Patient empowerment in the United States: a critical commentary

Abstract

Whilst there is no consensus amongst analysts regarding how best to define ‘patient empowerment’, at the very least, this concept entails a re‐distribution of power between patients and physicians. Empowered patients attempt to take charge of their own health and their interactions with health care professionals. Empowerment can occur at different levels (micro, meso, and macro) and patients have different ideas about what it means to ‘take charge’ and ‘be empowered’. Some patients simply want to be given information about their conditions whilst others want to have full control over all medical decision‐making. Some empirical evidence suggests that active patient participation in health care is associated with better patient outcomes. This field is ripe for future studies which both help to develop theoretical models of patient empowerment and articulate the conditions under which patient empowerment occurs.

Introduction

During the past three decades, ‘the…asymmetrical distribution of power between the physician…and the patient has become more symmetrical’ and a new vision of how individuals behave in matters pertaining to their health has emerged in the United States. ¹ This new vision is diametrically opposed to other theoretical conceptualizations of illness behaviour, such as Talcott Parsons’‘sick role’. ² In the Parsonian framework, patients are passive: once they find a competent physician, they ‘put themselves into her/his hands’, thus relinquishing responsibility for and control of their health. In the new vision of patients’ roles, the distribution of power between patient and physician is altered such that patients are more in control of their health and their encounters with health care professionals. In this paper, the term ‘patient empowerment’ is used to identify this new sort of patient role. [Link]

This paper explores the concept of patient empowerment, drawing primarily from the theoretical and empirical literature from the United States. Firstly, an overview of the socio‐historical situations through which the notion of patient empowerment emerged is provided. Secondly, assorted definitions of ‘empowerment’ and ‘patient empowerment’ are reviewed and an argument is made that patient empowerment should be viewed as multileveled construct with manifestations at the macro‐, micro‐, and meso‐levels of society. Thirdly, several key studies pertaining to patient empowerment as a particular type of patient role are reviewed. These studies were selected to articulate the breadth of ways in which the concept of patient empowerment has been operationalized in empirical work; they do not constitute a systematic literature review. The conclusion discusses the need for further research in this area.

Socio‐historical context

The concept of patient empowerment has historical significance. ³ As Steele, Blackwell, Gutmann and Jackson maintained, ‘The active patient concept is part of a dialectic that has waxed and waned for two centuries with broader societal interests in autonomy, self‐direction, and personal responsibility.’ ⁴ During the 18^th and into the latter half of the 19^th century in America, social attitudes and norms emphasized personal freedom and individual rights. Many people were wary of medicine and physicians were not well respected; ill people were tended to by (usually female) family members or lay healers. ⁵ Hence, lay people were ‘empowered’ at this time to take care of themselves, rather than to put their health into the hands of physicians. Beyond urban areas, most people lacked any alternative.

The popularity of self‐help and lay‐medicine slowly diminished during the latter half of the 19^th century as many important scientific discoveries were made (e.g. X‐rays, antisepsis, etc.). Scientific discoveries strengthened the professional status of ‘regular’ medicine, and as Steele and colleagues stated:

Following the Flexner report in 1910, medicine was recognized as a scientific profession. By the 1920s, the discovery of various vaccines, sera, and medications…cemented physicians’ power and authority. For the next 30–40 years doctors enjoyed unparalleled dominance; medical authority was seldom questioned, and patient acquiescence was assumed. ⁴

Thus, during this time period, patients came to rely on expert (physician) advice for problems which used to be handled by lay people. As Starr noted, ‘The public granted the legitimate complexity of medicine and the need for institutionalized professional authority.’ ⁵

By the early 1960s, broad social changes were once again occurring in the United States. Mistrust of authority and an emphasis on self‐determination were key concerns amongst the populace, and were expressed by many people via their participation in the consumer, civil rights, and/or women’s movements. Within the field of health care, changes occurred during the 1960s and 1970s that increased patients’ rights. Following the Nuremberg trials, the doctrine of ‘informed consent’, which ensured that patients receive adequate information about their treatment options, was drafted in the 1960s. In the 1970s, the American Hospital Association issued a ‘Patient Bill of Rights’ which laid out the rights that patients had when they were hospitalized. The ‘living will’, a legal document by which individuals could express their wishes regarding medical intervention, was also invented in the 1970s.

