
was selected because of the relatively coordinated and transparent form that the
 PATIENTS’ INFLUENCE ON DOCTORS BEHAVIOR / 321

patient’s influence had taken and because its detection was simplified by the
absence of significant objective pathological signs. A further simplification is that,
as a patient within the UK National Health Service, neither her nor her doctors’
decisions could be influenced by fee-for-service. The case therefore represents the
use of purposeful extreme-case sampling to develop and illustrate a theory of
general relevance [30, 311. The case study is based on two sets of data. First, the
patient was interviewed for fifty to sixty minutes on each of two occasions by one
of the authors (PS). Second, the patient’s medical records were read in detail by
both authors and used to chart her recent career of medical and surgical inter-
vention. The letters included in these records contained further evidence of the
way in which she presented to doctors.

THE CASE

History
Mrs. CS (age 47) was referred by her general practitioner in December 1992 to
a surgeon. She complained of a pain in her right breast dating from surgical
reduction by a different consultant early in 1992. Mrs. CS requested mastectomy
as the solution, although the firm opinion of the examining consultant was that
surgery was not indicated by objective signs.
By way of background, CS had been without any significant recorded medical
history, apart from a cholecystectomy, before her husband left her in 1983. He had
left her and their eight children for a much younger woman, to whom CS had
previously introduced him. Two years later her husband, now spumed by his new
partner, began pressing his wife to accept him back. She refused, still feeling bitter
and angry toward him. In 1984, CS presented with abdominal pain which led to an
appendectomy and then with menorrhagia, for which she underwent hysterec-
tomy. A few years later she developed backache which she attributed to the weight
of her breasts. Approximately 1 kg of histologically normal tissue was removed
surgically from each in March 1992. She was discharged from follow-up in March
but returned in April complaining of pain in her right breast. Fat necrosis was
discovered, containing a little fluid that was drained before she was once again
discharged in May. The pain returned and, in June, another referral requested
“urgent” treatment. The pain resolved for a while after an exploratory operation in
August (which again confirmed fat necrosis). Meanwhile she had been referred
to a plastic surgeon because she sought surgical removal of abdominal fat. He
examined her in August and declined to offer what he considered to be cosmetic
treatment. In December her GP referred her to a different surgeon for treatment of
her breast pain. He examined her in December, noting that she appeared depressed
and that surgery was not indicated. Unproductive referrals to a pain clinic and a
clinical psychologist followed, where she insisted on the need for mastectomy and
was unwilling to contemplate other treatment. In December 1993 the surgeon
322 I SALMONANDMAY

injected analgesic and an anti-inflammatory without effect. A wide excision of the

area of fat necrosis was performed. The pain subsided for some weeks but then
returned and CS underwent mastectomy shortly afterwards.
Any link between CS’s experiences and a desire for surgery on her breasts, and
previously, uterus, is beyond the scope of this article. Instead, the relevance of
her history, taken together with the absence of objective signs of significant
pathology, is to show that the drive for surgical treatment is the patient’s rather
than her doctors’, and to show that there is no evidence that such treatment is in
her best interests: it is not justified by objective signs, it is irreversible, entails the
risks of surgery and general anesthesia and might itself lead to further psycho-
logical problems. We can now examine the ways in which CS exerted this drive
for somatic treatment. Her account illustrated three separate strategies. In delineat-
ing these, our aim is to systematize issues that are part of the common clinical
experience of such patients. In addition we describe a fourth dimension to the
presentation which, although previously neglected, is fundamental to the influ-
ence that she exerted.

