Contents lists available at ScienceDirect Health & Place journal homepage: www.elsevier.com/locate/healthplace Three modes of power operation: Understanding doctor-patient conflicts in China's hospital therapeutic landscapes Peiling Zhou, Sue C. Grady ⁎ Department of Geography, Environment, and Spatial Sciences, Michigan State University, 673 Auditorium Rd, Room 207, East Lansing, MI 48824, USA ARTICLE INFO Keywords: Doctor-patient conflicts Therapeutic landscapes Micro-power relations Health care China ABSTRACT Doctor-patient conflicts in contemporary China are increasing in numbers and severity. This health geographic study shows how hospitals as a type of therapeutic landscape can shape doctor-patient relationships. First, the comprehensive nature of therapeutic landscapes with an emphasis on power operation within symbolic environments is provided as a framework for this study. Second, the results from participant observation and interviews with patients and doctors previously involved in conflicts are reported from Internal Medicine and Surgery Departments, within four hospitals in Anhui Province, Eastern China. The study finds that the spatial and temporal arrangements of spaces, the inside decorations and the different modes of discourses can build or ruin harmonious doctor-patient relations. The research concludes that adaptations to current hospital therapeutic landscapes can improve trust between patients and doctors, resulting in fewer conflicts and better health outcomes in China. 1. Introduction Over the last twenty years, conflicts between patients, families and doctors have escalated in China. Since 2002, such conflicts increased 22.9% annually (Wang and Li, 2012). According to the Ministry of Health of the People's Republic of China (China Annual of Sanitation., 2011), 98.4% of hospitals had on average 40 dispute incidents per year. Importantly, 90.0% of such disputes involved violence perpetrated by patients and families toward their health care provider (herein referred to as doctor-patient conflicts). Doctor-patient conflicts occur in various forms, including the eruption of violent attacks on individuals, block- ade of hospital entrances and the disruption of clinical work by family- operating funerals within hospitals (Tu, 2014). While central and local Chinese governments have implemented a series of reforms to increase the visibility of doctor's authority within hospitals, the mushrooming of doctor-patient conflicts and attacks have not declined, largely because their underlying cause(s) are not well understood (Liu, 2010). Since doctor-patient conflicts are important societal and health care pro- blems that are also on the rise in China, there is a need for further investigation. Previous research on doctor-patient conflicts is limited. In the United States, studies have focused on patient's lack of trust in the professional authority of health care providers (Parsons, 1951; Friedson, 1985; Roter and Larson, 2001). Freidson (1985) concluded that while physicians often view patient's bodies as “detached medical objects”, patients are also hesitant to give full control of their bodies over to the authority of physicians, especially as they become more educated in medical knowledge through media sources. These studies share the assumption that professional authority –i.e., authority based on physician's professional knowledge legitimates physician's control over patient's bodies and a lack of this authority will contribute to doctor-patient conflicts. Despite these assumptions and findings, there is no evidence that improvements in doctor's practices, such as increased knowledge and medical technology, will lead to greater professional authority to avoid these types of conflicts in China. Furthermore, with only a few exceptions (Maynard and Heritage, 2005; Curtis et al., 2013; Neuwelt et al., 2015), there is a continued need to investigate the various techniques (discursive and/or non- discursive) that doctors use to build trust with their patients and persuade them to follow their prescribed treatment orders. Importantly, Curtis et al. (2013) has shown that techniques doctors use to build trust may also prevent patients from asserting their rights –i.e., to find a good doctor, to learn about their condition(s) and to ensure they are being treated properly—findings that could help in part explain doctor-patient conflicts. This research investigates 30 doctor-patient conflicts by studying doctor-patient relationships in four reformed primary care hospitals in China. Therapeutic landscape is the theoretical framework used to understand doctor-patient relationships and conflicts in this study. The departments and clinics within the hospitals are viewed as a type of http://dx.doi.org/10.1016/j.healthplace.2016.09.005 Received 28 April 2016; Received in revised form 27 September 2016; Accepted 27 September 2016 ⁎ Corresponding author. E-mail addresses: zhoupeil@msu.edu (P. Zhou), gradys@msu.edu (S.C. Grady). Health & Place 42 (2016) 137–147 1353-8292/ © 2016 Elsevier Ltd. All rights reserved. Available online 19 October 2016 crossmark