The 1980s ‘witnessed many court cases… which reaffirmed the authority of the patients or families acting on their behalf to decide therapy.’ ⁶ Additionally, the 1980s witnessed the birth of the ‘outcomes movement’ which focused on the consequences of a medical intervention on its recipient, thus highlighting the patient’s view of illness and treatment. As Reiser stated:

In the…1980s, driven by concerns over variations in the way physicians use therapy and the growing costs of health care, a new interest in outcomes measurement appeared that led the patient’s view of events to become pivotal. ⁶

Interest in patients’ perspectives has persisted in the 1990s. Health care corporations are increasingly trying to attract and retain patients as the health care environment becomes more competitive. Companies regularly collect and evaluate measurements of patient satisfaction and other related outcomes. Patient involvement in health care has also been emphasized during the 1990s. For example, individuals are encouraged by government agencies as well as private insurance companies to take care of themselves (i.e. via breast self exams, good nutrition, etc.). Some health insurance companies have encouraged individuals to manage ‘minor’ illnesses at home, without the help of a physician, and have published books regarding various home‐care methods for common ailments specifically to help individuals do this. ⁷

Also affecting this shift toward the ‘era of the patient’ ⁶ during the past three decades has been the increasing popularity of various types of self‐help clubs and media (books, television shows, the Internet, etc.) which give lay people access to medical information. Individuals today are often so bombarded with health‐related information that many find it hard to read a newspaper or magazine without learning about some new scientific discovery.

These myriad changes occurring over the past few decades have had important effects on both patients and physicians. Many people now ‘take charge’ of their health much more so than in the past; physicians can no longer assume that individuals will, without question, acquiesce into passivity.

Definitions of empowerment

Empowerment is a difficult concept to define – so difficult, in fact, that one researcher suggested that empowerment could not be defined in any one way because its manifestations were variable in different contexts. ⁸ Different individuals and/or groups of people often define and use the term in slightly or even radically different ways: there is not one commonly accepted definition that applies to all individuals at all times. In fact, individuals themselves may change if and how they use the term over the course of time. Highlighting the elusive nature of the concept, one commentator suggested that:

Empowerment is…easier understood by its absence: powerlessness, helplessness, hopelessness, alienation, victimization, subordination, oppression, paternalism, loss of a sense of control over one’s life and dependency. ⁹

Whilst reviewing what it is not clarifies what empowerment is, for research purposes it is helpful to have a working definition of the term. Next, assorted definitions of empowerment and patient empowerment are reviewed.

Empowerment is a dynamic term which:

Originates in the techniques of ‘community participation’ and ‘community development’ [which were]…strategies to reduce poverty, apathy and impotence…in the early 1960s ¹⁰

In recent years, the term has gained popularity in fields such as business, politics, and education. ⁹ In such fields, empowerment has been described as both a process and an outcome (e.g., a process of becoming empowered or a state of being empowered). ¹¹

Definitions of empowerment focus on different levels of analysis – individual, organizational, and community. At the individual level, definitions are psychological in nature:

Individual empowerment is often viewed as separate from the social system, similar to self‐esteem, individual competency, or self‐efficacy. ¹²

Rissel defined psychological empowerment as ‘a feeling of greater control’ over one’s life. ¹³

Feminists have objected to empowerment definitions which ignore the structural conditions that shape if and how people are able to ‘feel powerful.’ Bookman and Morgen, editors of a book entitled Women and the Politics of Empowerment, wrote:

Empowerment is currently a fashionable term, particularly as it refers to…the psychological experience of ‘feeling powerful’….[Yet,] for… women…‘feeling powerful’ is constrained…by the ways in which their gender, as well as their race and class, limit their access to economic resources and political power. ¹⁴

These authors highlight the fact that ‘feeling powerful’ is easier for some people than others in the United States. Thus, whilst individual‐level empowerment is important, and should not be ignored, it is also crucial to investigate the larger structural context in which individual empowerment may or may not develop for particular individuals at particular times in history. The organizational and community levels of analysis help with this task.