The Components of the Patient’s Presentation

Symptom Presentation
At the heart of CS’s account was the report of pain. This was “unbearable,”
“burning,” “dragging.” She “can’t bear to be touched,” and would wince on
palpation of the lumps to which she attributed the pain. Sometimes her breast was
too tender for examination. Conventionally, the doctor is seen as the expert in
interpreting and responding to symptoms. However, because of the subjectivity of
these symptoms, the patient, rather than the surgeon, is the expert on their exis-
tence and nature. The inability of others to question the pain or subject it to
empirical test was often made explicit: “you can’t know what it’s like.” The
subjectivity of such symptoms confers on the patient enormous power over the
doctor. When CS resumes her complaints, the doctor’s formulation and treatment
of the symptoms has been a failure, regardless of its scientific merit. When
complaints cease, even if only for a short time, the doctor is rewarded for his
efforts and his analysis and management of the problem are vindicated, despite
evidence that patients often stop complaining about symptoms in response to
suitable attention rather than active treatment [32]. Indeed, the occasional remis-
sion of symptoms after intervention probably encouraged CS’s doctors and helped
to sustain their continued willingness to treat her surgically.
The power that subjective symptoms give a patient is, however, contingent
on the model of illness that the physician or surgeon uses. Shorter has argued
that, whereas sensory and motor symptoms conveyed power over Victorian
doctors using a reflex model of illness, contemporary medical models give
weight, instead, to pain and fatigue [33]. That is, whereas a physician can dis-
claim responsibility for a sensory or motor deficit that does not match current
 PATIENTS INFLUENCE ON DOCTORS BEHAVIOR / 323

neurological models, pain and fatigue are widely accepted as requiring medical
explanation and treatment. By this analysis, the power that symptoms give
patients such as CS is entirely contingent on the doctor’s choice of a model in
which pain alone, if sufficiently intense, justifies somatic treatment. It is possible
to use a different, broader model which encompasses evidence that the experience
and report of physical symptoms reflect psychological and social processes
[25, 26, 28, 34, 351 and its adoption by CS’s doctors would have allowed them
greater freedom to choose an effective non-organic response which did not deny
her experience of pain.
Suffering
A second element in CS’s account was the distress and psychosocial disruption
caused by her symptoms: that is, her suffering. She richly described the distress
caused by the pain: how “it’s unbearable” and how “it makes me feel like
screaming” or how she would “lie awake all night” with an ice-pack to her breast.
She described being tearful and having been forced to withdraw from life apart
from looking after her daughters: “all day I’ve got nothing to do”; “I need
something in life.” Although she did not report problems in dressing or moving
about the house, she explained that she could no longer knit (previously her main
pastime) because of the pain she would feel should a knitting needle touch her
breast through her clothes, that she could no longer swim because of the pressure
of the swimming costume on her breast and that she could no longer work as
a waitress because of the danger of someone brushing past her. Her account
extended to describe the suffering of the three of her daughters who still lived with
her: “I don’t have to say the pain’s bad; they can tell just by looking.”
This aspect of her presentation strengthens her influence over the doctor in two
ways. First, she strengthens her expert position by increasing the amount of
subjective or nonverifiable information about the intensity of her symptoms.
Additionally, by telling the doctor about her suffering, CS is giving him the
responsibility for managing it: he has now to be concerned, not only with her
symptoms, but with the poor quality of her life. The surgeon’s decision to operate
might be attributed to lack of time or resources to respond more effectively to the
patient’s distress [36]. However, his behavior also reflects agreement to take
responsibility for his patient’s distress. That is, the power that the patient acquires
by reporting suffering is contingent, not only on organizational constraints on the
doctor’s behavior, but also on decisions made by the doctor.
Coercion
Threat is implicit in many of CS’s statements of suffering: “sometimes I want to
pull the ceiling on top of me.” Here it was metaphorical, but often it was explicit:
“I’ve wanted to top myself twice, but I phoned the doctor [her general prac-
titioner] and she’s come and spoken to me.” Her discharge from the pain clinic
back to the surgeon was accompanied by a warning that “she feels like doing
324 I SALMONANDMAY

something to herself.” More dramatically, she threatened that “I’ll take a knife to
myself [to cut her breast]; then the doctors will have to do something about it.”
CS’s threats were restricted to herself. Other patients have described threats to
their spouses. “I don’t think he’ll cope much longer” or children “They’re living
half a life while I’m like this”; “I’m frightened what I’ll do to them.” These
statements are coercive: they transparently exert strong pressure for intervention.
Once again, however, the power that they give the patient is contingent on the way
that the doctor views a failure to respond to them. In particular, because of the
adoption of a model that assumes that physical symptoms are, in principle, always
explicable or remediable by physical medicine, their persistence would be per-
ceived as professional failure. The doctor has taken on the responsibility for his
patient’s suffering that the patient has given him. The corollary is the respon-
sibility that he would have for her suicide or self-harm, or even for further
deterioration in her quality of life.

