Countervailing powers constrain the authority and autonomy of the medical profession. One countervailing power is patient consumerism, a movement with roots in health social movements. Patient empowerment discourses that emerge from health social movements suggest that active patienthood is a normative good, and that patients should inform themselves, claim their expertise, and participate in their care. Yet, little is known about how patient empowerment is understood by physicians. Drawing on ethnographic fieldwork in an American medical school, this article examines how physicians teach medical students to carry out patient encounters while adhering to American cultural expectations of a collaborative physician–patient relationship. Overt medical paternalism is characterised by professors as ‘here's the orders’ paternalism, and shown to be counterproductive to ‘closing the deal’ – achieving patient agreement to a course of treatment. To explain how physicians accomplish their therapeutic goals without violating cultural mandates of patient empowerment I develop the concept of ‘constrained collaboration’. This analysis of constrained collaboration contrasts with structural‐level narratives of diminishing professional authority and contributes to a theory of the micro‐level reproduction of medical authority as a set of interactional practices.