Concepts of empowerment at the organizational level are derived largely from democratic management theory. As Wallerstein maintained:

In an ‘empowering’ organization, individuals assume genuine decision‐making roles and hence become empowered through their work. Empowered organizations…develop and exert influence in the larger community to promote system‐level change. ¹²

The term empowerment has been used to refer to management techniques which increase individual employees’‘feelings of power’, which, in turn, improve the ‘powerfulness’ of the organization as a whole.

At the community level, the concept of empowerment:

Includes a raised level of psychological empowerment among its members, a political action component in which members have actively participated, and the achievement of some redistribution of resources or decision‐making favourable to the community. ¹³

Toree argued that there were three types of community empowerment: micro, ‘mediating’, and macro. ¹⁵ Micro‐level empowerment refers to individuals’ own personal senses of efficacy or esteem. Mediating‐level empowerment refers to groups in which individuals come together to share knowledge to raise their critical consciousness. Macro‐level empowerment refers to social/political activities in which individuals or groups participate. These three types are analogous to the original conceptualizations of individual, organizational, and community empowerment described above. This suggests that community empowerment is intimately connected with individual and organizational empowerment, and even further, that each of the levels of empowerment is in a dialectical relationship with the other.

Empowerment and health care

The concept of empowerment has been used within the field of health care in several ways. Firstly, at the macro‐level, it has been used to describe the relationship between health and power. As Schulz and colleagues stated:

Empirical evidence has generally supported an inverse relationship between social stress and health, with income and social status indicators positively associated with health status, and chronic stressors such as poverty and racism associated with increased morbidity and mortality. ¹¹

In short, those who are empowered are healthier than those who are not: powerlessness is a broad‐based risk factor for disease. ¹² Structural factors such as socio‐economic status, gender, or race/ethnicity condition who is and who is not likely to be empowered in a given society.

The concept of empowerment has also been used within the field of health to describe a particular type of patient. As Funnell and colleagues stated:

Patients are empowered when they have the knowledge, skills, attitudes, and self‐awareness necessary to influence their own behaviour and that of others…to improve the quality of their lives. ¹⁶

This definition of empowerment is similar to the psychological/micro‐level definitions discussed above: empowerment is the experience of feeling powerful. How do patients come to feel powerful? The answer to this question reveals additional ways that the empowerment concept has been used within this body of literature.

First, patients may become empowered via health education programmes. Feste and Anderson described an empowerment approach to health education:

The empowerment approach to health education seeks to increase patient autonomy and expand freedom of choice. Health education…prepare[s] people to function as equal and autonomous members of their healthcare team and as competent providers of their…daily healthcare. ¹⁷

There is an implicit assumption in the empowerment approach to health education that health care professionals empower patients to change their behaviours in some positive way. Importantly, power does not come from the patients, it comes from health care professionals. The professionals have distinct goals in mind when they ‘empower’ patients (e.g. get patients to exercise or inject insulin regularly). One commentator suggested that the empowerment approach, in this capacity, is really akin to capitalistic marketing. ¹⁸ This approach may also be related to capitalistic work shift (i.e. when patients do for free what health care professionals used to do for pay). ¹⁹ Skelton argued that the empowerment approach to health education is a disguised form of paternalism:

Under the guise of the fashionable rhetoric of ‘empowerment’ there lurks an older view that ‘the professional knows best.’‘Empowerment’ is about getting you to come around to a way of behaving that I, the expert, knew in advance was good for you, whilst encouraging you to think that changing your behaviours was your idea in the first place. ¹⁰

Patients also may become empowered via their interactions with physicians. McKay, Forbes, and Bourner suggested that there is a style of interaction between physician and patient called empowerment caring in which:

…the doctor and the patient are mutually active, they respect one another’s needs and they work together to achieve a result. ²⁰

Both the empowerment caring style of physician–patient interaction and the empowerment approach to health education can be seen to occur at the meso‐level of analysis. In this domain, patients and health care professionals interact under the constraints of both macro‐level conditions (e.g. managed care) and micro‐level psychological dispositions (e.g. shyness).