The Patient’s Use of a Medical Model

It is well known that patients organize their descriptions of symptoms around
models which “explain” properties of the symptoms including severity, threat,
causation, and aetiology, and influence whether the patient consults and what they
seek when they do [37-401. Mrs. CS has, however, gone far beyond a conventional
“lay” explanatory model: her account shows how patients can incorporate key
medical and surgical elements into their models in the course of maintaining and
focusing the dialogue with their doctor.
Bound up with CS’s report of her symptoms and requests for mastectomy were
explanatory statements about them. She knew that “it’s the lumps what’s doing
it,” that these were getting bigger and that symptoms were radiating further
through her body from this focus: “often the pain travels down into my arm.” The
problem would therefore get worse and worse without treatment. Her model
extends to emotional and social phenomena: the pain has caused her misery and
led her to withdraw socially. She knows that her problems are impervious to talk,
“seeing (the psychologist) isn’t going to make no difference” and that the only
treatment is for the breast to be cut off, “if the breast gets left on, what have I got?’
Clearly, CS is producing an account of her symptoms that appeals to medical
knowledge in a general way (that is, one that is broadly consistent with medicine’s
own pathological models) but which also appeals in a practical way: the surgeon
is offered a surgical solution. This reflects the process, which Shorter has
described, whereby medical models diffuse into lay discourse [33].
CS’s model is, however, inconsistent with the surgeon’s opinion in important
respects. He doubts that necrotic tissue would cause such severe pain. Her doctors
have also noted that she is depressed, with the implication of an emotional
explanation of her symptoms. However, clinical decision making routinely is not
primarily a matter of reaching a diagnosis, but about problem solving on a wider
 PATIENTS’ INFLUENCE ON DOCTORS‘ BEHAVIOR I 325

scale [41]. CS has clearly perplexed her doctors: their own explanatory models
cannot explain her presentation. The solution to the problem is to acquiesce to her
model. Here, the patient has pressed a narrow medical model of her problems
upon the doctors. This direction of transmission is. of course, opposite to the
conventional view that doctors press a medical model of illness onto patients.

THE DOCTOR AS INSTRUMENTOF SOMATIZATION

We have described ways in which a patient can exert considerable influence in
interaction with a physician or surgeon by presenting her problems in a way that
compels a particular kind of clinical response. The case that we have discussed is,
however, inconsistent with the simplistic notion of an influential and powerful
consumer: it was unlikely that the surgical interventions that CS sought would be
in her best interests. Indeed they have been, in a literal sense, destructive to her.
Our analysis illustrates how the concept of power becomes restrictive when
applied to a diadic interaction, such as between doctor and patient, where the
power of one party to control the other is conditional on a particular position taken
by the other. In describing the power that the patient has, we have therefore not
freed the surgeons from responsibility for the course that her management fol-
lowed. On the contrary, our argument has shown that each component of the
patient’s power depends entirely on the position taken by the doctor. That is, the
power that each of the patient’s strategies gives her is contingent on decisions that
the doctors have taken about their chosen theoretical model and their role. By not
adopting a position which permits other responses, the doctors allow the following
paradox to emerge: the patient uses her power to secure symptomatic assistance
from the doctor which serves the doctor’s interests (by increasing demand for his
specialist services) at the expense of her own (since her needs are more probably
emotional than somatic).
Although our analysis of CS’s presentation is at a relatively late stage in her
career as a patient, there are clear implications for understanding the development
of that career and of the careers of other patients who request intervention in the
absence of pathology. The concept of somatization has been developed [28] to
explain why patients such as CS continue to present somatic complaints to the
extent of undergoing invasive investigations and interventions. The use of the
terms “somatizer” and “somatizing” to describe such individuals shows that this
concept attributes somatization to the patient. According to Shorter, the process is
the selection by patients of symptoms from a “symptom pool” [33]. For others, the
process is a result of cultural or linguistic constraints which prevent the emotional
expression of distress [42]; the patient then approaches the doctor with somatic
complaints that are, therefore, a metaphor for psychosocial distress [25]. The
doctor’s insensitivity to psychosocial concerns [7, 91 leads to misinterpretation
of the metaphor, resulting in somatic treatment [26] and reinforcement of the
associated illness behavior [43].
326 I SALMONANDMAY

