Abstract：
Against Medical Advice (AMA) discharges pose significant challenges to the healthcare system, straining patient-clinician relationships while contributing to avoidable morbidity and mortality. Furthermore, though these discharges culminate in patients\' departure from hospitals, their effects reverberate long after, propagated by clinician notes stored in patients\' medical records. These notes capture exceptionally fraught interactions between patients and providers, describing the circumstances surrounding breakdowns in clinical relationships. Additionally, they represent just one side of complex, contentious social interactions, for in describing AMA discharges, clinician notewriters quite literally have the last word. For these reasons, notes documenting AMA discharges provide insight into the ways in which clinicians conceptualize, characterize, and propagate power differentials in the contemporary healthcare system. Here, we present a qualitative thematic analysis of 185 notes documenting AMA discharges from a large urban US medical center, interpreting note dynamics through three sociological models of power analysis: (i) the distributive model of power promulgated by Max Weber, (ii) the collectivist power model characterized by Talcott Parsons and Hannah Arendt, and (iii) structural interpretations of power developed by Michel Foucault. We argue that in documenting AMA discharges, clinicians appear to conceive of their relationship with patients in almost exclusively distributive terms, which in turn contributes to an adversarial dynamic whereby both patients and clinicians ultimately suffer disempowerment. We furthermore argue that by facilitating clinicians\' recognition of power\'s collectivist and structural dimensions, we may help transform breakdowns in patient-clinician relationships into opportunities for collaboration.
摘要：
反对医疗咨询(AMA)的出院对医疗保健系统构成重大挑战，紧张的患者与临床医生的关系，同时有助于可避免的发病率和死亡率。此外，尽管这些出院最终导致患者离开医院，它们的效果在很久之后回荡，由存储在患者医疗记录中的临床医生记录传播。这些笔记记录了患者和提供者之间异常紧张的互动，描述了围绕临床关系崩溃的情况。此外,它们只代表复杂的一面，有争议的社会互动，在描述AMA放电时，临床医生的笔记本相当字面上有最后一句话。由于这些原因,记录AMA放电的笔记提供了对临床医生概念化的方式的洞察，表征，并在当代医疗保健系统中传播功率差异。这里,我们对185份记录美国大型城市医疗中心AMA出院的笔记进行了定性主题分析，通过三个权力分析的社会学模型来解释笔记动力学：(I)马克斯·韦伯颁布的权力分配模型，（ii）以塔尔科特·帕森斯和汉娜·阿伦特为特征的集体主义权力模型，和(iii)米歇尔·福柯提出的权力的结构解释。我们认为，在记录AMA出院时，临床医生似乎几乎完全以分布的方式设想他们与患者的关系，这反过来又导致了一种对抗性动态，即患者和临床医生最终都会被剥夺权力。我们还认为，通过促进临床医生对权力的集体主义和结构维度的认识，我们可以帮助将患者-临床医生关系的破裂转化为合作的机会.