Empowerment caring is really a ‘new’ way to describe a particular type of physician‐patient relationship – one in which there is a shared and equal distribution of power. As McKay and colleagues stated:

Empowerment does not take ‘power’ from one to give to another, but is a symbiosis that produces a greater and more helpful caring process than either the carer or the person in care can do individually….Empowerment allows the doctor and the patient to enjoy working together with a mutuality of regard that leaves neither feeling oppressed or oppressive. ²⁰

Hence, empowerment within the field of health care has been used to describe the relationship between health and power, a particular type of active and informed patient, a kind of patient education, and a type of physician‐patient relationship. All these conceptualizations of empowerment are intertwined with each other: patients may become empowered as a result of gaining knowledge and other resources via health education; once empowered, patients engage in more egalitarian‐type relationships with their physicians. Those individuals in society who have the most resources have the best chances of becoming empowered – they will have the resources to engage in various forms of health education.

What is missing from these conceptualizations of empowerment is recognition that the source of patients’ empowerment may not be health care professionals. Whilst health care professionals can facilitate patients’ empowerment, there are also other ways that people can take charge of their health. For example, many women who participated in lay‐controlled consciousness raising groups during the women’s health movement in the United States took the power that they gained with them back into the health care system. Physicians did not empower these women – they empowered themselves and each other. In a similar fashion, many individuals currently participate in support groups, read consciousness‐raising books about health, search the Internet for medical information, etc. People who do these things are empowering themselves. If and when individuals take the knowledge and/or skills they have acquired from these various sources back into the health care setting, they may then facilitate (demand?) an egalitarian relationship with their physicians. How this works in practice and under what conditions remains to be explored.

In summation, patient empowerment is a multileveled construct that has manifestations at the micro‐, meso‐, and macro‐levels of society. In order to best understand this concept, one should study all of these levels and acknowledge that each level can influence the others: they are co‐constitutive. [Link] The remainder of this paper focuses on patient empowerment solely as a characterization of a type of patient role – one in which individuals ‘take charge’ of their health and their interactions with health care professionals. What difference does it make if patients are active participants in their health care? And which patients want to ‘take charge?’ Studies that have investigated these questions are reviewed in the next section.

Patient empowerment: research evidence

Several studies have evaluated the impact of patient empowerment on various patient outcomes such as satisfaction, adherence to treatment, and functional status. Two literature reviews pertaining to physician–patient interactions have shown that patients’ active involvement in medical visits is related to higher levels of patient satisfaction and adherence to treatment regimens. ^{21 , 22}

One study investigated the effectiveness, dynamics, and consequences of a health education intervention designed to improve patients’ ability to voice questions during office visits with their physicians. ²³ Roter equated question asking with patient autonomy:

…because questions are the most usual indicator of patient activity in the interaction, [and] physicians may take the expression of a question as an indicator of patient desire for greater participation.

Poor, African‐American, elderly women who suffered from hypertension were randomly assigned to either a control group or experimental group. Prior to meeting their physicians, participants in the experimental group met with a health educator who assisted them in identifying and rehearsing questions they had about hypertension. The medical visits then were taped and patients completed a post‐visit questionnaire. A 4‐month follow‐up survey was conducted to determine patients’ adherence to appointments.