The present analysis provides an account of somatization that is more complex

than this. It is predicated on the diffusion of medical models into lay under-
standing, as described by Shorter [33]. However, it goes on to attribute somatiza-
tion to a destructive interaction between the patient, as agent, and the doctor as
willing instrument. At the center of the argument is the following proposition: the
biomedical model which underlies somatization is not the product of doctors’
rnisperception of a metaphorical or coded presentation by the patient, but is
actively and expertly proposed and defended by the patient, who lays out psycho-
social as well as physical material in such a way as to appeal to the biological logic
that underpins medical knowledge and practice [44].That is, psychosocial material
is used by the patient to constrain her doctors to work within a biomedical model.
Our account of CS’s interaction with her doctors indicates no immediate means
of escape for either party. The conditions that constrain Mrs. CS to seek help in the
way she does are clear: the availability of help tor emotional problems is restricted
by an incapacity or unwillingness to perceive and express distress psychologically
and by the absence of confiding relationships. The doctor has more scope for
changing the position that constrains him to respond as he does to CS: his position
is the product, in major part, of prior decisions including the choice of a model that
is fundamentally biomedical, the presumption that he has to resolve his patient’s
suffering and his view of professional “failure.” Therefore, to reverse or prevent
the development of somatization, the foundation on which the doctor’s position is
based must be changed. Recent years have, of course, seen attempts to develop
doctor-patient interaction in physical health care in a way that will increase
attention to aspects of the patient beyond the biological, particularly through
training in “communication skills” [9,451. The assumption is that doctors’
improved sensitivity to their patients’ psychosocial agendas should ensure that
patients receive more appropriate help. There are already indications that this
approach is flawed and does not necessarily empower the patient. For instance,
“good communication” has become inextricably linked with maximizing com-
pliance with medical requests and thereby with strengthening traditional, organic
approaches.
The present argument, however, indicates a more fundamental problem with
the presumption that, by enhancing doctors’ psychosocial sensitivity, clinical
management will better fit patients’ needs. The flaw in this logic is that, on the
contrary, doctors may thereby become bound, not by their patients ’ psychosocial
needs but, paradoxically, by the biornedical riiodel that their psychosocial agenda
is used to sustain. In this sense, presentation of psychosocial issues by the patient,
and sensitivity to them by the doctor, reflects the adoption of a very limited
biopsychosocial model such as that proposed by Engel, which is centered on
molecular biology and expands outwards through layers of “objective” pathology
into a diffuse realm of psychosocial factors [46]. “Good communications” may
therefore make it harder, not easier, for the doctor critically to take the somatizing
patient’s history.
 PATIENTS INFLUENCE ON DOCTORS’ BEHAVIOR / 327

Such caution about communication skills might be seen as “revisionist.” How-

ever, the argument does not point to an uncritical return to reliance on the doctor’s
conventional biological expertise. Indeed, we have argued that this is the very
position that constrains the doctor’s responses to a somatizing patient. Neither
does the argument lead to rejection of a biopsychosocial model of illness. On
the contrary, the physician or surgeon should be expert in the operation of a
biopsychosocial model in which biological presentation and surgical treatment are
inseparable from psychosocial mechanisms. That is, a model in which the bio-
logical, psychological, and social aspects of a presentation are given equal weight,
and that revolves around a recognition that a patient’s presentation is not merely
the sfimulus to her interaction with medical knowledge and personnel, but is the
product of this process. The two main functions that the model would require are
to interpret patient’s complaints and requests in terms which transcend the literal
and biophysical and to be reflexive to the extent of understanding how doctors’
own decisions as to their role and their relationship with patients influence their
responses to patients. Only where this is done could a surgeon, when confronted
with a patient such as CS,respond imaginatively to the patients’ psychological
needs rather than conservatively to the patients’ psychosocial complaints.

ACKNOWLEDGMENTS
W e are grateful to Dr. Keith Sharp and Dr. Michael Gopfert for comments on a
draft of this article, and to two anonymous reviewers for their helpful comments
on the version submitted to the journal.