Results showed that women in the experimental group asked significantly more questions during their office visits. Experimental group participants also scored higher on internal locus of control measures and had better appointment adherence rates. Importantly, however, the benefits for this group were coupled with negative consequences:

(i)  empowered patient encounters were filled with more tension, anxiety, and anger than control patient encounters,

(ii) empowered patients were less satisfied than control patients with their visits. Roter explained her results by stating:

The expected patient behaviour…was patient passivity, and increased patient participation was a new situation for both the patient and the provider. It is reasonable to suggest that the change from a traditional to a new pattern of interaction was attended by anxiety, anger, and dissatisfaction.

This study is often cited as evidence that patients can be ‘activated’ to become more involved in their health care. However exciting this idea is, caution is needed in interpreting the results of this study. Roter employed a very select sample of participants – poor, elderly, African‐American women. Results found with this group may or may not be found with other people, such as Asian‐American teenage boys or Hispanic men. Additionally, it is not clear that ‘question asking’ is the best (or only) way to measure patient engagement in care. It would be interesting to discover how the women themselves defined this concept (or if they even had a name for it) and what being involved in health care meant to them within the context of their everyday lives. This point highlights the value of feminist qualitative methodologies – only by talking to people and having them describe their lives and their actions can a real understanding be obtained of what patient empowerment means to people, both in the context of their everyday lives and in the health care setting.

This study could also have been strengthened by including a physician evaluation component. As Roter was studying interaction between patients and providers, it is imperative that both parties have a chance to evaluate the encounter. What did the physicians think about the women asking questions? Why? What does this tell us about patient empowerment? Answers to these questions would have given readers a more complete picture of the interaction between participants and may have helped to explain the reasons for the negative affective quality of the experimental groups’ encounters.

Greenfield, Kaplan, and Ware also evaluated the impact of a health education intervention on patients. ²⁴ Forty‐five middle‐aged, middle‐class, mostly male patients with peptic ulcer disease were randomly assigned to one of two groups. Patients in the experimental group were given individualized information about their disease and were encouraged to ask questions when they met with their physicians. These patients also were allowed to rehearse any questions they had before they saw the physician. Patients in the control group were given general information about peptic ulcer disease but did not receive any individualized attention or encouragement.

Results showed that patients in the experimental group talked more during the office visits than patients in the control group and also were better able to elicit information from their physicians. Additionally, at a 6 to 8‐week follow‐up visit, participants in the experimental group reported fewer functional limitations than those in the control group. To explain these results, Greenfield and colleagues suggested that, ‘a more active role in a visit to the physician may relate to a greater sense of control over the disease, and therefore better health outcome.’ These findings are consistent with other studies that show a positive relationship between sense of control and enhanced coping ability. ²⁵

In a related study, Kaplan, Greenfield, and Ware found that increased patient participation in the office visit was related to various positive outcomes:

More patient control (in the form of questions and interruptions) expressed during office visits was associated with improvements in blood sugar and blood pressure control as well as with improvements in functional limitations….More control expressed by doctors was associated with elevated subsequent blood sugar and blood pressure levels, and more functional limitations reported at follow up. ²⁶

Results from this and Greenfield and colleagues’ study suggest that if and how patients’ power is expressed in health care settings may have important effects on health outcomes. Moreover, they suggest that a specific type of interaction, one that facilitates patients’ empowerment such as the ‘empowerment caring’ model mentioned above, may lead to better outcomes.

What is intriguing about these studies is that the improvements in patients’ functional status were associated with the physician–patient interaction, presumably independent of other factors. The time individuals spend with physicians is often minuscule compared to the time they spend in their ‘real lives.’ Yet, these studies suggest that what happens during the brief office visit does matter to people’s well‐being. This points to the ‘cultural authority’ of medicine:

Patients consult physicians not just for advice, but first of all to find out whether they are ‘really’ sick and what their symptoms mean. ‘What have I got, doc?’ they ask. ‘Is it serious?’ Cultural authority, in this context is antecedent to action. The authority to interpret signs and symptoms, to diagnose health or illness, to name diseases, and to offer prognoses is the foundation of any social authority the physician can assume. ⁵

Given the authority inherent in the physician’s role, patients’ abilities to ‘hold their own’ in the medical setting may go a long way in their everyday lives. [Link]

Whilst the time patients spend with a physician is important in terms of patient empowerment, it is also worthwhile to consider the time patients spend outside of health care settings. For example, if individuals attend support group and conscious‐raising seminars, read medical journals regarding their condition, and ask questions during visits with their physicians, then are the improvements noted after the interaction attributable just to the asking of questions? or do all of the patients’ activities constitute a whole that cannot be teased apart? The studies reviewed above did not investigate patients’ activities outside the health care setting, therefore they cannot answer these questions. The underlying issue here has to do with the proper operationalization of patient empowerment: ‘asking questions’ or any other behaviour that occurs strictly within the health care setting may be too limited an operationalization for this complex concept.

The studies reviewed thus far indicate that some forms of patient empowerment, such as asking questions of one’s physician, are related to various patient outcomes. Next, attention is directed toward reviewing studies which focus on patients’ desire to ‘take charge’ of their health care. Haug and Lavin examined patients’ preferences for taking an active role in their health care. Attitudinal and behavioural indices were used to create a variable they labelled ‘challenge to physician authority.’ ²⁷ Results showed that 85% of respondents fell at the mid‐point or above on the attitudinal challenge index. Path analysis revealed that young, well‐educated individuals who were knowledgeable about health and sceptical of authority were most willing to adopt a consumerist stance and challenge physicians’ authority. Additionally, approximately 50% of respondents had taken a direct action that Haug and Lavin regarded as a challenge to the authority of the physician.

In later work, Haug and Lavin showed that patients’ willingness to challenge the physician depends on the characteristics of the actors as well as the particular illness situation. ²⁸ Some patients are more likely than others to challenge physicians, specifically:

…[patients] who claim to have challenged a physician’s authority tend to be younger, believe that medical errors occurred in their care and that physician competence leaves something to be desired, and perceive their health as poorer.

Together, these studies reveal that patient empowerment is not a static entity (one is either empowered or is not empowered) but is a condition that waxes and wanes according to the actors involved in particular situational contexts.

A recent study investigated patients’ desire for information and involvement in medical decision‐making. ²⁹ Respondents (n = 167) were men and women who suffered from benign prostatic hyperplasia, back pain, or hypertension. Results showed that most patients desired a lot of information about their condition; however, not all patients wanted to be involved in medical decision‐making. Women, younger, highly educated, and affluent individuals were more likely than others to want to be involved in decision‐making. Nease and Brooks suggested:

The variation we observed suggests that rigid recommendations about how much information to provide to patients and about how much to involve patients in decision‐making are likely to be inappropriate for some patients.

Some patients may wish to ‘take charge’ of their care by getting information from their physicians and leaving the decisions in the physicians’ hands. Others may wish to make all their own decisions. Others may want neither information nor decision‐making authority.

Another study investigated patients’ desire for information and involvement in decision‐making. ³⁰ Respondents were elderly patients from four racial/ethnic groups (Korean‐American, Mexican‐American, African‐American, and European‐American) who were facing a terminal illness. Results showed that African‐American and European‐Americans were more likely than other respondents to endorse a patient autonomy model of decision‐making. This model of decision‐making is in line with many of the definitions of patient empowerment reviewed above. Specifically, in the patient autonomy model, the patient, as an individual, is entitled to know the truth about his/her diagnosis, receive information about treatment options, and participate in medical decision‐making. Korean‐American and Mexican‐American respondents often rejected this model of decision‐making and endorsed an alternative, family‐centred style. Within the family‐centred style of decision‐making:

…it is the sole responsibility of the family to hear bad news about the patient’s diagnosis and prognosis and to make difficult decisions about life support. ³⁰

Blackhall and colleagues’ results, once again, indicate that all patients are not the same. Some patients may want to ‘take charge’ of their health care, others may want their family members to ‘take charge.’ One simple definition of patient empowerment or approach to patienthood is inadequate for the range of variation apparent amongst patients. Moreover, as Blackhall and colleagues stated:

Insisting on the patient autonomy model of medical decision‐making when that model runs counter to the deepest values of the patient may ironically be another form of the paternalistic idea that ‘doctor knows best’. ³⁰

These results highlight the importance of finding out, from people themselves, what type of role(s) they desire in their health care. Assuming that one role will fit all is simply erroneous.