REFERENCES
1. C. May, Individual Care? Power and Subjectivity in Therapeutic Relationships, Sociol-
ogy, 26589-602, 1992.
2. P. Strong, The Ceremonial Order of the Clinic, Routledge, London, 1979.
3. B. S . Tumer, Medical Power and Social Knowledge, Sage, London, 1987.
4. D. Armstrong, The Political Anatomy of the Body, Cambridge University Press,
London, 1983.
5. D. Silverman, Communication and Medical Practice, Sage, London, 1987.
6. E. Mishler, Social Contexts of Health, Illness and Patient Care, Cambridge University
Press, London, 198 1.
7. P. D. Campion, N. M. Butler, and A. D. Cox, Principal Agendas of Doctors and
Patients in General Practice Consultations, Family Practice, 9: 181-190, 1992.
8. J. A. Clark, D. A. Potter, and J. B. McKinlay, Bringing Social Structure Back into
Clinical Decision Making, Social Science and Medicine, 32:853-866, 1988.
9. M. Simpson, R. Buckman, M. Stewart, P. Maguire, M. Lipkin, D. Novack, and J. Till,
Doctor-Patient Communication: The Toronto Consensus Statement, British Medical
Journal, 303:1385-387, 1991.
328 / SALMONANDMAY

10. M. Kelly and D. May, Good and Bad Patients: A Review of the Literature and a
Theoretical Critique, Journal of Advanced Nursing, 7 147-156, 1982.
11. P. Ley, Communicating with Patients, Chapman and Hall, London, 1988.
12. Department of Health, The Patient’s Charter, HMSO, London, 1991.
13. M. D. Good, B. J. Good, and A. J. Nassi, Patient Requests in Primary Health Care
Settings: Development and Validation of a Research Instrument, Journal of Behavioral
Medicine, 6 151- 168, 1983.
14. P. Salmon and J. Quine, Patients’ Intentions in Primary Care: Measurement and
Preliminary Investigation, Psychology and Health, 3 103-110, 1989.
15. P. Salmon, N. Sharma, R. Valori, and N. Bellenger, Patients’ Intentions in Primary
Care: Relationship to Physical and Psychological Symptoms and their Perception by
General Practitioners, Social Science and Medicine, 38585-592, 1994.
16. C. F. Dowrick, Why do the O’Sheas Consult so Much? Social Science and Medicine,
34491-497, 1992.
17. P. Fink, Surgery and Medical Treatment in Persistent Somatizing Patients, Journal oj
Psychosomatic Research, 36439-447, 1992.
18. A. Coulter and K. McPherson, The Hysterectomy Debate, Quarterly Journal of Social
Affairs, 2379-396, 1986.
19. R. Pokras and V. G. Hufnagel, Hysterectomy in the United States 1965-1984,
American Journal of Public Health, 78852-853,1988.
20. R. W. Beard, E. N. Belsey, B. M. Lieberman, and J. C. M. Wilkinson, Pelvic Pain in
Women, American Journal of Obstetrics and Gynecology, 128566-570, 1977.
21. W. E. Whitehead, L. Bosmajian, A. Zonderman, P. Costa, and M. M. Schuster,
Symptoms of Psychological Distress Associated with Irritable Bowel Syndrome: Com-
parison of Community and Clinic Samples, Gastroeaterology, 92:709-7 14, 1988.
22. D. A. Drossman, D. C. McKee, R. S. Sandler, C. M. Mitchell, E. M. Cramer, B. C.
Lowman, and A. L. Burger, Psychosocial Factors in Initable Bowel Syndrome: A Multi-
variate Study of Patients and Nonpatients with IBS, Gastroenterology,91:701-708,1988.
23. R. Tessler, D. Mechanic, and M. Dimond, The Effect of Psychological Distress on
Physician Utilization: A Prospective Study, Journal of Health and Social Behaviour,
1Z353-364,1976.
24. J. Miranda, E. J. Perez-Stable, R. F. Munoz, W. Hargreaves, and C. Henke, Somatiza-
tion, Psychiatric Disorder and Stress in Utilization of Ambulatory Medical Services,
Health Psychology, 1046-51, 1991.
25. T. K. J. Craig and A. P. Boardman, Somatization in Primary Care Settings, in
Somatization: Physical Symptoms and Psychological Illness, C. M. Bass (ed.),
Blackwell, Oxford, pp. 73-103, 1990.
26. E. S.Paykel and R. G. Priest, Recognition and Management of Depression in General
Practice, British Medical Journal, 305 1198-1202, 1992.
27. P. F. M. Verhaak and M. A. R. Tijhuis, The Somatizing Patient in General Practice,
International Journal of Psychiatry in Medicine, 24: 157-177, 1994.
28. W. Katon, A. Kleinman, and G. Rosen, Depression and Somatization: A Review,
Part 1, American Journal ofMedicine, 72:127-135, 1982.
29. C. M. Bass and M. R. Murphy, Somatization Disorder: Critique of the Concept
and Suggestions for Future Research, in Somatization: Physical Symptoms and
Psychological Illness, C. M. Bass (ed.), Blackwell, Oxford, pp. 301-332, 1990.
 PATIENTS INFLUENCE ON DOCTORS BEHAVIOR I 329