Discussion

The patient empowerment body of literature suffers from a lack of theoretical guidance. Whilst scholars have provided many definitions of empowerment and patient empowerment, rarely are definitions used with any consistency or clear rationale. Moreover, within empirical studies, the complex concept of patient empowerment is often operationalized in overly simple ways. The lack of theoretical guidance and simplification of the concept call for the need for more qualitative research. Such research could elicit individuals’ own definitions of patient empowerment, which would, in turn, facilitate the development of better theoretical models of the concept. For example, researchers may wish to study patient empowerment amongst Hispanic adolescents living with HIV/AIDS, elderly African‐American men living with cancer, and Caucasian women who are receiving routine preventive care. How such varied groups define and embody patient empowerment would be interesting to compare and contrast. Moreover, such studies may highlight dimensions of empowerment that are common across various groups. These dimensions could then form the building blocks of a more generalized theoretical framework for the concept.

Whilst this paper has focused on patient empowerment in the United States, it would also be fruitful to consider cross‐cultural understandings of the concept. For example, Saltman (1994) showed that patients in Great Britain, Denmark, and Sweden have varying degrees of control regarding what physician and hospital they use when they are ill (choice of physician/hospital was one aspect of Saltman’s vision of patient empowerment). ³¹ Specifically, people in Great Britain and Denmark have more control regarding their choice of physician than do people in Sweden. This suggests that there may be important cross‐cultural differences in the enactment of patient empowerment. Hence, a comparison of how various nations’ economic and political conditions affect people’s understandings and embodiments of patient empowerment would be an excellent addition to the literature.

Next, this body of literature suffers from an overly professional or medicalized orientation. Within studies in this field, often there is no recognition of the fact that patients may become empowered outside of the health care setting, or that what happens within the health care setting is intimately connected with what occurs outside of it. Research is needed to explore both if and how individuals become empowered regarding their health outside of health care settings and how doing so influences their behaviour within the health care setting. This approach would pay tribute to individuals’ whole lives and not prioritize the few minutes they spend with their physicians over everything else.

Additionally, whilst the literature is professionally oriented, it also often neglects the actual perspectives of physicians. Little is known about how physicians define patient empowerment, what they like/dislike about empowered patients, how patient empowerment affects their jobs, etc. Since patient empowerment pertains to the interactions between patients and physicians, gathering the perspectives of all actors involved is imperative to best understand the concept.

Finally, whilst some studies have found relationships between certain patient socio‐demographic characteristics such as gender or socio‐economic status and the concept of patient empowerment, efforts have not been made to understand the reasons for these relationships. Virtually no research has been conducted regarding patient empowerment which has included an analysis of both patient and physician socio‐demographic characteristics. Clearly, this field is in need of additional research.

Conclusion

Whilst there is no consensus amongst analysts regarding how best to define ‘patient empowerment’, at the very least, this concept entails a re‐distribution of power between patients and physicians. Empowered patients take charge of their own health and their interactions with health care professionals. Empowerment can occur at different levels (micro, meso, and macro) and patients may have different ideas about what it means to ‘take charge’ and ‘be empowered.’ Some patients simply want to be given information about their conditions whilst others want to have full control over all medical decision‐making. Some evidence suggests that active patient participation in health care is associated with better patient outcomes. This field is ripe for future studies which both help to develop theoretical models of patient empowerment and articulate the conditions under which patient empowerment occurs.