30. M. Q. Patton, Qualitative Evaluation and Research Methods (2nd Edition), Sage,
Newbury Park, 1990.
31. A. L. Strauss, Qualitative Analysis for Social Scientists, Cambridge University Press,
New York, 1987.
32. W. B. Plotkin, A Psychological Approach to Placebo: The Role of Faith in Therapy
and Treatment, in Placebo: Theory, Research and Mechanisms, L. White, B. Turksy,
and G. E. Schwarte (eds.), Guildford, New York. 1985.
33. E. Shorter, From Paralysis to Fatigue: A History of Psychosomatic Illness, Free Press,
New York, 1992.
34. C. G. Helman, Culture, Health and Illness, Wright, London, 1990.
35. J. W. Pennebaker, The Psychology of Physical Symptoms, Springer-Verlag,New York,
1982.
36. D. Hughes, Control in the Medical Consultation, Sociology, 16:359-376, 1982.
37. D. Meyer, H. Leventhal, and M. N. Guttman, Commonsense Models of Illness: The
Example of Hypertension, Health Psychology, 4:1 15- 135, 1985.
38. M. Lalljee, R. Lamb, and G. Carnibella, Lay Prototypes of Illness: Their Content and
Use, Psychology and Health, 8:33-49, 1993.
39. M. Murray and M. Lay, Representationsof Illness, in Current Developments in Health
Psychology, P. Bennett, J. Weinman, and P. Spurgeon (eds.), Harwood, Switzerland,
pp. 63-92, 1990.
40. P. E. Fruend and M. B. McGuire, Health, Illness and the Social Body: A Critical
Sociology, Prentice-Hall, Englewood Cliffs, New Jersey, 1991.
41. M. Berg, The Construction of Medical Disposals. Medical Sociology and Medical
Problems Solving in Clinical Practice, Sociology of Health and Illness, 14: 151-180,
1992.
42. N. C. Ware and A. Kleinman, Culture and Somatic Experience: The Social Course of
Illness in Neurasthenia and Chronic Fatigue Syndrome, Psychosomatic Medicine,
54546-560,1992.
43. P. Salkovskis, The Cognitive-Behavioural Approach, in Medical Symptoms not
Explained by Organic Disease, F. Creed, R. Mayou, and A. Hopkins (eds.), Royal
College of Psychiatrists and Royal College of Physicians, London, pp. 70-84, 1992.
44. B. J. Good, Medicine, Rdonality nnd Experience: Ail Anthropological Perspective,
Cambridge University Press, London, 1994.
45. P. Meredith, Patient Participation in Decision-making and Consent to Treatment: The
Case of General Surgery, Sociology of Health and Illness, 15315-336, 1993.
46. G. L. Engel, The Need for a New Medical Model: A Challenge for Biomedicine,
Science, 196129-136, 1977.

Direct reprint requests to:

Peter Salmon
Department of Clinical Psychology
University of Liverpool, Whelan Building
P.O.Box 147
Liverpool L69 3BX, United Kingdom